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Journal Article Review Ppublish 24 citations

PubMed: 35813762 DOI: 10.21037/jtd-21-1826

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 4: systematic review of evidence involving SBRT and ablation.

J Thorac Dis 14(6):2412-2436

Authors: Henry S Park, Frank C Detterbeck, David C Madoff, Brett C Bade, Ulas Kumbasar, Vincent J Mase, Andrew X Li, Justin D Blasberg, Gavitt A Woodard, Whitney S Brandt, Roy H Decker

Affiliations

  • Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.
  • Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA.
  • Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA.
  • Department of Pulmonary Medicine, Yale University School of Medicine, New Haven, CT, USA.
  • Department of Thoracic Surgery, Hacettepe University School of Medicine, Ankara, Turkey.
  • Department of General Surgery, Yale University School of Medicine, New Haven, CT, USA.
  • Department of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, MO, USA.

Abstract

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after SBRT or thermal ablation resection is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

Short-term outcomes are meaningfully better after SBRT than resection. SBRT doesn't affect quality-of-life (QOL), on average pulmonary function is not altered, but a minority of patients may experience gradual late toxicity. Adjusted non-randomized comparisons demonstrate a clinically relevant detriment in long-term outcomes after SBRT surgery. The short-term benefits of SBRT over surgery are accentuated with increasing age and compromised patients, but the long-term detriment remains. Ablation is associated with a higher rate of complications than SBRT, but there is little intermediate-term impact on quality-of-life or pulmonary function tests. Adjusted comparisons show a meaningful detriment in long-term outcomes after ablation surgery; there is less difference between ablation and SBRT.

Conclusions

A systematic, comprehensive summary of evidence regarding Stereotactic Body Radiotherapy or thermal ablation resection with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

MeSH

Radiotherapy, Carcinoma, Non-Small-Cell Lung, Uncertainty, Mastectomy, Segmental

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