Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.
Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, California.
Ann Thorac Surg. 2018 Feb;105(2):425-431. doi: 10.1016/j.athoracsur.2017.07.048. Epub 2017 Nov 30.
Stereotactic body radiation therapy (SBRT) has been proposed as a potential alternative to surgery for early lung cancer, although we lack well-powered prospective randomized data comparing these treatments, and existing studies suffer from incomplete information on confounders that can bias results. Here, we evaluated the comparative effectiveness of surgery and SBRT in lung cancer treatment using a large extensively detailed database from the Veteran's Affairs system.
We identified veterans with biopsy-proven clinical stage I non-small cell lung cancer diagnosed between 2006 and 2015 from within the Veteran's Affairs Informatics and Computing Infrastructure. We compared cancer-specific survival among patients receiving lobectomy, sublobar resection, or SBRT using univariable and multivariable competing risk analyses. Multivariable analyses adjusted for confounders including preoperative pulmonary function, smoking status, comorbidity, and staging workup procedures.
In all, 4,069 patients were included (449 SBRT, 2,986 lobectomy, 634 sublobar resection). Unadjusted analysis found higher immediate postprocedural mortality in the surgery groups compared with the SBRT group. The multivariable analysis considering long-term survival found higher cancer-specific mortality for SBRT compared with lobectomy (subdistribution hazard ratio 1.45, 95% confidence interval: 1.09 to 1.94, p = 0.01), although no survival difference between SBRT and sublobar resection (subdistribution hazard ratio 1.25, 95% confidence interval: 0.93 to 1.68, p = 0.15).
Among a large cohort of early stage lung cancer patients, we found that lobectomy had improved survival compared with SBRT, although we found no survival difference between sublobar resection and SBRT. Despite these findings, the potential for unmeasured confounding remains and prospective randomized trials are needed to better compare these treatment modalities.
立体定向体部放射治疗（SBRT）已被提议作为早期肺癌手术的替代方法，尽管我们缺乏比较这些治疗方法的有力前瞻性随机数据，并且现有研究存在可能影响结果的混杂因素的信息不完整。在这里，我们使用退伍军人事务系统中的一个大型详细数据库来评估手术和 SBRT 在肺癌治疗中的比较效果。
我们从退伍军人事务部信息学和计算基础设施中确定了 2006 年至 2015 年间经活检证实的临床 I 期非小细胞肺癌患者。我们使用单变量和多变量竞争风险分析比较了接受肺叶切除术、亚肺叶切除术或 SBRT 治疗的患者的癌症特异性生存率。多变量分析调整了包括术前肺功能、吸烟状况、合并症和分期检查程序在内的混杂因素。
共纳入 4069 例患者（449 例 SBRT、2986 例肺叶切除术、634 例亚肺叶切除术）。未调整分析发现手术组与 SBRT 组相比，术后即刻死亡率较高。考虑长期生存的多变量分析发现 SBRT 组的癌症特异性死亡率高于肺叶切除术组（亚分布危险比 1.45，95%置信区间：1.09 至 1.94，p=0.01），尽管 SBRT 与亚肺叶切除术组之间的生存差异无统计学意义（亚分布危险比 1.25，95%置信区间：0.93 至 1.68，p=0.15）。
在一组大型早期肺癌患者中，我们发现肺叶切除术与 SBRT 相比具有更好的生存结果，尽管我们发现亚肺叶切除术与 SBRT 之间的生存差异无统计学意义。尽管有这些发现，但仍存在无法测量的混杂因素，需要进行前瞻性随机试验才能更好地比较这些治疗方法。
