Collaborating to assess the role of stereotactic body radiation therapy in medically operable stage I non-small cell lung cancer

We appreciate the editorial by Drs. Stokes and Rusthoven about our recent publication that compared the outcomes of patients treated with either a video-assisted thoracoscopic (VATS) lobectomy or stereotactic body radiation therapy (SBRT) for stage I non-small cell lung cancer (NSCLC) at a single Veterans Affairs (VA) medical center (1,2). Their comments shed an important light on the dilemma of “confounding by indication” that can undermine retrospective comparisons of patients who are treated according to guidelines that limits access to one of the treatments (SBRT) to only those who are unfit for the preferred standard of care treatment (lobectomy). We recognize that this may have contributed to our findings that showed better 3-year overall and recurrence-free survival with VATS lobectomy as compared to SBRT in our propensity-matched analysis, especially because the majority of our SBRT patients had been considered medically inoperable. Therefore, we agree with their conclusions that our data, or indeed any retrospective analysis of this nature, cannot rule out a potential role for SBRT in certain operable patients