# Comparison of Stereotactic Body Radiotherapy and Surgery for Stage I Lung Cancer: A Multidisciplinary Cohort Study Utilizing Propensity Score Overlap Weighting and AI-Based CT Imaging Analysis

## TL;DR

This study finds that stereotactic body radiotherapy and surgery are similarly effective for early-stage lung cancer, especially when considering patient-specific factors.

## Contribution

The study introduces AI-based CT imaging analysis combined with propensity score overlap weighting to compare SBRT and surgery for lung cancer.

## Key findings

- SBRT and surgery showed no significant differences in 5-year recurrence or survival rates.
- AI-based CT analysis identified a solid tumor diameter threshold linked to higher recurrence for both treatments.
- Overlap weighting balanced baseline differences, supporting the clinical value of SBRT for ineligible surgical patients.

## Abstract

This study compares stereotactic body radiotherapy (SBRT) and surgery in patients with stage I non-small cell lung cancer (NSCLC), using a robust overlap-weighted propensity score approach to address disparities in baseline characteristics. By incorporating artificial intelligence (AI)-based Chest CT features through computer-aided detection (CAD), the study provides a novel analysis of radiological tumor characteristics. No statistically significant differences in outcomes were found between SBRT and surgery, even after stratifying by tumor diameter, lobar location, or pleural attachment. Conducted in South Korea, a country with advanced lung cancer screening practices, the study highlights the clinical value of SBRT, especially for patients with comorbidities or limited surgical options. These findings may support more inclusive and personalized treatment strategies for early-stage lung cancer.

Background: With rising life expectancy and widespread lung cancer screening, early-stage non-small cell lung cancer (NSCLC) incidence has increased. While surgery is the standard treatment for operable stage I NSCLC, many patients are ineligible due to age or comorbidities. Stereotactic body radiotherapy (SBRT) has achieved good primary tumor control rates and overall survival. This study compares the outcomes of SBRT and surgery for stage I NSCLC using propensity score overlap-weighted dataset. Methods: This retrospective study analyzed clinical stage I NSCLC patients treated at a tertiary hospital from 2012 to 2021. Baseline differences between SBRT and surgery groups were adjusted using overlap weighting. AI-based CT analysis (CT AI-CAD) assessed tumor characteristics, verified by radiologists. Primary outcomes were 5-year cumulative incidence of recurrence and overall survival, with subgroup analyses based on tumor features. Results: Of 1474 patients, 1258 underwent surgery, and 216 received SBRT. After overlap weighting, baseline characteristics were well balanced. The 5-year cumulative incidence of recurrence and OS showed no statistically significant differences between SBRT and surgery groups (recurrence: 16.2% vs. 16.1%; OS: 80.5% vs. 82.9%). Further AI-based CT subgroup analysis showed no significant differences in recurrence rates across tumor features. A solid tumor diameter associated with a significant increase in recurrence was identified as 16.6 mm for SBRT and 18.6 mm for surgery. Conclusions: After overlap weighting, SBRT and surgery showed no statistically significant differences in treatment outcomes in stage I NSCLC. These findings may help guide the timing and selection of safe and effective treatment approaches.