Treatment recommendations for stage I non-small cell lung cancer: does patient preference matter?

Patients with stage I non-small cell lung cancer (NSCLC) are potentially cured by surgical resection. Over the last 10 years stereotactic ablative radiotherapy (SABR) has also become widely available as a treatment for some of these patients. The obvious benefits of SABR over surgery are the lack of immediate operative morality risk and post-operative complications, but the concern is that this early advantage may be off-set by tumour recurrence and reduced longer term survival. A prospective evaluation of SABR given between 2004 and 2006 to 59 medically inoperable patients with tumours less than 5cm diameter, showed that primary tumour control was excellent at 97%. Unfortunately a substantial number of cases (22% at 3 years) developed disseminated recurrence; 3.5% had hilar or mediastinal recurrence and the majority developed more distant metastases soon after SABR, suggesting occult disease at the time of treatment (1). A retrospective propensity matched analysis of video-assisted thoracoscopic surgery (VATS) lobectomy vs. SABR in early stage NSCLC (64 patients in each group) supported this finding: loco-regional control was superior in the SABR group although overall survival was not significantly different (2).