My colleague Matt Garabrant just pulled together this great commentary on the potential for SBRT in lung cancer that I wanted to share, as this has the potential to revolutionize lung cancer treatment.
The three major pillars of oncology treatment-surgery, radiation, and medicine-are often entangled in an intricate dance, with oncologists prescribing treatment courses that rely on time-sensitive collaboration between these approaches. When it comes to early-stage lung cancer, however, the historical gold standard for treatment of most early-stage cancer is surgery. Conventional wisdom holds that if you can cut it out, you probably should. And in the instance of stage I cancer in particular, many cases don't even require additional therapy beyond resection.
But as of fairly recently, there has been a growing debate over whether patients with early stage non-small cell lung cancer should receive the "newer" and non-invasive option of stereotactic radiosurgery (coined "SBRT"), or whether they should stick with the conventional approach of surgery. And although NCCN clinical practice guidelines-which still indicate that surgery is the recommended approach for these patients-carry immense weight in the way that patients are treated, in addition to physicians' recommendations, patient choice is a highly malleable variable that increasingly plays into these decisions. And I'd venture to guess that many of you reading this have noticed a billboard, commercial, or other advertisement highlighting the benefits of some advanced radiosurgery technology in your local market. This marketing force is fairly widespread across the country, and lung cancer is one of the fastest growing indications for this modality.
So, in the case of early stage non-small lung cancer, there is still no "right" answer when evaluating these two options. But rarely is there ever a definitive answer in cancer care when comparing two treatment options. What's more important, and perhaps more telling, is to analyze the recent past, taking into account not only the significant increase in the number of early-stage lung cancer patients who have been treated with SBRT in lieu of surgery, but also the growing volume of clinical studies (Aunt Minnie's Radiation Oncology Insider does a nice job of providing an overview of recent trial results) looking into the long-term efficacy and safety of the SBRT approach. These trends, while still relatively nascent, suggest an increasingly important role for SBRT in the management of this disease.
Clearly, the holy grail for answering this underlying question-and one that may in fact fall within the purview of the comparative effectiveness research initiative of our nation's healhcare reform process-lies in having some kind of comparative clinical trial that pits each modality against the other in a prospective, randomized setting. Interestingly enough, MD Anderson in Houston, TX is currently enrolling for a trial to do exactly this. (more can be read about this trial here). However, this is a trailblazing effort in this regard, and one that won't yield long-term results until at least five years following its formal kick-off.
With a growing pool of available, yet not perfectly comparative, data, the question remains: what does the future look like, and what role will SBRT play moving forward? From an overall volumes perspective, SBRT clearly still plays second fiddle to surgery in the vast majority of cases. But it's intriguing to monitor this progress, as the tenor of the field is continually evolving.
And to complicate matters further, the way in which surgeons secure reimbursement for involvement in SBRT procedures has changed significantly; perhaps not for the better. Given the surgeon's role as a critical determinant of how the patient is triaged and treated, this too plays a significant role in the future trajectory of SBRT for lung cancer. But more on that to come later, so stay tuned!