BTOG 2018: Lung cancer keyhole surgery increases survival and reduces recovery time.

Take away

Patients who underwent video-assisted thoracoscopic surgery (VATS) for lung cancer had better 30-day, 90-day and 1-year survival compared with patients treated with conventional open lobectomy and spent fewer days in hospital.

Why this matters

• First study to show differences in survival between lung cancer patients undergoing VATS and conventional open lobectomy.
• The study included 4,498 patients.

Study design

• The Lung Cancer Clinical Outcomes project extracted data for surgical resection carried out at 28 surgical trusts between 1^st January and 31^st December 2015.  
• The investigators calculated unadjusted survival at 30 days, 90 days and 1 year from the date of surgery and post-op median length of hospital stays.

Key results

• Of 4498 patients undergoing lung cancer surgery 2229 (49.6%) had open lobectomy, 1974 (43.9%) had VATS, 196 had open lobectomy after VATS (4.4%), 30 (0.7%) had robotic surgery and 4 (0.09%) had open lobectomy  from robotic and 65 (1.45%) were unknown.
• The median length of stay in hospital was 7 days for open, 5 days for VATS, 8 days for open from VATs, 5 days for robotic, 7.5 days for open from robotic and 8 days for unknown.
• Of 69 patients who had died by 30 days 47 (68.1%) had open, 17 (24.6%) had VATS, 1 had open from VATs(1.45%), 1 (1.45%) had robotic, and 1 (1.45%) had open from robotic and 2 (2.9%) were unknown.
• Of 147 patients who had died at 90 days 93 (63.3%) had open, 43 (29.25%) had VATS, 6 (4.1%) had open from VATS, 1 (0.68%) had robotic, 1 (0.68%) had open from robotic and 3 (2.04%) were unknown.
• Of 497 patients who had died at 1 year 294 (59.15%) had open, 171 (34.4%) had VATS, 23 (4.6%) had open from VATS, 2(0.4%) had robotic, 1(0.2%) had open from robotic, and 6 (1.21%) were unknown.
• Patients offered VATS in comparison to patients offered open lobectomy were more likely to be female (p=0.001), older than 65 years (p=0.001) and have earlier stage disease (p<0.001).

Limitations

• Retrospective registry analysis.
• Unclear from results whether patient factors or surgical approach accounted for the differences.

Expert commentary

Dr. Ian Woolhouse, from University Hospital of Birmingham, said: “This study can be used to reassure surgeons that they are right to push for less invasive surgery. Already half of UK centres perform VATS surgery and I think these results will encourage the others to take it up. There has been a randomised trial showing equivalence between the two forms of surgery and another trial is ongoing. The issue with trials is that they include less patients than registries with the result that the overall number of deaths is likely to be too small to show meaningful differences in  survival. Trials, however, can show effects on recovery times.”