AMSTERDAM – Wide adoption of stereotactic ablative radiation as radiotherapy for elderly patients with stage 1 non–small cell lung cancer in the Netherlands produced a dramatic rise in overall survival during the 2000s.

Dutch national data showed that median overall survival in patients aged 75 year or older with stage I NSCLC that was treated with radiation therapy jumped from 17 months in 2001-2003 to 26 months in 2007-2009 (P = .001), an improvement largely attributable to substantially increased use of sterotactic ablative radiation therapy (SABR), Dr. Cornelis J.A. Haasbeek said at the World Conference on Lung Cancer, which was sponsored by the International Association for the Study of Lung Cancer.

Dutch radiation oncologists began using SABR in 2003, and by 2009 more than 75% of early-stage NSCLC patients who received radiation therapy had it in the form of SABR.

"Our study provides high-level evidence to support the efficacy of modern SABR," said Dr. Haasbeek, a radiation oncologist at Vrije Universiteit Medische Centrum, Amsterdam.

SABR cut the number of treatments needed, compared with conventional radiation therapy, by 5- to 10-fold while also boosting efficacy, and it offers a better option for patients who are too old and frail to undergo surgical resection of their cancer. SABR is also a reasonable option for selected operable patients, said Dr. Suresh Senan, professor and vice-chairman of radiation oncology at Vrije Universiteit Amsterdam and senior investigator of the new report.

"The emerging data say that SABR is an option in patients who do not want to accept the risks of surgery, or for patients told by their surgeons that they have a significantly increased surgical risk. SABR is curative treatment for a frail group, producing excellent local control with very low toxicity," Dr. Senan said in an interview. "Elderly patients who could undergo open surgery should also be informed about SABR as an alternative curative, outpatient modality."

The main drawback of SABR compared with surgery is less-extensive long-term experience. "We have no track record of more than 5 years in a substantial number of patients, so there may still be surprises on recurrences," he said.

"What is important is that patients make a [treatment] decision, and are not told that they are too old for treatment. Surgery has the advantages of allowing for accurate tissue diagnosis and intraoperative staging, and in patients with emphysema, removal of the affected lung can improve lung function," commented Dr. David A. Waller, a thoracic surgeon at Glenfield Hospital in Leicester, England. "The risk [from surgery] is the general anesthesia, especially in patients with existing cardiovascular morbidity. It’s the patients with comorbidities who might do best with radiation therapy."

Speaking as a discussant of the Dutch report, Dr. Hak Choy said that the new findings and prior results make SABR a clear choice for elderly, inoperable patients, but existing data did not yet adequately support substituting SABR for surgery in operable patients. The definitive role for SABR in operable patients will grow clearer with results from two randomized studies now underway that compare SABR and surgery in high-risk operable patients, said Dr. Choy, a professor of radiation oncology at the University of Texas Southwestern Medical Center in Dallas.