Real-World Faceoff: EBRT vs. Interventions for Malignant Central Airway Obstruction

Background 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. Methods Using the TriNetX U.S. Collaborative Network (2008–2023), we identified adults with MCAO undergoing EBRT (n = 11,478), stenting (n = 11,478), debulking (n = 7,855), or stenting plus EBRT (n = 2,985). Patients were 1:1 propensity-matched by demographics, cancer type, 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 timepoints. Results In matched cohorts (n = 11,478), EBRT was associated with longer median survival than stenting (1,029 vs 627 days; HR 0.776; p < 0.0001) and debulking (1,068 vs 692 days; HR 0.762; p < 0.0001), with no mortality difference (OR 0.957, p = 0.097; OR 0.998, p = 0.948, respectively). Compared with stent+EBRT (n = 2,985), EBRT had superior survival (1,003 vs 545 days; HR 0.706; p < 0.0001) and lower mortality (OR 0.659; p < 0.0001). Combination therapy offered no advantage over stenting alone and was associated with higher mortality (OR 1.223; p = 0.000). Dyspnea independently predicted worse survival (HR > 2.0); age and ECOG were not significant predictors. EBRT’s advantage 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 (e.g., EBRT vs stenting: 60.1% vs 60.9%; HR 0.983), with HRs approaching or exceeding 1 by 10–15 years, limiting long-term interpretation due to low event counts. In 7- and 30-day landmark analyses, EBRT showed significantly lower hazards of death versus all other modalities, with the largest relative benefit at 7 days (HR 0.79–0.84; p < 0.001). Median survival remained longest with EBRT across all comparisons. Conclusions EBRT 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.