Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO 80045, USA.
Ann Transl Med. 2015 Jul;3(11):149. doi: 10.3978/j.issn.2305-5839.2015.06.15.
The gold-standard therapy for early stage non-small cell lung cancer (esNSCLC) has historically been lobectomy with mediastinal lymph node dissection. However, up to one-third of patients with esNSCLC are considered medically-inoperable due to factors such as advanced age and comorbid illnesses. The past decade has witnessed a dramatic increase in the use of high-dose conformal radiotherapy delivered over 1-5 fractions, synonymously termed stereotactic ablative radiotherapy (SABR) or stereotactic body radiation therapy (SBRT). High rates of tumor control and favorable toxicity profiles have led to the adoption of SABR as the treatment of choice for medically-inoperable patients. Limited but growing data exist using SABR for medically-operable patients who are also candidates for lobectomy. A recent pooled analysis of two multicenter prospective randomized trials, the STARS (NCT00840749) and ROSEL (NCT00687986) protocols, published by Chang and colleagues (PMID 25981812) reported improved overall survival (OS) and reduced toxicity with SABR over lobectomy for medically-operable patients with esNSCLC. In this article we review the outcomes of this analysis in the context of existing radiotherapy and surgical data for NSCLC. Further, we discuss the potential causes and implications of these provocative results, including the shifting balance between oncologic control and treatment-related mortality in comparisons of SABR and surgical resection, termed the Head Start Effect.
早期非小细胞肺癌（esNSCLC）的金标准治疗方法历来是肺叶切除术伴纵隔淋巴结清扫术。然而，多达三分之一的 esNSCLC 患者由于年龄较大和合并症等因素而被认为不适合手术。过去十年，高剂量适形放疗（1-5 次分割）的应用显著增加，同义词为立体定向消融放疗（SABR）或立体定向体部放疗（SBRT）。肿瘤控制率高且毒性谱良好，导致 SABR 被用作不适合手术的患者的治疗选择。对于也适合肺叶切除术的可手术患者，使用 SABR 的有限但不断增加的数据。Chang 及其同事发表的两项多中心前瞻性随机试验（STARS，NCT00840749 和 ROSEL，NCT00687986）的荟萃分析最近报告，对于可手术的 esNSCLC 患者，SABR 比肺叶切除术的总体生存率（OS）更高，毒性更低。在本文中，我们将根据 NSCLC 的现有放疗和手术数据，回顾该分析的结果。此外，我们讨论了这些令人振奋的结果的潜在原因和影响，包括在 SABR 和手术切除的比较中肿瘤控制和与治疗相关的死亡率之间平衡的变化，称为起始效应。
