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I thank Dr Senthi for his thoughtful comments on our data comparing recurrence and survival between stereotactic body radiotherapy (SBRT) and surgery. I agree that well-designed prospective trials are needed if we are to advance our understanding of the role of SBRT in the treatment of early-stage non–small cell lung cancer. Although the overall local recurrence rate was 4-fold higher in the SBRT cohort than among all those undergoing resection, from a surgical standpoint we remain concerned that the majority of these local recurrences occurred in patients undergoing sublobar resection, whereas local recurrence was rare with lobectomy, the current standard of care for low-risk patients. With these issues in mind, we recognize the importance of refining our selection criteria and optimizing our operative technique (in favor of anatomic segmentectomy) in patients most suitable for sublobar resection. Furthermore, we recognize that there is likely a subset of “very high-risk” surgical patients as well. In our previously published data on high-risk patients undergoing sublobar resection in the American College of Surgeons Oncology Group (ACOSOG) Z4032 trial, we demonstrated an extremely high-risk subset with a 2-fold increase in 90-day adverse events (48% vs 24%) with respect to the lowest risk quintile.1Crabtree T. Puri V. Timmerman R. Fernando H. Bradley J. Decker P.A. et al.Treatment of stage I lung cancer in high-risk and inoperable patients: comparison of prospective clinical trials using stereotactic body radiotherapy (RTOG 0236), sublobar resection (ACOSOG Z4032), and radiofrequency ablation (ACOSOG Z4033).J Thorac Cardiovasc Surg. 2013; 145: 692-699Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar This may represent the subset of patients with potential equipoise with SBRT treatment of early stage non–small cell lung cancer. With regard to the issue of preservation of pulmonary function with SBRT, although SBRT avoids actual resection, the parenchyma is largely nonfunctional in the treated field, and we have demonstrated that the decrement in forced expiratory volume in 1 second after SBRT is greater than after sublobar resection.1Crabtree T. Puri V. Timmerman R. Fernando H. Bradley J. Decker P.A. et al.Treatment of stage I lung cancer in high-risk and inoperable patients: comparison of prospective clinical trials using stereotactic body radiotherapy (RTOG 0236), sublobar resection (ACOSOG Z4032), and radiofrequency ablation (ACOSOG Z4033).J Thorac Cardiovasc Surg. 2013; 145: 692-699Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar Without belaboring the concerns and limitations regarding the current data on SBRT in this setting, we must move beyond this counterproductive “all or none” debate on the primary treatment of early-stage lung cancer. Treating with SBRT and offering salvage surgery after failures is not a tested strategy, either in trials or in the clinical setting. Treating low-risk patients with SBRT or surgery is investigatory, at best. The notion of having all stage I lung cancer care begin with treatment with SBRT, with surgery only as salvage treatment, is self-serving, without basis, and potentially a setback to our collaborative efforts to define the actual role of SBRT in the treatment of lung cancer. We can rather focus on collaborative efforts in a number of areas: (1) identification of objective selection criteria for treatment modality in high-risk patients; (2) evaluation of appropriate follow-up imaging and identification of recurrence after treatment with SBRT and surgery; (3) creation of composite end points that include morbidity, overall and cancer-specific mortality, and quality of life assessment, and incorporation of this measure in the selection of treatment; (4) determination of the role of salvage surgery after SBRT treatment; (5) standardization of SBRT and surgical treatment across institutions; and (6) identification of patients with limited life expectancy for whom no treatment may be appropriate. This is the short list of what we need to accomplish, working collaboratively, to improve patient care in this area. Use of stereotactic body radiation therapy with salvage surgery to improve outcomes for early stage non–small cell lung cancerThe Journal of Thoracic and Cardiovascular SurgeryVol. 148Issue 4PreviewThe role of stereotactic body radiation therapy (SBRT) and its integration into the treatment of early stage non–small cell lung cancer continues to evolve. The recent propensity-matched analysis by Crabtree and colleagues1 provides insights into how to combine SBRT with surgery to improve non–small cell lung cancer outcomes. Full-Text PDF Open Archive