Stereotactic Radiotherapy (SBRT), also known as Stereotactic Ablative Radiotherapy (SABR), is a special radiotherapy technique in which a high dose of radiation therapy is precisely projected onto an extracranial tumor lesion so that the tumor receives a high dose and the normal tissues around the tumor receive a low dose. What is the choice between surgery and stereotactic radiotherapy for early stage lung cancer? In 2004, MDACC started a study of SABR in the treatment of early-stage lung cancer, initially for patients who could not undergo surgical resection due to cardiopulmonary complications. 2009, Prof. Zhang Yujiao’s team also conducted an international multicenter, randomized, controlled, phase III clinical study (STARS) on the treatment of SABR in patients with operable stage I non-small-cell lung cancer (NSCLC) and in 2008, the Netherlands also conducted a study of SABR in the treatment of early-stage NSCLC in a randomized controlled clinical study (STARS). 2008, a similar multicenter randomized controlled phase III clinical study (ROSEL) was conducted in the Netherlands. Both studies were closed early due to slow enrollment. Prof. Yujiao Zhang’s team conducted a pooledanalysis of the intention-to-treat (ITT) populations from these two studies, with the primary study endpoint being overall survival (OS). A total of 59 patients were enrolled in the study and randomly assigned to the SABR group (n=31) and the surgical treatment group (n=27). The results showed that the 3-year OS rates were 95% and 79% (P=0.037), respectively; the 3-year recurrence-free survival rates were 86% and 80% (P=0.54).In the SABR group, there was 1 local recurrence, 4 local lymph node recurrences, and 1 distant metastasis; and in the surgical group, 1 local lymph node recurrence and 2 distant metastases.In the SABR-treated group, there were no grade 4 adverse events or treatment-related deaths; in the surgical treatment group, 1 patient died from surgical complications and 12 patients had grade 3-4 treatment side effects. The study showed that SABR is another treatment option, in addition to surgery, for patients with resectable stage I lung cancer. The results of this study were published in The LancetOncol in 2015. What is the choice between surgery and stereotactic radiotherapy for early stage lung cancer? 3-year OS rates and recurrence-free survival in the SABR and surgical treatment groups. Image from LancetOncology.2015Jun;16(6):630-637. Due to the challenges of patient enrollment in clinical stage III RCTs and the development and popularity of minimally invasive thoracic surgery in recent years, there are significant limitations in the previous combined analysis that demonstrated a higher patient survival rate for SABR versus surgery for early-stage NSCLC, despite the fact that that analysis had significant limitations. For example, the number of patient cases enrolled in the analysis was small and the follow-up time was short. In view of these factors, Prof. Zhang Yujiao’s team conducted a prospective analysis of the revised STARS study (revisedSTARS). This analysis reports the long-term follow-up results (5 years) of the revisedSTARS study, in which the SABR treatment group was recalculated with a larger sample size and compared with a group of prospectively enrolled cohort patients from the same time period at the same institution (undergoing thoracoscopic surgical lobectomy with mediastinal lymph node dissection: VATSL-MLND) in a protocol-specified propensity-matched ( propensity-matched) analysis. This single-arm prospective analytic study was completed at MDACC and excluded patients with previous combined analyses.The SABR treatment dose was 54 Gy given three times (peripheral lesions) or 50 Gy given four times (central tumors; 60 Gy for whole tumor synchronous augmentation therapy). The primary focus of the study was the 3-year OS rate. For propensity-matched analysis, the study applied a surgical patient cohort from the MDACC Thoracic and Cardiovascular Surgery’s prospectively registered, independent review board-approved database of all clinical stage I NSCLC patients treated with VATSL-MLND during the enrollment period of this study. Patients could be considered non-inferior if the 3-year OS rate after SABR treatment was 12% or less than after VATSL-MLND and the upper limit of the 95% CI for HR was <1.965. From September 2015 to January 2017, 80 patients were included in the efficacy and safety analysis. The median follow-up time was 5.1 years. The results showed that the 3- and 5-year OS in the SABR group were 91% and 87%, respectively; SABR treatment was well tolerated, with no grade 4-5 toxicity, one case (1%) each of grade 3 dyspnea, grade 2 pneumonia, and grade 2 pulmonary fibrosis, and no serious adverse events. The 3- and 5-year OS rates of patients in the surgical treatment group were 91% and 84%, respectively. Noninferiority was established because the 3-year OS rate after SABR treatment was not lower than that observed in the VATSL-MLND group. By multivariate analysis, there was no significant difference in OS rate between the two groups (HR=0.86, 95% CI 0.45-1.65, P=0.65); while the 5-year lung cancer-specific survival rates were 92% and 93%, respectively (P=0.69). The study suggests that long-term survival after SABR treatment is not lower than that of VATSL-MLND treatment for patients with operable stage Ia NSCLC, and that SABR has therapeutic value for this group of patients, but multidisciplinary management of patients is strongly recommended. The results of the study were published in September 2021 in LancetOncol, The Lancet-Oncology. What is the choice between surgery and stereotactic radiotherapy for early stage lung cancer? 5-year lung cancer survival and recurrence-free survival in the SABR and VATSL-MLND groups. Image from: LancetOncology.2021;22(10):1448-1457. In the prospective analysis of the study, there was a significant difference in the quality of life of the patients, despite the fact that patient survival was similar for both treatments. All patients treated with surgery experienced grade 2 or higher adverse events such as pain and inflammation, and more than 30% had grade 3 or 4 cardiopulmonary complications. In terms of quality of life and healthcare costs, SABR treatment offered significant advantages. In view of the above findings, physicians should fully communicate with patients and their families on how to choose appropriate treatment options for future patients. In the absence of significant differences in survival, for patients, especially the elderly and those with cardiopulmonary dysfunction, the risk of moderate-to-high surgical complications with surgical treatment is about 20% to 50%, and the mortality rate at 90 days postoperatively is about 0 to 5%, but the advantage is the ability to more adequately and in real time to field the lesion and to clear the lymph nodes. In contrast, SABR treatment is non-invasive, and with proper selection and application, the rate of more than moderate complications can be controlled at less than 5%, and death due to complications can be completely avoided. It should be noted that surgical resection is more helpful in detecting occult lymph node metastasis, and postoperative radiotherapy and chemotherapy can be carried out in a timely manner, thus helping to reduce tumor recurrence in patients. For patients treated with SABR, if local or lymph node recurrence occurs, as long as it is detected in time, the probability of being cured again is still up to 60%, which does not have much impact on the survival rate of the patients; meanwhile, among primary early lung cancer lesions that have been treated with SABR, the probability of recurrence is only 1.3%. Regardless of the treatment received, patients must be followed up rigorously. We are often concerned that there are more local recurrences in the SABR group compared to the surgical group, and whether such recurrences affect the survival prognosis of patients. The recent JCOG0802 study tells us that the local recurrence rate in the segmentectomy group was significantly two times higher than that in the lobectomy group, but the long-term survival advantage of segmentectomy over lobectomy may be due to the fact that the resection was less extensive in the segmentectomy group, and the postoperative follow-up suggests that more patients with segments of the lungs underwent additional intensive treatments, including resection of recurrent lesions, radiotherapy, or a second primary cancer. These may not actually affect patient survival. With advances in medical technology, minimally invasive surgery has replaced traditional open-heart surgical treatment as the standard surgical procedure for resection of lung nodules. There has been a benevolent split between the various options as to how to choose treatment for early stage lung cancer. On the whole, one more choice is also one more help for patients. How to make appropriate treatment choices for patients according to their physical conditions and disease characteristics requires the comprehensive participation of various disciplines including thoracic surgery, radiotherapy and oncology.