According to a recent study from The University of Texas MD Anderson Cancer Center, the removal of the entire lobe of the lung in patients with early-stage lung cancer, rather than the partial resection, may offer better overall survival. In addition, stereotactic ablative radiotherapy (SABR) may offer the exact same survival benefit as a lobectomy for some patients. Published in JAMA Surgery, it is the largest population based study ever to review the modalities of modern treatment for early-stage lung cancer.

The American Cancer Society expects that in 2014, 224,210 people in the United States will be diagnosed with lung cancer, of which 159,260 will die from it. Shervin M. Shirvani, M.D., first author of the study, attending radiation oncologist at Banner MD Anderson Cancer Center in Arizona, and an adjunct professor at MD Anderson, says that with the aging baby-boomer population colliding with spiral CT-screening’s acceptance as a screening tool for lung cancer, the diagnosed cases will be much more.

Lung cancer is a typically cancer that is driven by age; it is more frequent in older people. Furthermore, because it is associated with smoking, patients often carry other comorbidities such as chronic obstructive pulmonary disease (COPD), renal failure, and coronary artery disease.

For patients with early-stage disease, there are 3 treatment options: lobectomy, or removal of the entire lobe of lung; sublobar resection, or removal of the part of the lung that contains the tumor; and SABR, a precise form of radiation therapy that usually takes 3 or 5 sessions to be delivered.

“Currently, lung cancer is one of the most common and fatal cancers, and for the foreseeable future it will be one of the major health epidemics our country faces. Yet we don’t have strong evidence-based guidelines for how to best treat the disease — especially when it’s discovered early,” states Shervin M. Shirvani.

Several trials were organized to compare the 3 types of treatment, but there was no participation by patients and physicians and, consequently, none of them reached any conclusions. “In the absence of clinical trials, it was important to analyze observational data from a very large database to compare these three modalities. We wanted to compare lobectomy, the treatment generally thought to be the standard of care, to both the smaller surgery and stereotactic ablative radiotherapy, which does not carry surgical risk, and understand which may be best for this elderly patient population with extensive concurrent illnesses.”

Researchers analyzed the Surveillance, Epidemiology and End Results (SEER) Medicare database looking for patients treated for non-small cell lung cancer (NSCLC) between 2003 and 2009. 9,093 patients were identified, and they all received 1 of the 3 treatments available: lobectomy (7,215 patients, or 79.3 percent); sub lobar resection (1,496 patients, or 16.5 percent); and SABR (382 patients, or 4.2 percent).

Researchers were surprised, finding that the lobectomy was associated with better overall and lung-specific survival when compared to sub lobar resection. “The assumption was that for an elderly patient with a number of co-morbidities, the smaller surgery would be better than a whole lobectomy because there would be fewer surgical complications. Yet, it appears that the ability to eradicate the cancer with the bigger surgery may be more important than minimizing surgical risk,” explained Shirvani.

Patients with similar disease conditions treated with lobectomy and SABR were compared and the two modalities were associated with similar overall survival and lung-cancer specific therefor SABR may be a promising alternative to surgery for patients with very advanced age or with multiple medical problems.

“Clearly, the incidence of early-stage lung cancer will increase dramatically in the next few years, and we need to be prepared to treat patients in the right way — balancing the effectiveness versus risk of treatment in an elderly population,” explained Benjamin Smith, MD, associate professor, Radiation Oncology at MD Anderson, hoping that physicians begin to rethink their thoughts about a smaller surgery being better-suited for this patient population.