For the treatment of early-stage lung cancer, the existing guidelines clearly suggest that complete surgical resection is still the “gold standard”, and local treatments such as radiotherapy and ablation are only used for patients who are not suitable for surgery or are unwilling to undergo surgery. However, with the continuous development of radiotherapy technology, there are attempts to use it as a radical treatment for early-stage lung cancer patients. A recent article published in The Lancet Oncology has caused a huge international debate: Is radiotherapy a better choice for early-stage lung cancer? In this regard, I would like to share my opinion from a surgeon’s point of view. Flawed studies A big problem in the debate over surgery versus stereotactic radiotherapy (SBRT or SABR) for early-stage non-small cell lung cancer is the lack of rigorously designed prospective randomized controlled studies (RCTs). The available evidence comes mainly from non-randomized studies or retrospective database based comparisons in inoperable or elderly patients. There were three multicenter RCT studies in previous years that resulted in early termination due to patient enrollment difficulties. To get out of the no evidence dilemma, Professor Yu-Jiao Zhang of the Department of Radiotherapy, MD Aderson Cancer Center, USA, combined two of these studies (ROSEL and STARS studies) for analysis and showed that SBAR had similar efficacy and lower toxicity than surgery. This pooled analysis was published in this year’s Lancet Oncology, and it has stirred up a thousand waves internationally. However, from an evidence-based perspective, this study does not change the status of surgery as the standard of care for early-stage non-small cell lung cancer due to data shortcomings. First, the study was based on two retrospective RCTs with incomplete enrollment and a small sample size of just over 50 cases in both groups combined. The small sample size is susceptible to chance and the level of evidence is insufficient. Second, the follow-up period of this study was just over 3 years, and in fact the 5-year survival rate for stage I lung cancer can be over 80%, so it is difficult to see a difference in survival at 3 years for early stage lung cancer. Third, the surgical group in this study was dominated by open lobectomy (70.3%) with high perioperative complications, which is not representative of modern minimally invasive lumpectomy lobectomy. More importantly, the mortality rate of surgical patients in this study (6.25%) was significantly higher than the actual situation, even reaching 8 times the American Association for Thoracic Surgery lumpectomy database for lung cancer (0.8%)! Presumably, the reason for this is either a problem with the surgical technique or too severe bias in the enrolled patients. This would not be credible even if the study was completed, as it would not truly represent the response of the early lung cancer population to both treatments. Fourth, pathologic verification was not required for enrollment in the ROSEL study, and 14 patients had no pathologic findings at enrollment, including 1 of 6 patients who had surgery and an unknown percentage of benign nodules in the 8 patients treated with radiation therapy, which may have resulted in an overestimation of the efficacy of radiation therapy. Fifth, also in the ROSEL study, which contained 3 cases (11.1%) of non-lobectomy, 1 of which had biopsy-only surgery, 1 failed resection, and 1 wedge resection for benign nodes, was not the standard procedure for surgical treatment of lung cancer – “lobectomy + mediastinal lymph node dissection “, so the results of radiotherapy versus surgery in this study cannot be extrapolated to the clinical practice of early-stage lung cancer in the real world. Possible blind spots for radiotherapy Going beyond the above study, the choice of SBRT is also risky in terms of the characteristics of early-stage lung cancer. We know that there is a clinical possibility of small tumors with large metastases. For example, we have seen a case where the tumor was very small in size and the clinical stage was basically stage I or IA. But during surgery, the patient was found to have metastases in groups 4, 7, 9 and 12 lymph nodes. For this type of patients, without surgery, these lymph nodes that have metastasized cannot be cleared, the staging is inaccurate, and the subsequent treatment plan must be deviated. This is an unavoidable blind spot in choosing SBRT for early stage lung cancer. The diagnosis of SBRT is based on clinical staging, not the staging after surgical lymph node dissection, and there is a high false-negative rate in the evaluation of mediastinal lymph nodes. Approximately 1 in 10 patients clinically require upward adjustment of clinical staging after surgical treatment. There is also a new view that lung cancer may have the possibility of air cavity spread metastasis. This is a new infiltrative form of lung cancer, which refers to the possibility of tiny airway or air cavity metastases around the tumor. These metastases, however, are not visible preoperatively and can only be detected by pathological examination after it has been removed. Researchers believe that the chance of metastasis through this route can reach 15%-38%, and for these patients, if SBRT treatment is done, there is also a possibility of blind spot and incomplete treatment. Finally, from the perspective of pathological staging, it has been confirmed that different pathological staging of lung adenocarcinoma has different sensitivity to chemotherapy, such as micropapillary type or solid predominant type has significantly higher yield of chemotherapy than other types. However, it is difficult to identify subtypes by transthoracic puncture biopsy alone. The most accurate differential staging often needs to be made after surgery based on pathology. This is a limitation of SBRT treatment. In fact, the 2016 edition of the NCCN non-small cell lung cancer guidelines radiotherapy section treatment principles states that “the evidence provided in this Lancet Oncology study is insufficient to shake the gold standard status of surgery, but can only be seen as a reason to support SBAR in patients who are inoperable or refuse surgery.” Based on the available evidence, minimally invasive surgery for early-stage lung cancer is safe, thorough and effective; it allows for precise staging, guides postoperative adjuvant therapy and makes effective prognostic judgments, and should be the current treatment of choice for early-stage non-small cell lung cancer. However, it must be acknowledged that radiotherapy is also one of the important means of lung cancer treatment, and it is an indispensable treatment option for early-stage lung cancer that cannot tolerate surgery or is unwilling to undergo surgery. In the face of lung cancer, we are comrades in the same trench, and we all expect patients to receive more appropriate and individualized treatment.