To cut or not to cut.

That has been the question of late for the definitive treatment of early stage non-small cell lung cancer (NSCLC). With lots of good data for either resection or stereotactic body radiation (SBRT), it seems like the easy answer would be a randomized trial. On that front, we’ve had a swing and a miss time (ROSEL), and time (STARS), and time (RTOG 1021) again due to consistent big fat failures to accrue. But that doesn’t mean we struck out. We did the best we could with pooled data from ROSEL (accrued 22 of an estimated 960...yikes) and STARS (accrued a whopping 36), which each had similar inclusion criteria (cT1-2 <4 cm), and the big finale showed 17 of 18 SBRT patients were alive at 3 years numerically outweighing resection. So, yeah. Besides feeling a bit sick over how much money was probably spent to give us this result, we’re also left with a lot of questions. Last week brought us a large (read: >4K patients) retrospective VA database analysis aimed to provide clarity. It reported that early-stage lung cancer-specific death at 5 years is significantly lower with lobectomy (23%)--but not sublobar resection (32%)--when compared to SBRT (45%). The HUGE elephant in the room? The whole retrospective part. Meaning most patients probably got SBRT after getting a hard pass from surgeons, a stipulation supported by the 5 year overall survival rates among patients who received lobectomy (70%) versus SBRT (44%). All we can do is hope to get back to you in 2027...that is if open clinical trials can accrue with more VALOR.