Drew Moghanaki MD, MPH , Tomer Karas MD , Robert D. Timmerman MD , Robert B. Cameron MD , Timothy A. Ritter PhD , Hairong Shi PhD , Matthew K. Leiner MS , Hua Feng PhD , Vicki L. Skinner RN, MSN , Lisa Robin MA , Cheryl Odle MBA , Tom Sindowski BS , Amanda J. Snodgrass PharmD , Grant D. Huang MPH, PhD , Domenic J. Reda PhD , David H. Harpole MD , Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy Study Team
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Abstract
Background
Standard-of-care treatment options for stage I non-small cell lung cancer (NSCLC) include surgery and stereotactic body radiation therapy (SBRT). Notwithstanding a lack of prospective evidence demonstrating superior long-term survival with either of these treatments, evidence-based guidelines currently recommend only surgery for patients with operable disease and to limit SBRT for patients with inoperable disease.
Research Question
Do surgery or SBRT lead to superior survival rates for operable stage I NSCLC?
Study Design and Methods
A phase 3 randomized clinical trial was designed to compare the overall survival (OS) rates after surgery or SBRT for stage I NSCLC. Eligible participants must have biopsy-confirmed NSCLC measuring ≤ 5 cm in maximum diameter located > 1 cm from the trachea, proximal bronchial tree, esophagus, and spinal cord. Participants must be staged with fluorodeoxyglucose PET scans with mandatory biopsies of all radiographic areas concerning for regional or distant metastatic disease. The planned accrual is 670 patients to detect a 10% absolute benefit in 5-year OS with surgery or SBRT. Secondary outcome measures include patient-reported quality of life, respiratory function, health state utilities, patterns of lung cancer relapse, and causes of mortality by independent adjudication.
Results
The study was initiated in April 2017 with a planned ramp-up phase at six Veterans Affairs medical centers. Adapted recruitment interventions contributed to overcoming historical barriers to randomizing eligible participants between surgery and SBRT, and the study was expanded to 16 sites in May 2019. As of July 5, 2023, 280 of 670 planned participants have been enrolled.
Interpretation
The final results are expected to clarify the role of SBRT in lieu of surgery for patients with operable stage I NSCLC and to facilitate more informed discussions about these treatment options.
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