Surgery or radiation?

Deciding between
two cancer therapies



Week after week, newly diagnosed patients with early-stage lung cancer — mostly men in their mid-60s who are longtime smokers — come to Washington University physicians, seeking a successful form of treatment. If they are otherwise healthy, thoracic surgeons Traves D. Crabtree, MD, and Varun Puri, MD, perform minimally invasive surgery to remove the lesion; if they have complicating conditions that preclude surgery, radiation oncologist Jeffrey D. Bradley, MD, relies on stereotactic body radiation therapy (SBRT). But for patients in the gray area between the two extremes, which treatment is best?

For several years, these physicians and surgeons have been trying to resolve this question by mining local and national databases of past patients for answers. Further, they have been working collaboratively, without the competition often seen at other institutions. Together, they are not only trying to determine which therapy to use in which cases, but more broadly what characterizes “risk” in such patients. Does it mean diabetes, coronary artery disease or respiratory problems? Which factors really matter in determining a patient’s ability to survive surgery and return to the best possible stamina and function?

“The colleagues we have aligned in thoracic surgery and radiation oncology are unique,” says Bryan F. Meyers, MD, MPH, chief of thoracic surgery and the Patrick and Joy Williamson Professor of Surgery. “We scrutinize each other’s patient data together, we go over each analysis together and we have no shyness about challenging the other’s work. Our papers have truly been joint efforts and represent our best effort to inform the patients about the most likely outcomes from either modality.”

The result has been national prominence in this area for Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine. “Only a handful of other institutions have looked at this problem in as much detail as we have,” says Crabtree, assistant professor of surgery, who was the first author on a 2010 study comparing groups of patients treated with both therapies and tracking long-term outcomes.


Before they adopted SBRT as a treatment option in 2004, their results from the previous method — daily radiation for 35 treatments —were “just lousy,” says Bradley, the S. Lee Kling Professor of Radiation Oncology. Intrigued by reports of SBRT, he traveled to Germany and Japan to learn the technique, and he and his colleagues became national leaders in adopting it. They have since treated some 500 patients, and the outcome “has been excellent,” he adds. “Our primary tumor control rate is better than 90 percent, and we’re thrilled with the results.”

SBRT works so well because it is a precisely targeted treatment in which radiation beams are arrayed around a tumor, and the maximum dose is focused directly on the cancer, minimizing the exposure of adjacent tissue. Specialized equipment is necessary for the therapy: body-positioning apparatus to keep the patient immobile for the 30-minute session, and a linear accelerator with multi-slice CT imaging that shows even slight tumor movement. Over a week’s time, a patient has three to five treatments and then is done, with little post-operative discomfort.

Bradley’s early advocacy for SBRT drew the attention of thoracic surgeons, and his team began collaborating with them on widely published multidisciplinary research.

Recently, Clifford Robinson, MD, assistant professor of radiation oncology, became chief of the SBRT service.

The service has grown under Robinson’s leadership, and he undertook surgery/SBRT analyses with Crabtree and Puri.

“Without Cliff’s work, we would not have been able to accomplish these studies,” says Crabtree.


Jeffrey D. Bradley, MD, right, confers with dosimetrist Michael B. Watts regarding a patient’s SBRT treatments.



Removing the lobe of the lung containing the cancer long has been the recommended treatment for early-stage non-small cell lung cancer, a biologically aggressive disease with a five-year survival of 60 to 75 percent. In recent years, cancer surgery has become safer, with a surgical mortality rate of just 1 percent; recovery is also much easier because of the increasing dominance of minimally invasive techniques. More than 75 percent of lung cancer surgery at Barnes-Jewish Hospital is now done using this approach.

“Large-incision patients will feel much worse than those who have had three small incisions and cancer removal. Small-incision patients go home sooner, feel better, are less likely to need pain medications and are more likely to be independent,” says Puri, assistant professor of surgery. “Long-term, oncologically, this surgery provides equal benefit to the big operation.”

These minimally invasive techniques mean thoracic surgeons are more likely to offer surgery to a patient with complicating conditions because they can do the operation more safely than they could have a decade ago. Thus, the gray area of patients who may or may not be candidates for surgery has shrunk somewhat because of these surgical innovations.


Traves D. Crabtree, MD, right, and Varun Puri, MD, center, work with a surgical team to remove a tumor.



The gray zone For those patients who fall within the puzzling gray zone, further research is needed. After Crabtree’s 2010 paper in The Journal of Thoracic and Cardiovascular Surgery, Puri — who has received support from an NIH Career Development Award and from the Foundation of Barnes-Jewish Hospital — was principal author of an analytic modeling paper that looked at cost-effectiveness for both options. These studies, based on retrospective data, showed that surgery was somewhat more expensive than SBRT but resulted in better overall survival. In the gray-area patients, cancer-specific survival was similar between SBRT and surgery.

For even more conclusive results, the best solution would be to mount a prospective trial, randomizing new patients to SBRT or surgery — but that has proved difficult. Three multicenter national trials have failed to accrue enough patients; the last one, with Bradley as a principal investigator, closed in May 2013. In large part, the reason is that patients have strong opinions about the form of treatment they want.

“On one end of the spectrum, patients say: ‘I want this out of me. Let me have surgery.’ On the other end, they say: ‘I am 75 years old, and you think I want to have a big surgery? If SBRT doesn’t work, I can have surgery afterward.’ It is hard to randomize patients because you’re taking the choice away from them,” says Bradley.

Right now, he and his colleagues continue to plan new studies. Thoracic surgeon Stephen Broderick, MD, is collecting data on the quality of life of lung cancer patients treated either with surgery or with SBRT. In the short term, Crabtree, Puri and Robinson hope to develop one computer-based algorithm for SBRT patients and another for surgery patients, so that physicians will be able to describe their chances of long-term survival with each method.


An example of the type of tumor in question. Studies underway will better inform patients and physicians regarding probable therapeutic outcomes in cases such as these.