by Dennis Thompson
HealthDay Reporter
WEDNESDAY, May 10, 2023 (HealthDay News) — More and more patients are choosing radiation therapy over surgery to treat their early-stage lung cancer, but a new study argues they might be making a mistake.
People who are good candidates for lung cancer surgery appear to have a five-year survival rate that is 15 percentage points lower if they choose to undergo radiation treatment, according to findings presented Monday at a meeting of the American Association for Thoracic Surgery, in Los Angeles. Angels.
“It appears that surgical patients are getting a real long-term survival benefit, and you’re seeing a real separation in the survival curve after two years,” said lead investigator Dr. Brooks Udelsman, a cardiothoracic surgeon at the College of of Medicine from Yale. “If you have a patient who is expected to live longer than two years, they will probably benefit from surgery.”
For the study, the researchers analyzed data from the National Cancer Database on more than 30,000 patients with non-small cell lung cancer who were diagnosed and treated between 2012 and 2018.
The data included about 24,700 patients whose tumors were surgically removed and nearly 6,000 who underwent stereotactic body-directed radiation therapy (SBRT). SBRT targets small tumors with large doses of radiation without damaging nearby healthy tissue and organs.
The percentage of early-stage lung cancer patients receiving targeted radiation therapy instead of surgery rose to 26% in 2018, up from 16% in 2012, Udelsman said.
It’s not surprising that some choose radiation over surgery, because it’s an easier option, he said.
SBRT for early-stage lung cancer typically involves three to five treatments over the course of a week, while a person could remain in the hospital for days and in pain for weeks after surgery, Udelsman said.
“Surgery requires time in the hospital, and there is some associated pain,” Udelsman said. “Radiotherapy is a little more convenient. You don’t have to be hospitalized. There’s almost no pain associated with it.”
Cleveland Clinic radiation oncologist Dr. Gregory Videtic agreed that the comparative ease of radiation therapy is leading more patients to choose SBRT over surgery.
He offered the example of a man in his 50s who was in line to have surgery for his lung cancer, until he discovered that the surgery would be more invasive than expected because he had already had heart surgery. The patient weighed his options and opted for radiation therapy.
“I have to tell you, the first thought on his mind is, if I don’t have to open up and go to the hospital, nothing else matters, right?” Videtic said. “The rise of SBRT is not really driven by radiation oncologists. In fact, I think it’s the patients who are saying, oh my gosh, who wants to have surgery?
Both options are equally good in terms of short-term survival, the new data showed. Three months after treatment, approximately 97% of surgical patients are still alive compared to 98% of patients who receive radiation therapy.
But the overall five-year survival rates between the two groups are very different, according to the new study: 71% for people treated with surgery versus 42% for those who received radiation.
However, that difference could be because people who get radiation therapy are too frail or sick to have surgery, and are therefore more likely to die of any reason.
Therefore, the researchers adjusted their approach to 528 patients who were healthy enough to be offered surgery and specifically declined it, instead receiving radiation therapy.
These patients also had a lower five-year survival rate compared with those who had surgery, 56% vs. 71%.
“Radiation therapy has generally been reserved for patients who couldn’t tolerate surgery, who were too frail, too sick, for whatever reason,” Udelsman said. “But we have seen this increasing number of patients who would be good candidates for the operation opt to receive radiation therapy instead. We understand that it is convenient and less scary, but there is a downside to long-term survival.”
The survival advantage of surgery over radiation therapy persisted regardless of the type of procedure, the researchers found: 73% for removal of an entire lung lobe; 72% for removing part of a lobe; and 62% to remove a small wedge-shaped piece of lung tissue, compared with 42% for radiation treatment.
“We really should warn patients before they choose to have radiation therapy that there are some downsides down the road and that surgery is a fairly safe option,” Udelsman said. “I think it’s a little worrying that we’re now seeing about 25% of patients who would otherwise be good candidates for the operation have radiation therapy instead of surgery. That’s a pretty high number: 1 in 4 choose what looks like a treatment that isn’t that great.”
But the matter may not be as clear cut as that, said Dr. Kenneth Rosenzweig, chair of radiation oncology at Mount Sinai Health System in New York City.
There are many reasons why a person who appears to be a good candidate for surgery might choose radiation, including some that would lower their chances of long-term survival, regardless of the therapy chosen, Rosenzweig said.
“A patient’s decision to have surgery or not is a very complex psychosocial decision,” Rosenzweig said. “Is it documented that the patient refused surgery because the surgeon gave a very discouraging picture of the postoperative state the patient would be in? Or are you a patient who was an excellent surgical candidate and against medical advice decided not to have surgery? Both people would be in the same category of refusing surgery, but they could represent two very different clinical situations.”
Videtic agreed with Rosenzweig that the national data used in this study contain too many uncontrolled variables that could affect the outcome, including differences in patients’ general health and the specific circumstances of their lung cancer.
“In this setting, where there are confounding factors in terms of who these patients are and what their actual medical comorbidities are, there is no way to measure what the competing risks are for these patients,” Videtic said. “Regardless of whether or not a person says they are healthy or refuses a surgeon, it is not known what are the other factors with these patients that could lead to their death.”
Instead, the ultimate response to surgery versus radiation will be answered by ongoing clinical trials directly comparing surgery to radiation therapy in patients with early-stage lung cancer, Videtic said.
Two of these trials are in progress now, he said, and the results should be available within a couple of years.
“Those will answer the question,” Videtic said. “All these retrospective studies will basically fall by the wayside once the results of those trials are published. And if it turns out that one of them is superior to the other, I have no problem with that.
Findings presented at medical meetings are considered preliminary until published in a peer-reviewed journal.
More information
The American Cancer Society has more about the treatment of non-small cell lung cancer.
SOURCES: Brooks Udelsman, MD, cardiothoracic surgeon, Yale School of Medicine, New Haven, Conn; Gregory Videtic, MD, radiation oncologist, Cleveland Clinic; Kenneth Rosenzweig, MD, professor and chair, radiation oncology, Mount Sinai Health System, New York City; Presentation, American Association for Thoracic Surgery Meeting, May 8, 2023, Los Angeles
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