Stage I non-small cell lung cancer: Improving patient selection for minimally invasive lobectomy or stereotactic ablative radiotherapy based on clinical characteristics

Background: We aimed to identify patient and tumour characteristics associated with differential benefit from minimally invasive lobectomy (MIL) or stereotactic ablative radiotherapy (SABR) for stage I non-small cell lung cancer (NSCLC). Methods: Patients with clinical stage I NSCLC (TNM7), treated with MIL or SABR in 2014-2016, were included in this retrospective cohort study. Propensity score (PS) weighting was used to create a virtual SABR cohort with characteristics comparable to the MIL group. We assessed interactions between treatment type and clinical characteristics affecting overall survival (OS) and recurrence-free survival (RFS). Results: 1211 MIL and 972 SABR patients were included. After PS weighting, the impact of treatment type on OS differed significantly between patients with prior myocardial infarction or heart failure (HR 0.51, 95% CI 0.32-0.82; favouring MIL) versus patients without (HR 1.09, 95% CI 0.70-1.67) (p = 0.02). Moreover, MIL yielded superior OS in patients with both FEV ₁ and DLCO ≥ 80% (HR 0.61, 95% CI 0.30-1.26), while SABR favoured patients with FEV ₁ and/or DLCO < 80% (HR 1.50, 95% CI 0.95-2.36) (p = 0.04). Conclusions: Interactions of treatment type with lung function and with prior myocardial infarction or heart failure impacted OS for patients with stage I NSCLC. These findings warrant validation in other studies to further refine treatment decision-making.