Among 12,546 people treated for early-stage lung cancer in England, three-year survival was higher for those who had surgery than for those who received a focused form of radiotherapy, a study from the London School of Hygiene & Tropical Medicine suggests.
The research looked at non-small cell lung cancer, the most common broad type of lung cancer, in patients considered suitable for either treatment. Surgery is already the main option for people able to undergo it. Stereotactic ablative radiotherapy, or SABR, aims high doses of radiation directly at a tumor. It is offered with the goal of curing cancer to patients who are not medically fit for surgery or do not want it. But evidence comparing the two treatments for patients eligible for both has been limited: earlier trials struggled to recruit enough people, while ongoing studies have not yet reported results.
The team used England’s National Cancer Registry, linked to hospital and radiotherapy records, to study people diagnosed between 2015 and 2020. In a first-of-its-kind approach, researchers used an “emulated target trial,” a method that applies some of the principles of a randomized clinical trial to records collected during real-world care. Of the participants, 10,247 had surgery and 2,299 received SABR.
After adjusting for differences between the groups, researchers estimated that 21.6% of people who had surgery died from any cause within three years, compared with 30.3% of those treated with SABR. That was an average difference of 8.8 percentage points. The study also estimated that lung cancer-specific deaths were 14.5% after surgery and 20.6% after SABR. However, the cancer-specific mortality estimates and the higher estimated rate of recurrence after SABR were not statistically significant, meaning the study could not rule out chance as an explanation for those differences.
Age also mattered. Among patients aged 80 and older, the researchers found no evidence of a clinically meaningful difference in three-year deaths from any cause between the treatments. That finding suggests SABR may remain a curative option for selected older patients. The results do not mean surgery is right for everyone; treatment choices still depend on a person’s health and circumstances.
In England, around 2,000 people diagnosed with early-stage lung cancer each year may be eligible for either treatment. About one in five currently receive SABR, and its use has risen in recent years. Eva Kagenaar, a research fellow at LSHTM and a study co-author, said the findings show how patient records can help guide decisions when clinical trials cannot answer important questions quickly.
Co-author Richard Grieve, a professor of health economics at LSHTM, said the results support current guidance from NICE, England’s health guidance body: for most eligible patients, surgery remains the treatment most likely to improve survival. By using routinely collected NHS data, the study adds evidence to help doctors and patients weigh their options. Further research may sharpen the picture, especially for older people and for those for whom surgery is not suitable.