title: Lobectomy versus stereotactic body radiotherapy in healthy patients with stage I lung cancer.
abstract: OBJECTIVE
  Stereotactic body radiotherapy is an effective treatment for patients with early-stage non-small cell lung cancer who are not healthy enough to undergo surgery; however, the relative efficacy versus surgery in healthy patients is unknown. The National Cancer Database contains information on patient health and eligibility for surgery, allowing the long-term survival associated with lobectomy and stereotactic body radiotherapy to be compared in healthy patients with clinical stage I disease.
  
  
  METHODS
  The National Cancer Database was queried for patients who underwent lobectomy or stereotactic body radiotherapy for clinical stage I lung cancer between 2008 and 2012. Healthy patients were selected by excluding patients not offered surgery because of health-related reasons and only including patients documented to be free of comorbidities.
  
  
  RESULTS
  A total of 13,562 comorbidity-free patients with clinical stage I lung cancer treated with lobectomy were compared with 1781 patients treated with stereotactic body radiotherapy. Time-stratified Cox proportional hazards models found lobectomy to be associated with a significantly better outcome than stereotactic body radiotherapy for both T1N0M0 tumors (hazard ratio, 0.38; 95% confidence interval, 0.33-0.43; P < .001) and T2N0M0 tumors 5 cm or less (hazard ratio, 0.38; confidence interval, 0.31-0.46; P < .001). In a propensity-matched analysis of 1781 pairs, lobectomy remained superior to stereotactic body radiotherapy (5-year survival 59% vs 29%, P < .001). Furthermore, when the subset of stereotactic patients who had refused a recommended surgery (n = 229) were propensity matched to lobectomy patients, lobectomy was associated with improved survival (5-year survival 58% vs 40%, P = .010).
  
  
  CONCLUSIONS
  Among healthy patients with clinical stage I non-small cell lung cancer in the National Cancer Database, lobectomy is associated with a significantly better outcome than stereotactic body radiotherapy. Further study is warranted to clarify the comparative effectiveness of surgery and stereotactic body radiotherapy across various strata of patient health.
authors.affiliation: Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
authors.forename: Joshua E
authors.initials: JE
authors.lastname: Rosen
authors.affiliation: Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
authors.forename: Michelle C
authors.initials: MC
authors.lastname: Salazar
authors.affiliation: Yale School of Public Health, New Haven, Conn.
authors.forename: Zuoheng
authors.initials: Z
authors.lastname: Wang
authors.affiliation: Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Conn.
authors.forename: James B
authors.initials: JB
authors.lastname: Yu
authors.affiliation: Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Conn.
authors.forename: Roy H
authors.initials: RH
authors.lastname: Decker
authors.affiliation: Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
authors.forename: Anthony W
authors.initials: AW
authors.lastname: Kim
authors.affiliation: Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
authors.forename: Frank C
authors.initials: FC
authors.lastname: Detterbeck
authors.affiliation: Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn. Electronic address: Daniel.boffa@yale.edu.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Boffa
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D008297:Male; D009367:Neoplasm Staging; D011013:Pneumonectomy; D016634:Radiosurgery; D015996:Survival Rate
keywords: NSCLC; SBRT; lobectomy; lung cancer; stereotactic body radiotherapy; survival