How do you approach the discussion and decision-making regarding surgery vs SBRT for stage I NSCLC in patients who are candidates for both?

I agree with Dr. @Dr. First Last that it requires a very nuanced and personalized discussion. Our Yale approach (led by Frank Detterbeck) has been detailed in a 4-paper series in the Journal of Thoracic Disease 2022 (overview and SBRT/ablation focus), with the general paradigm balancing short-term, medium-term, and long-term effectiveness and side effect risk based on our available imperfect data.

I also make sure to warn patients about the unique challenges of interpreting SBRT follow-up imaging...

First, I would provide available randomized and non-randomized prospective clinical studies that indicated that both modalities have similar 5-Y OS. I would review the side effects of surgery vs SBRT (G3+ 50+% vs 1-3%). I would discuss the limitations of the studies and SBRT.

Finally, based on the patient’s age, KPS, PFT, and cardiovascular status, I would discuss with the patient the surgical resection risks vs. the SBRT option. The final decision will be made among the patient, thoracic surger...

There are contemporary reviews that clarify the uncertainties of benefit with surgery or SBRT for stage I NSCLC whenever lung cancer-specific or overall survival is the driving concern. The 2022 reference posted by @Dr. First Last is one of the more thoughtful ones published on the topic (28p): Detterbeck et al., PMID 35813719.

At our institution, if a patient is a surgical candidate, they have surgery as per the NCCN guidelines unless the patient declines surgery then we offer SBRT.