Surgery Correlates With Better Survival Vs SABR in Early-Stage NSCLC

Surgical resection was associated with better survival than stereotactic ablative radiotherapy (SABR) among patients with early-stage non–small cell lung cancer (NSCLC) who were eligible for either treatment, according to an emulated target trial published in the Journal of Clinical Oncology.¹

What were the survival outcomes?

After adjustment, an estimated 21.6% of patients who underwent surgery died of any cause within 3 years, compared with 30.3% of those who received SABR, an average difference of 8.8 percentage points, although no clinically meaningful difference was observed among patients aged 80 years and older.Using national cancer data from 12,546 people diagnosed with early-stage NSCLC in England between 2015 and 2020, researchers compared surgery and SABR in patients eligible for either treatment. Among the patients, 10,247 underwent surgery and 2299 received SABR.

“Using data from England’s Cancer Registry, we found that surgery resulted in better survival than SABR for people with early-stage lung cancer,” said Eva Kagenaar, MSc, a research fellow at the London School of Hygiene & Tropical Medicine (LSHTM) and a co-author of the study, in a news release.² “Our findings show how valuable patient records can be for guiding treatment decisions, particularly when clinical trials aren’t able to answer critical questions quickly.”

How did outcomes differ in older patients?

Among people aged 80 years and older, the researchers found no evidence of a clinically meaningful difference in 3-year all-cause mortality between the 2 interventions. The findings suggest that SABR could offer an alternative treatment with curative intent for selected older populations. SABR is already recommended as a curative-intent treatment for people with early-stage NSCLC who are not medically fit for, or do not wish to undergo, surgery.

What did the cancer-specific analyses show?

The study also reported average estimates of 3-year lung cancer–specific mortality of 20.6% following SABR vs 14.5% after surgery, along with higher estimates of cancer recurrence following SABR than surgery. However, these differences were not statistically significant. In England, the researchers estimate that approximately 2000 people diagnosed with early-stage lung cancer each year could be eligible for either SABR or surgery, with roughly 1 in 5 currently receiving SABR—a proportion that has increased in recent years.

What was the study design?

Evidence directly comparing SABR and surgery in eligible patients with early-stage NSCLC remains limited, as previous randomized trials failed to recruit enough patients and ongoing studies have yet to report their data. To help address this gap, the researchers analyzed data from England’s National Cancer Registry linked with hospital and radiotherapy records, applying an emulated target trial design, an approach that applies the principles of a randomized controlled trial to real-world data. The analysis was described by the investigators as a world-first comparison of the 2 modalities using this method. The study was supported by the National Institute for Health and Care Research Biomedical Research Centre in Manchester.

What are the clinical implications?

The investigators concluded that surgery should remain the primary treatment for people with early-stage NSCLC who are suitable for either surgery or SABR.

“For most patients with early-stage NSCLC who are eligible for surgery, our results provide reassurance that it remains the treatment most likely to improve survival rates,” said Richard Grieve, PhD, professor of health economics at LSHTM and a co-author of the study, in the news release.² “Our findings support current NICE guidance, while also helping to clarify where alternative treatments, such as SABR, may improve patient outcomes and their quality of care.”

References

1. Kagenaar E, Lugo-Palacios DG, Aggarwal D, et al. Stereotactic ablative radiotherapy versus surgical resection for early-stage non–small cell lung cancer: an emulated target trial. J Clin Oncol. Published online November 2, 2026. doi:10.1200/JCO-26-00399
2. Surgery offers best survival for early-stage lung cancer, study finds. News release. London School of Hygiene & Tropical Medicine. News release. November 2, 2026. Accessed November 3, 2026. https://tinyurl.com/58xd5d4z