SBRT versus surgery for early-stage NSCLC: A propensity-matched systematic review, meta-analysis, and meta-regression.

Abstract

e20037 Background: For early-stage non-small cell lung cancer (NSCLC), surgery is preferred for operable patients, while stereotactic body radiotherapy (SBRT) is standard for inoperable cases. This meta-analysis compared survival and disease control outcomes using propensity-matched data to minimize confounding. Methods: A systematic review and meta-analysis was conducted per PRISMA guidelines, including propensity-matched studies comparing SBRT and surgery for stage I-II NSCLC through June 2025. Pooled hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), local control (LC), distant control (DC), and recurrence. Results: 34 propensity-matched studies comprising 14,224 patients were included. Surgery was associated with improved overall survival (pooled HR = 0.70, 95% CI 0.54–0.91) and cancer-specific survival (HR = 0.72, 95% CI 0.52–0.99). Fixed-time analyses reinforced these findings, showing significantly higher 1-year (OR = 1.33) and 3-year (OR = 1.89) survival with surgery, with the benefit increasing over longer follow-up (P for subgroup difference = 0.039). Surgery also demonstrated superior disease-free survival (OR = 1.99, 95% CI 1.49–2.64) and local control (HR = 0.25, 95% CI 0.09–0.64; OR = 2.57, 95% CI 1.66–3.99). In contrast, distant control did not differ significantly between treatments (OR = 1.30, 95% CI 0.99–1.72). Local recurrence was more common after SBRT (OR = 2.96, 95% CI 1.56–5.61). Meta-regression showed no significant temporal trend in outcomes. Residual demographic differences persisted, with SBRT patients being older on average (73.3 vs. 70.3 years). Conclusions: For operable early-stage NSCLC, surgical resection provides superior OS, CSS, DFS, and LC compared to SBRT, with the survival benefit becoming more pronounced over longer follow-up. SBRT remains a vital, effective option for inoperable patients, offering excellent short-term control with lower procedural risk. The findings underscore the importance of surgical staging and complete tumor removal for maximizing long-term outcomes in fit patients. Multidisciplinary, patient-centered decision-making, considering comorbidities, functional status, and diagnostic needs, is essential for optimal treatment selection. Summary of meta-aAnalysis results. Outcome Hazard Ratio (95% CI) Odds Ratio (95% CI) Favors Overall Survival 0.70 (0.54–0.91) 1.67 (1.43–1.96) Surgery Cancer-Specific Survival 0.72 (0.52–0.99) 1.99 (1.47–2.70) Surgery Disease-Free Survival - 1.99 (1.49–2.64) Surgery Local Control 0.25 (0.09–0.64) 2.57 (1.66–3.99) Surgery Distant Control 0.28 (0.11–0.73) 1.30 (0.99–1.72) Neutral Locoregional Control 0.45 (0.28–0.72) 0.64 (0.14–3.00) Surgery (HR only)