Stereotactic ablative radiotherapy (SABR) offers patients with early-stage non-small cell lung cancer (NSCLC) an effective alternative to the standard of care surgery — with significantly fewer severe complications in the short-term.

The stereotactic ablative radiotherapy vs surgery for stage I NSCLC (STARS) trial showed similar efficacy with SABR vs video-assisted thoracoscopic surgery (VATS) in this patient group at 10 years, according to data presented by senior author Joe Y. Chang, MD, PhD, a professor of thoracic radiation oncology and director of Stereotactic Ablative Radiotherapy at The University of Texas MD Anderson Cancer Center in Houston at American Society for Radiation Oncology (ASTRO) 2025 Annual Meeting in San Francisco.

The findings are welcome in a cancer patient group that is typically diagnosed at age 71, an age when many have several comorbidities that would make surgical resection impossible or very difficult, said Chang. Surgical complications are significant even for operable cases. However, surgery provides pathologic staging that SABR cannot offer, which remains an important consideration in guiding treatment, he said.

“Our study confirms, based on a decade of data, that stereotactic radiotherapy is a strong alternative to surgery for most patients with operable stage I NSCLC,” Chang said. “This highly targeted, noninvasive treatment achieved the same long-term overall survival [OS] as lobectomy, while offering many patients an easier recovery and potentially better quality of life.”

Chang noted that the two treatments provide comparable results for tumors < 3 cm. However, data suggests that SABR is less effective for larger tumors, particularly those > 5 cm.

“If tumors are > 3 cm, particularly > 5 cm, we always say if surgery can remove it, go for it.”

Tumor location can also be a deciding factor in treatment. SABR can’t be used for tumors close to the heart, esophagus, or major vessels, Chang said.

SABR vs VATS

SABR is a highly precise radiation technique that delivers very high doses to small, well-defined tumors in just a few sessions, while sparing surrounding healthy tissue. The noninvasive treatment offers excellent local control and minimal recovery time. Its downsides include that it does not provide pathologic staging and comes with a risk for recurrence near critical structures, an ASTRO site for patients says.

VATS with lobectomy and mediastinal lymph node dissection (VATS L-MLND), was the specific approach used for patients who received surgery in the STARS trial. It combines minimally invasive lobectomy with mediastinal lymph node dissection, offering definitive tumor removal and staging with less pain and faster recovery than open surgery, though it still carries operative risks and requires surgical fitness. The treatment provides thorough tumor and lymph node removal with proven long-term survival and faster recovery than open surgery, but it remains invasive, requires surgical candidacy, and carries risks for complications, according to NCCN guidelines.

Methods and Results

The researchers found no significant difference between SABR and VATS L-MLND at 10 years follow-up for OS, the primary outcome of the STARS trial. OS was 69% and 66% for SABR and VATS L-MLND, respectively (P = .4). Cancer-specific survival was 92% and 89% (P = .9), and recurrence-free survival was 57% and 65% for SABR and VATS-MLND (P = .6).

Eighty patients with early-stage NSCLC, defined as tumor size < 3 cm with no lymph node or distant metastasis, were enrolled and treated as outpatients with SABR using focused radiotherapy for 15 minutes per session per day for 3-4 days. These patients were propensity score matched to 80 patients from the VATS surgical cohort, using a multivariable logistic regression model that controlled for potential confounding factors, including age, tumor size, histology, performance status, and the interaction of age and sex as covariates. (Propensity matching is a statistical method that pairs patients with similar characteristics across treatment groups so outcomes can be compared more fairly, as if they had been randomly assigned.)

The rate of moderate-to-severe short-term complications was greater with surgery than with SABR — 50% vs 1%.

Quality of life and financial burden of surviving patients at 10 years were comparable between those who received SABR and those who underwent VATS. These were measured by the 12-Item Short Form Health Survey, Version 2 (a patient survey measuring physical and mental health) and the comprehensive score for financial toxicity tool, a validated questionnaire of patients’ experiences with the costs of cancer care.

A New Standard of Care?

Press briefing moderator Kenneth Rosenzweig, MD, reacted positively to the results.

“If there’s a patient for one reason or another who isn’t a good candidate for surgery, [SABR is an] excellent option that’s going to be equally as effective,” said Rosenzweig, who is the chair of the ASTRO Annual Meeting Scientific Committee and the chairman of the Department of Radiation Oncology at Icahn School of Medicine at Mount Sinai in New York City.

Given comparable outcomes with SABR and VATS L-MLND, Chang said the current standard of care should be multidisciplinary management with discussion to talk about the advantages and limitations of both modalities.

Research on molecular biomarkers-based personalized SBRT is an important next step, Change added.

This study was funded in part by Varian Medical Systems and the National Institutes of Health National Cancer Institute.

Chang reported receiving research grants from Bristol Myers Squibb, Siemens, and AstraZeneca. Rosenzweig reported that he had no relevant financial disclosures.