Real-world Decision-making Process for Stereotactic Body Radiotherapy Versus Minimally Invasive Surgery in Early-stage Lung Cancer Patients.

Objective: To generate a prediction model for selection of treatment modality for early-stage non-small cell lung cancer (NSCLC).
Summary Background Data: Stereotactic body radiotherapy (SBRT) and minimally invasive surgery (MIS) are used in the local treatment of early-stage NSCLC. However, selection of patients for either SBRT or MIS remains challenging, due to the multitude of factors influencing the decision-making process.
Methods: We analyzed 1291 patients with clinical stage I NSCLC treated with intended MIS or SBRT from January 2020 to July 2023. A prediction model for selection for SBRT was created based on multivariable logistic regression analysis. The receiver operating characteristic curve analysis stratified the cohort into 3 treatment-related risk categories. Post-procedural outcomes, recurrence and overall survival (OS) were investigated to assess the performance of the model.
Results: In total, 1116 patients underwent MIS and 175 SBRT. The prediction model included age, performance status, previous pulmonary resection, MSK-Frailty score, FEV1 and DLCO, and demonstrated an area-under-the-curve of 0.908 (95%CI, 0.876-0.938). Based on the probability scores (n=1197), patients were stratified into a low-risk (MIS, n=970 and SBRT, n=28), intermediate-risk (MIS, n=96 and SBRT, n=53) and high-risk category (MIS, n=10 and SBRT, n=40). Treatment modality was not associated with OS (HR of SBRT, 1.67 [95%CI: 0.80-3.48]; P=0.20).
Conclusion: Clinical expertise can be translated into a robust predictive model, guiding the selection of stage I NSCLC patients for MIS versus SBRT and effectively categorizing them into three distinct risk groups. Patients in the intermediate category could benefit most from multidisciplinary evaluation.
Competing Interests: Disclosures: Prasad S. Adusumilli declares research funding from ATARA Biotherapeutics, is a scientific advisory board member and consultant for ATARA Biotherapeutics, Bayer, Bio4T2, Carisma Therapeutics, Imugene, ImmPactBio, Johnson & Johnson, Orion, Outpace Bio, has patents, royalties, and intellectual property on mesothelin-targeted chimeric antigen receptor and other T-cell therapies, which have been licensed to ATARA Biotherapeutics, and has an issued patent method for detection of cancer cells using virus and pending patent applications on PD-1 dominant negative receptor, a wireless pulse-oximetry device, and an ex vivo malignant pleural effusion culture system. Daniel Gomez receives research funding from AstraZeneca and Varian. He has received personal fees from Varian, AstraZeneca, GRAIL, Johnson & Johnson, Medtronic, Physicians Education Resource, and Regeneron. Daniela Molena serves on a steering committee for AstraZeneca, as a consultant for Johnson & Johnson, Bristol-Myers Squibb, AstraZeneca, and Boston Scientific, and has been an invited speaker for Merck and Genentech. Bernard J. Park serves as a consultant for Intuitive Surgical, CEEVRA, Medtronic, and Becton Dickinson. Matthew J. Bott is a consultant for AstraZeneca Pharmaceuticals, Iovance Biotherapeutics, and Intuitive Surgical and receives research support from Obsidian Therapeutics. Andreas Rimner served on a steering committee for Merck, served as a consultant for AstraZeneca and Merck, and received grant support (institutional) from Varian Medical Systems, Boehringer Ingelheim, AstraZeneca, Merck, and Pfizer, payments from NIH/Coordinating Center for Clinical Trials. Valerie W. Rusch reports grant support (institutional) from Genelux and Genentech, travel support from Intuitive Surgical, and travel support and payments from NIH/Coordinating Center for Clinical Trials. Smita Sihag is a member of the AstraZeneca Advisory Board. James M. Isbell has served as an advisory board member for AstraZeneca and Merck, as an uncompensated steering board member for Genentech, has received institutional research support from ArcherDx/Invitae, Guardant Health, GRAIL, and Intuitive Surgical and travel support from Intuitive Surgical, and has equity/ownership interest in LumaCyte. David R. Jones is a member of the Advisory Council for AstraZeneca and receives research grant support from Merck. Gaetano Rocco has financial relationships with Scanlan International, Medtronic, and Merck. The other authors have no conflict of interest to disclose.
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