In the Journals

Minimally invasive surgery effective for early-stage lung cancer

Photo of Daniel Boffa 2018
Daniel J. Boffa

Survival rates among patients with stage I non-small cell lung cancer who underwent video-assisted thoracic surgery appeared similar to those of patients who underwent traditional thoracotomy, according to results of a retrospective cohort noninferiority study.

“Our study suggests that the minimally invasive approach is just as effective as the traditional approaches through a bigger incision,” Daniel J. Boffa, MD, associate professor of thoracic surgery at Yale School of Medicine, told HemOnc Today. “Minimally invasive surgical techniques can be used in patients with early-stage lung cancer without compromising the potential for surgery to cure the patient.”

Studies have suggested minimally invasive approaches do not allow surgeons to completely evaluate lymph nodes, which could negatively impact cure rate. Further, studies conducted specifically for lung cancer have suggested the minimally invasive approach — video-assisted thoracic surgery (VATS) — is inferior to traditional approaches.

Still, minimally invasive surgery has also been associated with “less pain, fewer complications and a faster return to work,” which has presented a more appealing option for patients, according to Boffa.

Because it would be difficult to conduct a randomized controlled trial in this setting, observational studies of large data registries have been used to decipher approach-specific survival differences between the surgical approaches.

In 2002, the Society of Thoracic Surgeons created the General Thoracic Surgery Database to improve the quality of patient care. To enhance observational studies, the database has evolved to provide detailed data on comorbidities, performance status, pulmonary function, tumor attributes and surgical procedures.

Boffa and colleagues linked the General Thoracic Surgery Database with CMS longitudinal follow-up and health care use data to compare VATS with thoracotomy approaches.

Researchers evaluated data from 10,597 patients aged 65 years and older (median age, 73 years) with clinical stage I lung cancer who underwent lobectomy between 2002 and 2013 — 4,448 patients underwent thoracotomy and 6,149 underwent VATS.

Patients who underwent VATS showed more favorable distribution of all health-related variables — including intact spirometry (59% vs. 51%; P < .001) — than patients who underwent thoracotomy.

Researchers used Cox proportional hazards models from two eras — 2002 to 2008 and 2009 to 2013 — to consider expanded practice standards over time.

Overall, mortality risk associated with the VATS approach was not significantly higher than thoracotomy from 2002 to 2008 (HR = 0.97; 95% CI, 0.87-1.09) or 2009 to 2013 (HR = 0.84; 95% CI, 0.75-0.93).

Kaplan-Meier survival estimates performed at a median follow-up of 2.31 years included 2,901 propensity-matched VATS-thoracotomy pairs and demonstrated a modestly superior 4-year survival for VATS over thoracotomy (68.6% vs. 64.8%; P = .003).

Secondary analyses focused on a cohort of pathologic stage I tumors to address bias observed in the primary analyses by tumor characteristics not found by the General Thoracic Surgery Database. Researchers observed similar findings in this cohort.

Still, the use of databases may limit these findings, Boffa noted.

“Databases don’t let us know why the patient was treated in the way they were,” Boffa said. “Therefore, even though we attempted to correct for any differences that were seen between patients who had minimally invasive surgery and those who had a traditional approach through a larger incision, it is possible that the two groups were different in ways that are not captured by the database, and that these differences biased one of the groups.

“Hopefully, more patients will be given the opportunity to have their early-stage lung cancer removed by way of a minimally invasive surgery,” he added.

Linking data from the General Thoracic Surgery Database and CMS allowed for high-quality estimates of long-term outcomes, Jessica S. Donington, MD, MSCR, assistant professor of cardiothoracic surgery and director of the Thoracic Surgery Translational Laboratory at NYU Langone Health, wrote in a related editorial.

“For the first time, we can investigate the impact of specific aspects of perioperative surgical care

on long-term oncologic outcomes; this has never before been possible on a large-scale basis,” Donington wrote. “We should expect to see other insightful studies from this collaborative effort in the future.”

Minimally invasive resection is becoming the standard of care for early-stage lung cancer, so patients and clinicians should be open to finding a surgeon who is an expert in the procedure.

“As we move into an era where CT screening should result in the diagnosis of [smaller], early-stage tumors, the ability to remove them safely with minimal morbidity and mortality and rapid return to normal health is of increased importance,” Donington wrote. – by Melinda Stevens

For more information:

Daniel J. Boffa , MD, Yale School of Medicine, PO Box 208062, New Haven, CT 06520-8062; e-mail: daniel.boffa@yale.edu.

Disclosures: Boffa reports research funding from Epic Sciences. Please see the full study for a list of all other authors’ relevant financial disclosures. Donington reports honoraria, a consultant or advisory role, and travel, accommodations and expenses from AstraZeneca.

Photo of Daniel Boffa 2018
Daniel J. Boffa

Survival rates among patients with stage I non-small cell lung cancer who underwent video-assisted thoracic surgery appeared similar to those of patients who underwent traditional thoracotomy, according to results of a retrospective cohort noninferiority study.

“Our study suggests that the minimally invasive approach is just as effective as the traditional approaches through a bigger incision,” Daniel J. Boffa, MD, associate professor of thoracic surgery at Yale School of Medicine, told HemOnc Today. “Minimally invasive surgical techniques can be used in patients with early-stage lung cancer without compromising the potential for surgery to cure the patient.”

Studies have suggested minimally invasive approaches do not allow surgeons to completely evaluate lymph nodes, which could negatively impact cure rate. Further, studies conducted specifically for lung cancer have suggested the minimally invasive approach — video-assisted thoracic surgery (VATS) — is inferior to traditional approaches.

Still, minimally invasive surgery has also been associated with “less pain, fewer complications and a faster return to work,” which has presented a more appealing option for patients, according to Boffa.

Because it would be difficult to conduct a randomized controlled trial in this setting, observational studies of large data registries have been used to decipher approach-specific survival differences between the surgical approaches.

In 2002, the Society of Thoracic Surgeons created the General Thoracic Surgery Database to improve the quality of patient care. To enhance observational studies, the database has evolved to provide detailed data on comorbidities, performance status, pulmonary function, tumor attributes and surgical procedures.

Boffa and colleagues linked the General Thoracic Surgery Database with CMS longitudinal follow-up and health care use data to compare VATS with thoracotomy approaches.

Researchers evaluated data from 10,597 patients aged 65 years and older (median age, 73 years) with clinical stage I lung cancer who underwent lobectomy between 2002 and 2013 — 4,448 patients underwent thoracotomy and 6,149 underwent VATS.

Patients who underwent VATS showed more favorable distribution of all health-related variables — including intact spirometry (59% vs. 51%; P < .001) — than patients who underwent thoracotomy.

Researchers used Cox proportional hazards models from two eras — 2002 to 2008 and 2009 to 2013 — to consider expanded practice standards over time.

Overall, mortality risk associated with the VATS approach was not significantly higher than thoracotomy from 2002 to 2008 (HR = 0.97; 95% CI, 0.87-1.09) or 2009 to 2013 (HR = 0.84; 95% CI, 0.75-0.93).

Kaplan-Meier survival estimates performed at a median follow-up of 2.31 years included 2,901 propensity-matched VATS-thoracotomy pairs and demonstrated a modestly superior 4-year survival for VATS over thoracotomy (68.6% vs. 64.8%; P = .003).

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Secondary analyses focused on a cohort of pathologic stage I tumors to address bias observed in the primary analyses by tumor characteristics not found by the General Thoracic Surgery Database. Researchers observed similar findings in this cohort.

Still, the use of databases may limit these findings, Boffa noted.

“Databases don’t let us know why the patient was treated in the way they were,” Boffa said. “Therefore, even though we attempted to correct for any differences that were seen between patients who had minimally invasive surgery and those who had a traditional approach through a larger incision, it is possible that the two groups were different in ways that are not captured by the database, and that these differences biased one of the groups.

“Hopefully, more patients will be given the opportunity to have their early-stage lung cancer removed by way of a minimally invasive surgery,” he added.

Linking data from the General Thoracic Surgery Database and CMS allowed for high-quality estimates of long-term outcomes, Jessica S. Donington, MD, MSCR, assistant professor of cardiothoracic surgery and director of the Thoracic Surgery Translational Laboratory at NYU Langone Health, wrote in a related editorial.

“For the first time, we can investigate the impact of specific aspects of perioperative surgical care

on long-term oncologic outcomes; this has never before been possible on a large-scale basis,” Donington wrote. “We should expect to see other insightful studies from this collaborative effort in the future.”

Minimally invasive resection is becoming the standard of care for early-stage lung cancer, so patients and clinicians should be open to finding a surgeon who is an expert in the procedure.

“As we move into an era where CT screening should result in the diagnosis of [smaller], early-stage tumors, the ability to remove them safely with minimal morbidity and mortality and rapid return to normal health is of increased importance,” Donington wrote. – by Melinda Stevens

For more information:

Daniel J. Boffa , MD, Yale School of Medicine, PO Box 208062, New Haven, CT 06520-8062; e-mail: daniel.boffa@yale.edu.

Disclosures: Boffa reports research funding from Epic Sciences. Please see the full study for a list of all other authors’ relevant financial disclosures. Donington reports honoraria, a consultant or advisory role, and travel, accommodations and expenses from AstraZeneca.