Real-world faceoff: EBRT vs interventions for malignant central airway obstruction

Malignant central airway obstruction (MCAO) is a life-threatening complication in thoracic oncology. While external beam radiation therapy (EBRT), stenting, bronchoscopic debulking, and combination approaches are widely used, real-world comparative survival data are limited.

Using the TriNetX US Collaborative Network (2008-2023), we identified adults with MCAO undergoing EBRT (n = 11 478), stenting (n = 11 478), debulking (n = 7855), or stenting plus EBRT (n = 2985). Patients were 1:1 propensity-matched by demographics, cancer type, Eastern Cooperative Oncology Group (ECOG) status, and dyspnea. Kaplan-Meier and Cox proportional hazards models assessed survival; mortality risk was quantified with hazard ratios (HRs) and odds ratios (ORs) at multiple time points.

In matched cohorts (n = 11 478), EBRT was associated with longer median survival than stenting (1029 vs 627 days; HR, 0.776; P < .0001) and debulking (1068 vs 692 days; HR, 0.762; P < .0001), with no mortality difference (odds ratio [OR], 0.957 and P = .097; OR, 0.998 and P = .948, respectively). Compared with stent + EBRT (n = 2985), EBRT had superior survival (1003 vs 545 days; HR, 0.706; P < .0001) and lower mortality (OR, 0.659; P < .0001). Combination therapy offered no advantage over stenting alone and was associated with higher mortality (OR, 1.223; P =  .000). Dyspnea independently predicted worse survival (HR, >2.0); age and ECOG were not significant predictors. The advantage of EBRT was greatest early. At 6 months, EBRT showed lower mortality than stenting (17.2% vs 23.5%; HR, 0.652), debulking (16.9% vs 23.0%; HR, 0.636), and stent + EBRT (20.2% vs 24.8%; HR, 0.808). One-year survival remained higher for EBRT vs stenting (87.7% vs 85.2%; HR, 0.813) and stent + EBRT (86.7% vs 84.1%; HR, 0.825). By 5 years, survival rates converged (eg, EBRT vs stenting: 60.1% vs 60.9%; HR, 0.983), with HRs approaching or exceeding 1 by 10 to 15 years, limiting long-term interpretation due to low event counts. In 7- and 30-day landmark analyses, EBRT showed significantly lower hazards of death vs all other modalities, with the largest relative benefit at 7 days (HR, 0.79-0.84; P < .001). Median survival remained longest with EBRT across all comparisons.

External beam radiation therapy confers early survival benefits over stenting, debulking, and combined therapy without increasing mortality. It should be considered first-line treatment for MCAO, reserving procedural interventions for patients with acute or complex airway compromise.