• 2019-07
  • 2019-08
  • 2019-09
  • 2019-10
  • 2019-11
  • 2020-03
  • 2020-07
  • 2020-08
  • 2021-03
  • B br surgery br Odds Ratio br Odds Ratio


    Odds Ratio
    Odds Ratio
    Study or Subgroup log [Odds Ratio] SE Weight IV, Random, 95% CI
    FIGURE 1. Forest plot of the OR of overall survival in unmatched patients (A), overall survival in matched patients (B), and cancer-specific survival in matched patients (C) after SBRT versus surgery in patients with early-stage NSCLC. The estimate of the OR of each study corresponds to the middle of the squares, and the horizontal line shows the 95% CI. On each line, the numbers of events as a fraction of the total number randomized are shown for both 
    The Journal of Thoracic and Cardiovascular Surgery c Volume 157, Number 1 369
    THOR  Thoracic: Lung Cancer: Review Cao et al
    Overall 25%
    Years after procedure
    FIGURE 2. Reconstructed Kaplan–Meier graph of overall survival using aggregated data from matched patients with early-stage NSCLC who underwent SBRT versus surgery. Shading represents the 95% confidence limits around the central estimate. SBRT, Stereotactic body CORM-3 therapy.
    30 and 90 days for surgery than SBRT.53 In addition, it should be acknowledged that clinical benefits in overall and cancer-specific survival associated with surgery were not apparent until 2 to 4 years after the operation, an impor-tant consideration for patients with limited life expectancies. Other important findings from the systematic review include significant variations in patient and tumor characteristics among studies, especially between institutions in Europe and the United States. Histopatholo-gic confirmation of NSCLC in the SBRT arm varied widely, between 30% and 100%, with 5 studies reporting less than
    studies were the only publications that showed a trend of longer disease-free survival for SBRT than surgery.7,37
    Study Limitations
    The present study has several limitations. The most impor-tant limitation is the lack of level I clinical evidence in the form of randomized controlled trials and the intrinsic patient selection bias present in observational studies. Despite a strong international effort to enroll patients, only 68 of the combined target of 2410 patients (2.8%) were ever success-fully enrolled in 3 planned randomized controlled trials.54,55 Slow accrual of patients may be at least partially attributable to a lack of equipoise for surgeons who still favor surgical resections with well-established long-term clinical data.47 Pa-tients allocated to the SBRT arm were often those considered 
    inoperable or high risk, with increased comorbidities that pro-hibited a surgical resection. The Sublobar Resection Versus Stereotactic Ablative Radiotherapy for Lung Cancer (STA-BLE-MATES) trial (NCT02468024 on is currently recruiting high-risk patients with peripherally located stage I NSCLC, who are randomized to SBRT or sub-lobar resection, with the primary end point defined as overall survival and secondary end points of progression-free sur-vival and toxicity. In randomized trials that experienced diffi-culties accruing patients, one method of minimizing potential bias was to compare the 2 treatment arms using propensity scores. Although this statistical technique can balance selected observed covariates, trophoblast does not replace the robust-ness of randomized trials, owing to a wide range of unob-served covariates.10,56 The closeness of matching, also known as the caliper, differed among studies, depending on the reservoir of potential matches and the number of measured covariates between treatment groups.57 Additional statistical limitations of the present meta-analysis included relatively high heterogeneity identified among studies, poten-tial overlapping of individual patients between institutions and databases, and the intrinsic limitations of the Guyot’s method such as assumptions on constant censoring at each time interval. This assumption affects the relative weights of different portions of the curve, particularly as follow-up durations increase and the levels of information is reduced, potentially underestimating the uncertainty in the reconstructed hazard ratios.15 Other limitations of the current