Surgery was superior to stereotactic radiation for early non-small cell lung cancer, even in the setting of surgical delays brought on by COVID-19.

“Deciding whether to offer, postpone, or even cancel treatments to patients has become a crucial recurrent dilemma for lung cancer specialists in the pandemic era,” Christopher W. Towe, MD, and colleagues wrote. “The European Society for Medical Oncology (ESMO) guidelines for operable non-small cell lung cancer (NSCLC) T1aN0M0 during the COVID-19 pandemic suggest that stereotactic radiation (SBRT) is an ‘alternative if no surgical capacity is available.’”

While SBRT has been compared with surgery among high-risk patients, comparisons among patients who are eligible for surgery is limited, according to the researchers. “Therefore, the utility of SBRT in low-risk patients with lung cancer during the pandemic is not well-defined yet,” they wrote in the Journal of Surgical Research.

To assess this research gap, Dr. Towe and colleagues compared oncologic outcomes with delayed surgical resection versus early SBRT among patients with early-stage NSCLC (eNSCLC) and limited comorbidities. The aim of the study was “to model possible changes in resource allocation during the [COVID-19] pandemic.”

The investigators utilized the National Cancer Database to identify patients with eNSCLC who underwent surgery or SBRT, excluding individuals older than 80 or who had comorbidities.

Surgery Associated With Improved Survival

Dr. Towe and colleagues included 6,720 patients with eNSCLC in the analysis. Most patients (N=6,008; 89.4%) underwent surgery; far fewer patients (N=712; 10.6%) were treated with SBRT. Both cohorts were composed primarily of White patients and included fewer men than women. Patients treated with SBRT were older than patients undergoing surgery (median age, 71 vs 66; P<0.001).

Among patients who underwent surgery, a time to surgery of more than 30 days was associated with poorer survival (HR>1.4, P≤0.013) compared with surgery within 14 or fewer days (Table).

Compared with SBRT, surgery was associated with superior survival at all time points examined: 0-30 days, 31-60 days, 61-90 days, and more than 90 days (all P<0.001). In a propensity-matched cohort that included 256 pairs of patients, delayed surgery (>90 days) remained associated with improved overall survival relative to early SBRT (5-year survival, 76.9% vs 32.3%; HR=0.266; P<0.001).

Dr. Towe and colleagues also examined the possible effect of different surgical techniques. “Both sublobar resection (HR=0.507; P<0.001) and lobectomy (HR=0.355; P<0.001) provided superior survival benefit over SBRT,” they wrote.

Surgical Resection ‘Standard of Care’ in Early NSCLC

The investigators noted that, while all patients with lung cancer would “ideally” receive expedited treatment, delays in treatment do happen, including the delays brought on by the COVID-19 pandemic.

The onset of the pandemic led “some to suggest that SBRT should be performed if surgery was unavailable,” Dr. Towe and colleagues wrote. “Our study demonstrated that, relative to SBRT, surgical resection is associated with superior survival among patients [younger] than 80 without significant comorbidity in [eNSCLC].”

The study team acknowledged the limitations of their research, including that the data did not include details about why a particular treatment was chosen (eg, surgeon preference, hospital resources, etc.). Additionally, significant differences in median age and the use of private insurance could result in unseen differences in factors related to the need for, or the choice of, SBRT, all of which would confound analyses of long-term survival.

Despite these limitations, however, and regardless of the delays brought on by the COVID-19 pandemic, “surgical resection should remain the standard of care for operable, early-stage NSCLC,” the researchers wrote. “SBRT could be an alternative only if surgical capacity is not available and [if] inferior overall survival of SBRT is clearly communicated with the patients.”