A Prospective Outcomes and Cost-Effective Analysis of Surgery Compared to Stereotactic Body Radiation Therapy for Stage I Non-Small Cell Lung Cancer

Background To evaluate long-term outcomes, treatment costs, and quality of life associated with curative treatment of newly diagnosed stage I non-small cell lung cancer (NSCLC), by comparing surgery to stereotactic body radiation therapy (SBRT). Methods Multicenter consecutive prospective study of newly diagnosed stage I NSCLC patients independently assigned surgery or SBRT by a multidisciplinary tumor board, recruited prior to therapy initiation (n=59). Outcomes included total hospital charges, toxicities, complications, readmissions, and patient satisfaction/ quality of life (FACT-L). Multivariable logistic regression models analyzed the association of treatment type with dichotomous endpoints controlling for age, Charlson Comorbidity Index (CCI), and pre-treatment FACT-L; multiple linear regression was used for delta FACT-L. Results Of the 55 evaluable patients, 19 (35%) were males and 36 (65%) females. Thirty (55%) patients received SBRT and 25 (45%) received surgery with a mean age of 73 (57-85) and 67 (55-84) years, respectively. Median follow-up time was 514 days after SBRT and 648 days after surgery. The mean CCI for SBRT and surgery patients was 3.87 and 2.36, respectively. SBRT patients experienced significantly greater improvement in quality of life compared to surgery (delta FACT-L, 14, 95%CI, 2 to 26, p=0.0232) after adjusting for baseline FACT-L. CCI but not age, treatment type, or baseline FACT-L was significantly associated with readmissions (OR, 1.42, 95%CI, 1.08 to 2.00, p=0.0226). Interestingly, CCI was significantly lower (2.36±1.66, 3.87±2.84, p=0.0418) yet total hospital charges were significantly greater ($251,759±$215,643, $129,238±$86,588, p=0.0009) for patients receiving surgery verses SBRT. Conclusions Although limitations include small sample size and absence of recurrence data, these analyses justify further evaluation of long-term outcomes, including cost and quality of life, to optimize treatment assignment of early stage NSCLC patients. These observations reveal that, despite targeting patients with higher CCI, SBRT is more cost-effective, with a greater improvement in quality of life than surgery. Trial Registration Central Institutional Review Board (IRB) approval was obtained under expedited review and deemed minimal risk to patients (WCG Clinical IRB00000533 Study 1171593). All participating sites obtained local IRB approval before study initiation. Informed consent was obtained from all patients prior to study entry.