• Christopher Cao, Daniel Wang, Caroline Chung, David Tian, Andreas Rimner, James Huang, and David R Jones.
• Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Collaborative Research Group, Macquarie University, Sydney, Australia.
• J. Thorac. Cardiovasc. Surg. 2019 Jan 1; 157 (1): 362-373.e8.

ObjectiveStereotactic body radiation therapy is the preferred treatment modality for patients with inoperable early-stage non-small cell lung cancer. However, comparative outcomes between stereotactic body radiation therapy and surgery for high-risk patients remain controversial. The primary aim of the present meta-analysis was to assess overall survival in matched and unmatched patient cohorts undergoing stereotactic body radiation therapy or surgery. Secondary end points included cancer-specific survival, disease-free survival, disease recurrence, and perioperative outcomes.MethodsA systematic review of relevant studies was performed through online databases using predefined criteria. The most updated studies were selected for meta-analysis according to unmatched and matched patient cohorts.ResultsThirty-two studies were identified in the systematic review, and 23 were selected for quantitative analysis. Surgery was associated with superior overall survival in both unmatched (odds ratio, 2.49; 95% confidence interval, 2.10-2.94; P < .00001) and matched (odds ratio, 1.71; 95% confidence interval, 1.52-1.93; P < .00001) cohorts. Subgroup analysis demonstrated superior overall survival for lobectomy and sublobar resection compared with stereotactic body radiation therapy. In unmatched and matched cohorts, cancer-specific survival, disease-free survival, and freedom from locoregional recurrence were superior after surgery. However, stereotactic body radiation therapy was associated with fewer perioperative deaths.ConclusionsThe current evidence suggests surgery is superior to stereotactic body radiation therapy in terms of mid- and long-term clinical outcomes; stereotactic body radiation therapy is associated with lower perioperative mortality. However, the improved outcomes after surgery may be due at least in part to an imbalance of baseline characteristics. Future studies should aim to provide histopathologic confirmation of malignancy and compare stereotactic body radiation therapy with minimally invasive anatomical resections.Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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