Lung cancer is the leading cause of cancer-related deaths in the United States (US). The majority of lung cancers are diagnosed at advanced stages but with the advent of lung cancer screening, the number of individuals diagnosed with early-stage lung cancer has continued to rise. Within the Veterans Health Administration (VA), approximately 8,000 Veterans are diagnosed with and treated for lung cancer every year. Surgery, including lobectomy, segmentectomy, wedge resection, and sleeve resection with or without the use of minimally invasive approaches, has been considered the standard of care for individuals with early-stage lung cancer who are deemed to be medically operable. Stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) are frequently offered to individuals considered to be medically inoperable for various reasons (due to advanced age or with comorbidities that place them at high risk for severe perioperative complications). Promising results with SBRT/SABR in patients deemed to be medically inoperable have led to studies evaluating the efficacy and long-term outcomes of this therapy as an alternative to surgery in medically operable patients. These results raise questions about definitive treatment options for early-stage lung cancer.
This review addresses important questions regarding the comparative effectiveness of surgery versus SBRT/SABR as well as the current body of evidence for ablative therapies such as radiofrequency ablation, cryoablation, microwave ablation, laser ablation, and brachytherapy in the management of medically operable stage I lung cancer. This topic was nominated by the National Radiation Oncology Program. Additionally, this review provides the background rationale for an ongoing VA Cooperative Study, a randomized trial of surgery versus SBRT (