Surgical Resection vs. Stereotactic Ablative Radiotherapy for Early-Stage Lung Cancer: Which Is the Better Choice?

Understanding Stereotactic Ablative Radiotherapy (SABR)

Stereotactic ablative radiotherapy (SABR), also known as stereotactic body radiation therapy (SBRT), is a highly precise form of radiation treatment designed to deliver high-dose radiation directly to tumors outside the brain—particularly in the lungs—while minimizing exposure to surrounding healthy tissues. This advanced technique enables oncologists to target early-stage non-small cell lung cancer (NSCLC) with exceptional accuracy, making it a compelling alternative for patients who may not be ideal candidates for surgery.

The Evolution of SABR in Early-Stage Lung Cancer Treatment

In 2004, the University of Texas MD Anderson Cancer Center (MDACC) initiated pioneering research into the use of SABR for early-stage lung cancer, initially focusing on patients deemed inoperable due to cardiopulmonary comorbidities. By 2009, Dr. Zhongxing Liao's team launched the international, multicenter, randomized phase III STARS trial, evaluating SABR versus surgical resection in operable stage I NSCLC patients. Around the same time, the Netherlands began a similar trial called ROSEL, aiming to compare these two approaches head-to-head.

Challenges in Clinical Trial Enrollment and Combined Analysis

Despite their scientific rigor, both the STARS and ROSEL trials faced slow patient accrual and were ultimately terminated early. To maximize the available data, Dr. Liao's team conducted a pooled intention-to-treat (ITT) analysis combining results from both studies. This analysis included 59 patients—31 in the SABR group and 28 in the surgery group—with a primary endpoint of overall survival (OS).

The findings were striking: at three years, the OS rate was 95% in the SABR group compared to 79% in the surgical group (P = 0.037). Recurrence-free survival rates were comparable—86% versus 80% (P = 0.54). Notably, there were no grade 4 adverse events or treatment-related deaths in the SABR arm, whereas the surgery group reported one procedure-related death and 12 cases of grade 3–4 complications. These results, published in The Lancet Oncology in 2015, suggested that SABR could offer superior survival outcomes with significantly lower toxicity than surgery.

Limitations and the Need for Further Evidence

While promising, the pooled analysis had limitations—including a small sample size and relatively short follow-up duration. Additionally, advances in minimally invasive thoracic surgery, such as video-assisted thoracoscopic lobectomy with mediastinal lymph node dissection (VATS L-MLND), have improved surgical safety and recovery times, prompting renewed debate over optimal treatment selection.

Long-Term Outcomes from the Revised STARS Study

To address these concerns, Dr. Liao's team conducted a prospective single-arm analysis based on a revised version of the STARS trial (revised STARS). This updated study focused on long-term outcomes, particularly five-year survival, and involved a larger cohort of patients treated with SABR between September 2015 and January 2017 (n = 80).

Dosage and Delivery Protocols

Patients received either 54 Gy in three fractions for peripheral tumors or 50 Gy in four fractions for central lesions, with simultaneous integrated boosts up to 60 Gy when needed. The primary endpoint was three-year overall survival, with non-inferiority defined as a hazard ratio (HR) upper bound of less than 1.965 and a difference in 3-year OS of no more than 12% compared to VATS L-MLND.

Survival and Safety Results

After a median follow-up of 5.1 years, the 3-year and 5-year OS rates in the SABR group were 91% and 87%, respectively. In contrast, the VATS L-MLND group showed nearly identical survival rates—91% at 3 years and 84% at 5 years. The adjusted multivariable analysis revealed no significant difference in OS between the two groups (HR = 0.86; 95% CI: 0.45–1.65; P = 0.65). Lung cancer–specific survival was also comparable: 92% (SABR) vs. 93% (surgery) at five years (P = 0.69).

Importantly, SABR demonstrated excellent tolerability: no grade 4–5 toxicities occurred, and only isolated cases of grade 3 dyspnea, grade 2 pneumonitis, and grade 2 pulmonary fibrosis were reported. These findings, published in The Lancet Oncology in 2021, confirmed that SABR is non-inferior to VATS surgery in terms of long-term survival for operable stage Ia NSCLC.

Quality of Life and Cost-Effectiveness Considerations

Beyond survival metrics, quality of life plays a crucial role in treatment decision-making. All surgical patients experienced at least grade 2 pain or inflammation post-operation, and over 30% developed grade 3 or 4 cardiopulmonary complications. In contrast, SABR is non-invasive, typically completed within one to two weeks, and associated with minimal downtime. From both patient comfort and economic perspectives, SABR offers clear advantages in reduced hospitalization, faster recovery, and lower healthcare costs.

Key Clinical Implications and Patient Selection

When survival outcomes are statistically equivalent, clinicians must weigh procedural risks, patient preferences, and individual health profiles. Surgical resection remains advantageous in certain scenarios: it allows real-time pathological assessment of the tumor and regional lymph nodes, enabling immediate staging and guiding adjuvant therapies like chemotherapy or radiation if occult nodal disease is discovered.

On the other hand, SABR carries a slightly higher risk of local recurrence—though recent evidence suggests this does not necessarily impact overall survival. For instance, the JCOG0802 trial found that segmentectomy had twice the local recurrence rate of lobectomy but resulted in better long-term survival, likely because patients underwent timely salvage treatments upon recurrence, including repeat resection, radiation, or management of second primary cancers.

Notably, the local recurrence rate after SABR for early-stage NSCLC is remarkably low—only about 1.3%. And should recurrence occur, approximately 60% of patients can still achieve curative outcomes through salvage interventions. Therefore, close monitoring via regular imaging and multidisciplinary follow-up is essential regardless of initial treatment modality.

A Multidisciplinary Approach to Optimal Care

Modern lung cancer care demands collaboration across specialties. Thoracic surgeons, radiation oncologists, medical oncologists, pulmonologists, and radiologists should jointly evaluate each case to determine the most appropriate strategy. Factors such as tumor size and location, pulmonary function, cardiac health, age, and patient preference all influence the final decision.

For elderly patients or those with compromised heart or lung function, SABR presents a safer, less invasive option with excellent survival outcomes and fewer complications. Meanwhile, younger, healthier individuals may opt for surgery to gain comprehensive staging information and potentially reduce long-term recurrence risk.

Looking Ahead: Personalized Medicine in Early-Stage Lung Cancer

As technology continues to evolve—from robotic-assisted surgery to adaptive radiotherapy and AI-driven imaging analysis—the line between "curative" and "minimally invasive" blurs. The choice between surgery and SABR is no longer binary but part of a personalized treatment continuum. With robust evidence supporting both modalities, the focus now shifts toward tailoring therapy to the individual rather than adhering to a one-size-fits-all approach.

In conclusion, stereotactic ablative radiotherapy has emerged as a powerful, non-surgical alternative for early-stage lung cancer, offering survival rates on par with surgery while preserving quality of life. As clinical guidelines continue to integrate these findings, shared decision-making between physicians and patients will remain paramount in delivering truly patient-centered care.