When “Operable” Isn’t Enough
How Modern Evidence—and One Patient’s Story—Are Rewriting the Standards for Stage I Lung Cancer
My mother learned she had lung cancer at seventy-seven, facing her fourth cancer in a decade. During those ten years, her health shifted from near-perfect to a series of life-altering diagnoses. First, she developed follicular lymphoma, which was treated with radiation. Then came Richter’s transformation to diffuse large B-cell lymphoma, requiring R-CHOP chemotherapy (a regimen that includes rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) and later ongoing immunotherapy, which she still receives every few weeks. Two years ago, she underwent a Whipple procedure for pancreatic adenocarcinoma, followed by months of FOLFIRINOX (an intensive combination chemotherapy regimen that includes folinic acid, 5-fluorouracil, irinotecan, and oxaliplatin). And now, during routine surveillance imaging, a tiny new adenocarcinoma in her left lower lung appeared.
Yet through all of that, she lived in a way that defied her medical history. She continued to make it a priority to accompany my stepfather on their annual month-long trip to Paris, where they walked for miles through gardens, museums, side streets, and river paths. At home, she played bocce ball with friends, maintained a regular Pilates schedule, and adhered to a steady routine at the gym. Movement was integral to her identity. It was not something she squeezed into her life, but something she built her life around. She worked fiercely to protect that identity through every diagnosis, treatment, and recovery.
Her lungs, however, were less resilient. Over the years, she developed COPD, a chronic lung disease characterized by airflow limitation, due to several contributors: recurrent MAC infections (lung infections caused by Mycobacterium avium complex bacteria, which can lead to chronic airway inflammation and scarring), bronchitis, decades of smoking one or two cigarettes a day, and severe scoliosis that limited her chest expansion. These factors explained the moderate airway obstruction and reduced diffusing capacity measured on her pulmonary function tests. She viewed herself as physically strong, and in many ways she was. That confidence persisted until she met with the thoracic surgeon.
He asked, “Can you climb one or two flights of stairs?” She answered yes without hesitation. Her husband gently added, “After one flight, you stop to rest because you get short of breath.” She paused, then acknowledged it. In that moment, the difference between how she imagined her capability and how her lungs truly functioned came into focus.
A Case That Should Have Been Simple
Her staging workup was reassuring. A PET/CT scan showed no evidence of spread. An endobronchial ultrasound, or EBUS, which uses ultrasound to biopsy nearby lymph nodes within the airway, detected no nodal disease. These minimally invasive staging techniques are supported by randomized clinical trials demonstrating accuracy comparable to mediastinoscopy, the traditional surgical method for evaluating mediastinal lymph nodes [1][2]. She was staged as T1bN0M0 non-small cell lung cancer, or NSCLC, meaning a small, localized tumor without nodal involvement or distant spread.
Two definitive treatment options existed. Lobectomy, which removes an entire lobe of the lung, has long been considered the standard treatment for operable stage I NSCLC. The alternative was stereotactic body radiation therapy, or SBRT, a highly targeted radiation technique delivered over 3–5 outpatient treatments with millimeter precision. The NCCN (National Comprehensive Cancer Network, a consortium of leading cancer centers that publishes widely followed evidence-based treatment guidelines) endorses both for the treatment of early-stage disease.
Her anatomy narrowed these options. The tumor was located close to her heart and sat along a fissure (the natural division between lung lobes), which made sublobar resection, a lung-sparing surgery removing only part of a lobe, like a wedge or segment, oncologically unsuitable due to risks of incomplete cancer removal or inadequate lymph node sampling. While sublobar resection is an option for many with small, peripheral tumors to preserve function, it is often debated as insufficient for oncologic control in complex anatomies like hers. Given this anatomical reality, lobectomy remained the traditional choice.
At her multidisciplinary tumor board, the familiar framing returned: if her lung function allowed it, lobectomy was preferred.
Her preoperative pulmonary function tests and performance status painted her as operable. I knew these metrics only scratched the surface of what truly mattered for her vibrant life. Her FEV1, that crucial spirometry value measuring how much air she could forcefully exhale in one second, hovered around 70% predicted, indicating moderate obstruction from her COPD and history, yet still within acceptable limits for lobectomy (typically >60% to mitigate perioperative risks). Her DLCO, assessing alveolar–capillary gas exchange efficiency, was diminished (likely due to scoliosis, recurrent infections, and prior treatments), but not critically low enough to rule out surgery (above the 40–50% predicted threshold, where postoperative shortness of breath or oxygen needs often spike). On paper, she checked the boxes for being operable, but I couldn’t ignore how these numbers overlooked her real-world stamina and the potential long-term hit from losing a lobe.
Her thoracic surgeon knew her entire medical history, including COPD, limited chest expansion from scoliosis, low diffusing capacity, prior Whipple surgery, multiple rounds of chemotherapy, ongoing immunotherapy, and the age-related decline in physiologic reserve. Her radiation oncologist reinforced the view that surgery remained the appropriate course of action. In an academic center where lobectomy has long been the institutional default, the recommendation felt decisive to my mother. She left those consultations believing surgery was not only a viable option but the better one.
What “Operable” Does Not Capture
Operability answers a very narrow question: can the patient safely undergo surgery? Patients care about a much broader one: what will life feel like afterward?
Lobectomy reduces lung volume. Studies show a lasting reduction of 10–30% in FEV1 [3][4]. Reduced DLCO strongly predicts exertional shortness of breath. Older adults recover less of their baseline physiologic reserve after lung resection [4]. These outcomes are not complications. They are expected physiological consequences of removing part of a lung.
For someone whose identity is built around movement, walking, climbing stairs, playing bocce ball, traveling, and staying active, that difference matters.
The Conversations That Changed Everything
After her consultations, my mother repeated what she understood: “You will be fine.” “You likely will not need oxygen.” “They think surgery is the better option.”
She trusted her clinicians. They have the best reputations. They were compassionate and took the time to explain the treatments and risks. They were not rushed. However, the way the information was presented made the decision feel straightforward. If she could undergo surgery, she should.
My mother and I had a series of phone conversations in which she asked questions, and I tried to answer them as clearly and neutrally as I could, careful not to steer her toward any particular choice. I wanted her to understand the facts, but just as importantly, to reach the issues I knew mattered most to her as her son.
I asked what she believed surgery would give her. “They made it sound like removing the tumor is the best option,” she said.
So I reframed the conversation in two parts. First, we talked about outcomes: whether surgery or SBRT offered a better chance of eliminating the tumor. She later told me that this was the moment things truly shifted for her. Once she learned that both treatments had very similar outcomes in terms of getting rid of the cancer, that was step one.
Step two came when we talked about what her life would likely feel like after each option. She had worked hard to remain independent, walking daily, traveling, staying active, and she realized that surgery would compromise her quality of life in ways that would significantly alter her current lifestyle. Once she understood that, there was no question in her mind that SBRT was the way she wanted to proceed.
I explained what the data now show. For a small, well-staged tumor like hers, SBRT achieves local control rates of 93–97 percent [5]. Several contemporary analyses indicate that when staging includes PET/CT and EBUS, long-term outcomes are comparable to those seen with lobectomy [5][6][7]. In earlier eras, surgery was viewed as superior; however, modern cohorts show that this gap has narrowed substantially. I also informed her about the ongoing VALOR trial, a large randomized comparison of SBRT and lobectomy in operable patients, which will provide the clearest answer once it is completed.
I also explained why she came away from her surgical consultation believing that mediastinal lymph node dissection might be more precise. I was listening during that visit and heard the discussion. Her surgeon correctly noted that lymph node dissection is the most definitive way to determine if cancer has reached the mediastinum, and that this information can guide treatment decisions. It was natural for her to interpret this as meaning PET/CT and EBUS were less reliable.
Later, I clarified that while this used to be true, the evidence has since evolved. Modern SBRT pathways rely on PET/CT and EBUS or EUS, and multiple randomized trials now show that these minimally invasive techniques achieve staging accuracy comparable to surgical dissection [1][2][8].
I also emphasized that although surgical dissection provides the highest degree of pathologic certainty, it does not improve survival for small, well-staged stage I tumors. What matters is accurate staging—regardless of whether it is obtained surgically or through high-quality PET/CT and EBUS. Many patients understandably assume lymph node removal is a therapeutic advantage; in modern early-stage NSCLC, correct staging is the priority, not the method used to obtain it.
Once she understood that she was choosing between two highly effective treatments, her real question emerged: What kind of life will I return to?
I said, “Surgery offers excellent cancer control, but it may affect your stamina and your breathing over the long term. SBRT offers similarly excellent control and is more likely to preserve the way you live now.”
Quality of life mattered more to her than the physical act of removing the tumor. Once she understood that, her decision became clear.
An Approach That Preserves More Than It Takes
SBRT is outpatient and convenient. There is no incision, no anesthesia, and no hospitalization. Lung function decline is generally minimal and often temporary [9]. Symptomatic pneumonitis occurs in less than 10 percent of patients [10][11].
She completed her treatment over the course of one week. A few days later, she boarded a plane to Paris. She was able to walk her usual five miles per day. Her breathing felt unchanged. Her independence remained intact.
She felt like herself.
A New Frame for Decision-Making
Lobectomy remains an excellent option for younger, healthier patients with abundant physiologic reserve. For older adults or those whose bodies have been shaped by years of illness and treatment, the decision is more nuanced.
When two treatments offer similar chances of controlling the cancer, the central question becomes a personal one: Which option allows the patient to return to the life they want?
For my mother, the choice became unmistakably clear.
References
[1] Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy versus endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA. 2010;304(20):2245–2252.
https://doi.org/10.1001/jama.2010.1705
[2] Kuijvenhoven JC, Korevaar DA, Tournoy KG, et al. Five-year survival after endosonography versus mediastinoscopy for mediastinal nodal staging of lung cancer. JAMA. 2016;316(10):1110–1112.
https://doi.org/10.1001/jama.2016.10349
[3] Jeon YJ, Shin S, Park S, et al. Lobe-Specific Variability in Postoperative Pulmonary Function in Lung Cancer Patients: A Longitudinal Analysis and Comparison With Traditional Predictive Models. Respirology. 2025 Oct 2. https://doi.org/10.1111/resp.70133
[4] Vanstraelen S, Tan KS, Dycoco J, et al. A New Functional Threshold for Minimally Invasive Lobectomy. Ann Surg. 2024;280(6):1029-1037. https://doi.org/10.1097/SLA.0000000000006343
[5] Chang JY, Mehran RJ, Feng L, et al. Ten-year results from the STARS trial: Stereotactic ablative radiotherapy versus surgery for early-stage non-small cell lung cancer. Presented at: American Society for Radiation Oncology (ASTRO) Annual Meeting; September 28-October 1, 2025; Washington, DC. https://amportal.astro.org/sessions/ss-29-21601/ten-year-outcomes-of-the-revised-stars-trial-comparing-radiation-and-surgery-for-early-stage-106737
[6] De Ruiter JC, van der Noort V, van Diessen JN, Smit EF, Damhuis RAM, Hartemink KJ; on behalf of the ESLUNG group. The optimal treatment for patients with stage I non-small cell lung cancer: minimally invasive lobectomy versus stereotactic ablative radiotherapy – a nationwide cohort study. Lung Cancer. 2024;191:107792.
https://doi.org/10.1016/j.lungcan.2024.107792
[7] Flores R, Yankelevitz D, Taioli E, et al. Prospective Cohort Study to Compare Long-Term Lung Cancer-Specific Survival for Clinical Stage IA Non-Small-Cell Lung Cancer in Patients Treated With Lobectomy Versus Stereotactic Ablative Radiation Therapy: Results From an International Collaborative Initiative (I-ELCAP and IELCART). J Thorac Oncol. 2023;18(12):1720-1735. https://doi.org/10.1016/j.jtho.2023.09.1445
[8] Bousema JE, van Dorp M, Hoeijmakers F, et al. Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial. J Clin Oncol. 2023;41(21):3805-3815. https://doi.org/10.1200/JCO.22.01728
[9] Stone B, Mangona VS, Johnson MD, et al. Changes in Pulmonary Function Following Image-Guided Stereotactic Lung Radiotherapy: Neither Lower Baseline Nor Post-SBRT Pulmonary Function Are Associated with Worse Overall Survival. J Thorac Oncol. 2015;10(12):1762-1769. https://doi.org/10.1097/JTO.0000000000000670
[10] Vuong SQ, Liu M, Tsarovsky NW, Wudtke JD, Wallat EM, Bayliss RA. Outcomes of Patients With Interstitial Lung Disease and Early-Stage Non-Small Cell Lung Cancer Treated With Stereotactic Body Radiotherapy. Clin Lung Cancer. 2025 Aug 5. https://doi.org/10.1016/j.cllc.2025.07.017
[11] Park S, Park JW, Lee EH, Suh YJ, Lee CY, Park BJ, Lee CG, Yoon HI, Lee SH, Cui R, Kim EY, Cho J. Stereotactic body radiotherapy for early-stage non-small cell lung cancer: Prognostic factors, symptomatic radiation pneumonitis and patterns of failure. Oncol Lett. 2025;29(6):239. https://doi.org/10.3892/ol.2025.15060