# Surgery Versus Stereotactic Radiotherapy in Patients over 75 Years Treated for Stage IA–IIA NSCLC

## TL;DR

This study compares surgery and stereotactic radiotherapy for elderly lung cancer patients, finding that surgery may offer better long-term survival but with higher initial risk.

## Contribution

The paper introduces a novel decision-making tool to optimize treatment selection for elderly NSCLC patients.

## Key findings

- Surgery showed higher 5-year survival (47.3%) compared to SABR (31.5%), though not statistically significant.
- Early mortality was influenced by gender, WHO status, FEV1, and treatment type.
- Surgery remains preferable for overall survival and recurrence control despite SABR's good tolerance.

## Abstract

Lobectomy with lymph node dissection remains the gold standard for early-stage Non-Small Cell Lung Cancer (NSCLC) but carries a higher early mortality risk, particularly in elderly patients with comorbidities. Stereotactic radiotherapy (SABR) has shown promising local control and tolerance in this population. This retrospective study (2012–2022) compared 127 surgical patients and 85 SABR patients using propensity score matching. Five-year survival was higher in the surgery group (47.3%) than in the SABR group (31.5%), though the difference was not statistically significant (p = 0.068). Factors influencing early mortality included gender, WHO status, FEV1, and treatment type. A novel decision-making tool is proposed to optimize patient selection.

Introduction: Lobectomy with lymph node dissection is the gold standard treatment for stage IA–IIA Non-Small Cell Lung Cancer (NSCLC). Surgery is responsible for higher early mortality but offers better overall long-term survival. The patient population concerned is often elderly and combines the comorbidities of smoking and age. Several trials have shown good results of stereotactic radiotherapy (SABR) in terms of local control and tolerance in elderly subjects. Our objective is to study the survival and regional control of patients over 75 years treated by surgery or SABR for localized NSCLC. Materials and Method: We conducted a single-center retrospective study between January 2012 and December 2022 including elderly patients who received surgery or SABR for NSCLC less than 5 cm in size, N0, M0. A cumulative comorbidity index was calculated for each patient, considering severity and impact of treatment. We performed subgroup analyses using CART method to identify factors impacting survival and early death. Results: After propensity score matching, 127 operated patients were matched to 85 patients treated with SABR. Overall survival at 1 and 5 years for the operated patients was 83.87% and 47.30% compared with 88.8% and 31.5% in the radiotherapy group (p = 0.068). We have identified four factors influencing the incidence of early mortality: gender, World Health Organization Performance status (WHO status), Forced Expiratory Volume in 1 s (FEV1), and treatment group. Conclusions: Surgery seems to remain the standard of treatment in terms of overall survival and locoregional recurrence, in a context where SABR nevertheless provides excellent local control and tolerance in the short and long term. In order to improve patient selection, we are proposing for the first time a tool to aid therapeutic decision-making.