Surgery versus SABR for resectable non-small-cell lung cancer – Part 5 of 9

This is a letter in response to the article by Chang and colleagues. The authors focus on two key points: the difference in 3-year survival between the two treatment groups and the proposed use of endobronchial ultrasound (EBUS) in combination with SABR to decrease the likelihood of false-negative results from imaging for clinical staging of lymph nodes. First, the original article found a 3-year survival rate of 79% in the surgical arm and 95% in the SABR arm. They point out that this survival difference is driven by the small sample size of the STARS trial in which all 20 patients in the SABR arm survived and 5 of 16 patients in the surgical arm died. Furthermore,  although basic baseline characteristics were similar, differences in comorbidities between the two groups were not accounted for. Second, they disagree with using EBUS in the hopes of reducing the false-negative results associated with staging by PET/CT. A recent study demonstrated that the sensitivity of EBUS is 35% in patients with NSCLC who have negative CT and PET/CT. They conclude by disagreeing that surgery can be replaced by SABR and EBUS as staging would likely be inaccurate and for those who are understaged, adjuvant therapy would not be offered thereby worsening prognosis.