Pros: After stereotactic ablative radiotherapy for a peripheral early-stage non-small cell lung cancer, radiological suspicion of a local recurrence can be sufficient indication to proceed to salvage therapy
Stereotactic ablative radiotherapy (SABR), also known as “stereotactic body radiation therapy” (SBRT), has revolutionized the treatment of early-stage non-small cell lung cancer (NSCLC), providing an effective treatment option for medically-inoperable patients. Modern advancements in the planning and targeting of radiotherapy have allowed SABR to deliver ablative doses as high as 150 Gy (when converted to 2 Gy per fraction) in a precise and highly conformal manner (1). After SABR, rates of primary tumor control are excellent, in excess of 90% at 5 years (2). These promising results have led to suggestions that SABR may be comparable to the historic gold standard, surgical resection, as first-line treatment in operable patients. Three randomized control trials (RCTs)—the STARS trial, the ROSEL trial and ACOSOG Z4099—attempted to compare SABR and surgical resection, but all closed prematurely due to insufficient enrollment. A pooled analysis of the patients accrued to STARS and ROSEL suggested that, at a minimum, there was equipoise between the two treatments, with significantly better overall survival demonstrated in the patients receiving SABR (3). More robust RCT evidence is still awaited, and at least two RCTs examining this question are ongoing including the STABLE-MATES and SABR-Tooth trials (4).