Table 1. Studies included in the narrative synthesis.
| Author, date and country, study type (level of evidence) | Patient group | Outcomes | Key results | Comments |
|---|---|---|---|---|
| RCT trial | ||||
| Louie et al., Radiother Oncol, Netherlands [2015] (2), RCT: small sample size (level 2b) | Secondary analysis of a non-blinded, phase 3 RCT of SABR versus surgery for stage IA NSCLC patients. 22 patients. Tools: EORTC QLQ-C30 and LC-13; EQ-5D. FU: baseline, and then 3, 6, 2, 18, and 24 months | Time to deterioration of at least 10 points decrease (global/functional scales) and of at least 10 point increase (symptom scales/items) | GH: surgery 8, SABR 2 (HR 1 vs. 0.19, P=0.038). RF: surgery 7, SABR 4 (HR 1 vs. 0.47, P=0.22). EF: surgery 4, SABR 1 (HR 1 vs. 0.25, P=0.21) | Small sample size |
| SABR studies | ||||
| Lagerwaard et al., JTO, Netherlands [2012] (3), Cohort study (level 3) | 382 patients. QoL tool: EORTC QLQ-C30 FU: baseline, 3, 6, 12, 18 and 24 M | Baseline GH | 62.9±1.1 | 15.4% of patients refused surgery. Drops-out: 64% and 61% of patients, were unavailable for at 18 and 24 months |
| Baseline PF | 61.8±1.1 | |||
| Baseline RF | 63.5±1.5 | |||
| Dyspnea | 47.1±1.7 | |||
| Fatigue | 37.4±1.3 | |||
| Insomnia | 21.1±1.6 | |||
| Changes over time | PF decreased in 24M (P<0.01) but not clinically significant than 10 points) | |||
| Mathieu et al., Pract Radiat Oncol, France [2015] (4), Cohort study (level 3) | 45 patients. QoL tool: QLQ-C30 and QLQ-LC13. FU: baseline, 2, 6, 12, 18, 24, 30, 36 M | Baseline GH | 66%±20% | 16% of patients refused surgery. Data from patients who had disease recurrence were excluded. Collection of QoL data at the 2 and 3 Y in 63% and 33% |
| Baseline PF | 73%±22% | |||
| Baseline EF | 77±26 | |||
| Social functioning decline | Transient declines: 12%±29% 12 M; 11%±29% 24 M | |||
| QLQ-LC13 coughing symptom | Reduction:13%±17% 30 M; 13%±22% 36 M | |||
| Ubels et al., Radiation Oncology, Netherlands [2015] (5), observational study (level 3) | 39 patients. QoL tool: EORTC QLQ-C30, EORTC QLQ-LC13. FU: baseline, 3 weeks, 2, 4, 6, 9, 12, 15, 18, 21, 24 M, then every 6 M until 5 years | GH | Near the baseline in the first year, then improve to decline again over the 5 years (P<0.0001) | 15% refused surgery. At 5 years only 10 patients were still alive without progression and had filled the QoL survey |
| PF, RF and cognitive functioning | Significantly improved over time; fatigue deteriorated over time (P=0.05) | |||
| Dyspnea | Deteriorated over time (P=0.006) | |||
| EF | Improved significantly at 1 year compared to the baseline | |||
| van der Voort van Zyp et al., Int J Radiation Oncology Biol Phys, Netherlands [2010] (6), observational study (level 3) | 39 patients. QoL tool: EORTC QLQ-C30, EORTC QLQ-LC13. FU: baseline, 3 weeks, 2, 4, 6, 9, 12 M | GH, PF, RP, SP | No changes over time | 15% patients refused surgery. Small sample size. The lack of >10-point changes suggests that there are no perceived changes in QoL scores |
| EF | Improvement over time (P=0.02) | |||
| Widder et al., Int J Radiation Oncology Biol Phys, Netherlands [2011] (7), Cohort study (level 3) |
Medically inoperable patients: 27 3D-CRT vs. 202 SABR. QoL tool: EORTC QLQ-C30 GH and PF + dyspnoea LC13. FU: 3, 6, 12 months | Dyspnea | Increase by 3.2 (95% CI: 1.0–5.3; P<0.01) | Different sample sizes (202 vs. 27). Comparison between techniques |
| PF | Stable for all patients except for those with a high CCI | |||
| GH | No significant changes | |||
| Ferrero et al., Lung Cancer, Italy [2015] (8), Cohort study (level 3) | 30 patients with inoperable Stage I NSCLC. QoL tool: Lung Cancer Symptoms Scale (LCSS). FU: baseline, 1.5, 4.5, 7.5, 10.5 M | Fatigue (baselines vs. 135 D) | 29 vs. 39.8, P=0.05. No other significant changes | Small sample size |
| Jain et al., Radiat and Oncol, UK [2013] (9), RCT (level 2b) | 54 patients with NSCLC <5 cm. Comparing two groups: Group 1: 4 days of SABR. Group 2: 11 days of SABRQoL tool: EORTC QLQ-C30 and LC-13. FU: discharge, 1 and 4 M | (Group 1 vs. group 2): PF | BS: 79 vs. 68.6, 4 M: 71.3 vs. 69.9 | Small sample size and limited follow-up |
| RF | BS: 93.8 vs. 71.6, 4 M: 83.3 vs. 77.3 | |||
| Dyspnea | BS: 25.9 vs. 44.4*, 4 M: 38.5 vs. 26.7 | |||
| % of patients with a clinically meaningful worsening (>10 points) | Dyspnea: 1 M, 44.4% vs. 15.4%*; 4 M, 38.5% vs. 12.0%*. PF: 4 M, 46.2% vs. 16%* | |||
| Videtic et al., Support Care Cancer, USA [2013] (10), Cohort study (level 3) | 22 patients. QoL tool: FACT-L and UCSD SOBQ (University of California at San Diego Medical Centre-Pulmonary Rehabilitation Program Shortness-of-Breath Questionnaire). FU: baseline, 3, 6, 9 and 12 months | Global scores: difference 1–12 M | 109 vs. 112 | 4.8% patients refused surgery. Limited sample size. A non-significant 9-point drop in mean UCSD SOBQ dyspnea scores |
| Sun et al., J Community Support Oncol, USA [2014] (11), Cohort study (level 3) | Observational study on 19 patients treated with SABR. QoL tool: FACT-L, Memorial Symptom Assessment Scale (MSAS) and FACIT-Sp-12. FU: baseline, 6 and 12 weeks | QoL | No detrimental changes in QOL scores over time | Small sample size |
| Emotional domains | Improvement in nervousness and worry scores over time but no significant change in overall emotional functioning | |||
| VATS studies | ||||
| Bendixen et al., Lancet Oncol, Denmark [2017] (12), RCT (level 2a) | RCT VATS vs. anterolateral thoracotomy. 201 patients. QoL tools: EORTC QLQ-C30 and EQ-5D. FU: baseline, 2, 4, 8, 12, 26, and 52 weeks | GH | VATS baseline: 73.2, open baseline: 73.3; VATS 4 W: 67.5, open 4 W: 64.8; VATS 52 W: 77.2, open 52 W: 74.1 | All the differences were only in few time points. They did not use the Lung Cancer module of the EORTC QLQ-C30 |
| PF | VATS baseline: 88.6, open baseline: 88.4; VATS 4 W: 83.9, open 4 W: 75.8*; VATS 52 W: 86.1, open 52 W: 82.9 | |||
| EF | VATS baseline: 77.5, open baseline: 77.4; VATS 52 W: 90, open 52 W: 83.03*. EQ5D only significant differences were in self-care and anxiety | |||
| Burfeind et al., J Thorac Cardiovasc Surg, USA [2007] (13), Cohort study (level 3) | 422 patients submitted to lobectomy. QoL comparison. Group 1: <70 years and group 2: ≥70 years. QoL tool: EORTC QLQ-C30+2 scales of LC13. FU: 3, 6, 12 months | Group 1 vs. 2: PF | Baseline: 83.7 vs. 81, 3 months: 77.9 vs. 73.9, 12 months: 81.9 vs. 78 | Retrospective analysis. The most commonly missed survey time point was the 3-month survey with 28% of group 1 and 38% of group 2 |
| EF | Baseline: 74.1 vs. 78.9, 3 months: 74.2 vs. 77.2, 12 months: 78.5 vs. 82.4 | |||
| GH | Baseline: 18.3 vs. 16.8, 3 months: 33.4 vs. 26.1, 12 months: 22.2 vs. 17.6 | |||
| Handy et al., Eur J Cardiothorac Surg, USA [2010] (14), retrospective study (level 3) |
241 patients submitted to lobectomy (open: 192 vs. VATS: 49). QoL tool: Short Form 36 Health Survey (SF-36) and Ferrans and Powers quality-of-life index (QLI). FU: baseline and 6 months | Difference from baseline to 6 M (open vs. VATS): PF | −11.6 vs. −1.4 (P=0.042) | Limited follow-up (6 months) |
| GH | −3.3 vs. 4.8 (P=0.010) | |||
| Bodily pain | −4.4 vs. 9.6 (P=0.020) | |||
| Role physical | −18.6 vs. 12 (P=0.002) | |||
| MH | −0.5 vs. 4.2 (P=0.38) | |||
| Energy | −3.6 vs. 5.3 (P=0.054) | |||
| Khullar et al., Ann Thorac Surg, USA [2017] (15), Cohort study (level 3) | 127 patients. QoL tool: 7 fixed-length PROMIS instruments. FU: baseline, 1 and 6 months | PF | Significantly lower (worse) at 1 M visit than at baseline | Short follow-up. Only 70 VATS lobectomies included |
| Pain intensity, interference, fatigue, and sleep impairment | All significantly higher (worse) at the 1 M. No difference identified at 6 M | |||
| Anxiety/fear and depression | Significantly improved after the operation | |||
| Rizk et al., Ann Thorac Surg, USA [2014] (16), Cohort study (level 3) | 206 stage I NSCLC patients (74 VATS vs. 132 thoracotomy). QoL tool: SF-36, physical component summary (PCS) and mental component summary (MCS). FU: baseline, 2 weeks, 4.8 and 12 months | MCS | Baseline: 42.4 vs. 43.5; 4 M: 43.6 vs. 44.9 (P=0.036); 12 M: 47.2 vs. 49 (P=0.08) | Only 59% patients completed all the surveys |
| PCS | Baseline:48.9 vs. 50.3; 4 M: 45.7 vs. 45.5 (P=0.86); 12 M: 48.1 vs. 48 (P=0.93) | |||
| Pain | BPI: no statistical difference between two groups | |||
| Fagundes et al., J Thorac Cardiovasc Surg, USA [2015] (17), Cohort study (level 3) | 60 stage I–II NSCLC patients treated with open and VATS lobectomy. QoL tool: MD Anderson Symptom Inventory (MDASI). FU: baseline, 3 and 5 days after surgery, and weekly for 3 M | Moderate to severe symptoms | Day 3: 51.6% for pain, 59.7% for fatigue, 54.8% for drowsiness, 33.9% for shortness of breath, and 56.5% for disturbed sleep. 3 months: all symptoms had improved to better than preoperative | No objective measures affecting duration of hospital stay |
| Li et al., Chest, China [2002] (18), cross-sectional study (level 3) | 51 patients with NSCLC following resection, comparing VATS with thoracotomy. QoL tool: EORTC QLQ-C30, EORTC QLQ-LC13, Self-developed module. FU: 33.5 mo (VATS) and 39.4 M (open) | Fatigue (74–92%), coughing (75–82%), dyspnea (75–85%), pain (67–71%) | Additional non-validated surgery-related questions. One-off survey | |
*, statistical significant. FACT-L, Functional Assessment of Cancer Therapy-Lung questionnaire; FACIT-Sp-12, Functional Assessment of Chronic Illness Therapy-Spirituality Tool; GH, general health; RF, role functioning; EF, emotional functioning; HR, hazard ratio; PF, physical functioning; CCI, Charlson comorbidity index; MCS, mental composite score; PCS, physical composite score; MH, mental health.