Long-term outcome and cost-effectiveness of complete versus assisted video-assisted thoracic surgery for non-small cell lung cancer

Systematic Literature Review to Identify Cost and Resource Use Data in Patients with Early-Stage Non-small Cell Lung Cancer (NSCLC)

BACKGROUND

Approximately 2 million new cases and 1.76 million deaths occur annually due to lung cancer, with the main histological subtype being non-small cell lung cancer (NSCLC). The costs and resource use associated with NSCLC are important considerations to understand the economic impact imposed by the disease on patients, caregivers and healthcare services.

OBJECTIVE

The objective of this systematic literature review (SLR) is to provide a comprehensive overview of the available direct medical costs, direct non-medical costs, indirect costs, cost drivers and resource use data available for patients with early-stage NSCLC.

METHODS

Electronic searches were conducted via the Ovid platform in March 2021 and June 2022 and were supplemented by grey literature searches. Eligible patients had early-stage (stage I-III) resectable NSCLC and received treatment in the neoadjuvant or adjuvant setting. There was no restriction on intervention or comparators. Publication date was restricted to 2011 onwards, and English language publications or non-English language publications with an English abstract were of primary interest. Due to the anticipation of many studies meeting the inclusion criteria, analyses were restricted to full publications from countries of primary interest (Australia, Brazil, Canada, China, France, Germany, Italy, Japan, South Korea, Spain, UK and the US) and those with > 200 patients. The Molinier checklist was applied to conduct quality assessment.

RESULTS

Forty-two full publications met the eligibility criteria and were included in this SLR. Early-stage NSCLC was associated with significant direct medical costs and healthcare utilisation, and the economic burden of the disease increased with its progression. Surgery was the primary cost driver in stage I patients, but as patients progressed to stage II and III, treatments such as chemotherapy and radiotherapy, and inpatient care became the main cost drivers. There was no significant difference in resource use between patients with early-stage disease. However, these data were heavily US-centric and there was a paucity of data relating to direct non-medical and indirect costs associated with early-stage NSCLC.

CONCLUSIONS

Preventing disease progression for patients with NSCLC could reduce the economic burden of NSCLC on patients, caregivers and healthcare systems. This review provides a comprehensive overview of the available cost and resource use data in this indication, which is important in guiding the decisions of policy makers regarding the allocation of resources. However, it also indicates a need for more studies comparing the economic impact of NSCLC in markets in addition to the US.

Effects of da Vinci robot versus thoracoscopic surgery on body trauma and lymphocyte subsets in lung cancer patients: A propensity score matching study

BACKGROUND

To assess the impact of da Vinci robot versus thoracoscopic surgery on body trauma and lymphocyte subsets in lung cancer patients.

METHODS

Retrospective analysis of 352 patients with lung cancer treated by minimally invasive surgery completed by the same operator in the Department of Thoracic Surgery, Gansu Provincial People's Hospital from October 2019 to October 2022. According to the surgical procedure, the patients were divided into a robotic-assisted thoracic surgery (RATS) group (n = 159) and a video-assisted thoracoscopic surgery group (VATS) (n = 193), respectively. Propensity score matching (PSM) analysis was performed in both groups, and perioperative indicators were recorded. Levels of inflammatory markers (C-reactive protein, CRP; interleukin-6, IL-6) and lymphocyte subsets (CD3+ , CD4+ , CD8+ , and CD4+ /CD8+ ) were measured 1 day before surgery and 1, 3, and 5 days after surgery, respectively. To compare the effects of the two surgical procedures on the trauma and lymphocyte subsets of the patient's organism.

RESULTS

One hundred and thirty-eight patients in each group after PSM. Compared with the VATS group, the RATS group had shorter operative time (p < 0.001), less intraoperative bleeding (p < 0.001), less postoperative chest drainage (p = 0.029), shorter postoperative chest drainage time (p = 0.008), and shorter postoperative hospital stay (p = 0.005). The levels of CRP and IL-6 increased in both groups after surgery compared with those before surgery, and the increase was less in the RATS group than that in the VATS group. Postoperative T-lymphocyte levels were lower in both groups compared with preoperative levels, and T-lymphocyte levels were significantly lower in the VATS group compared with the RATS group.

CONCLUSION

Compared with VATS for treating lung cancer, RATS has advantages in short-term efficacy, and smaller surgical trauma to patients, which can reduce the body's inflammatory response. It also has less impact on T lymphocyte subpopulations, which can better protect patients' immune function.

Post-Treatment Mortality After Surgery and Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer

Purpose In early-stage non-small cell lung cancer (NSCLC), post-treatment mortality may influence the comparative effectiveness of surgery and stereotactic body radiotherapy (SBRT), with implications for shared decision making among high-risk surgical candidates. We analyzed early mortality after these interventions using the National Cancer Database. Patients and Methods We abstracted patients with cT1-T2a, N0, M0 NSCLC diagnosed between 2004 and 2013 undergoing either surgery or SBRT. Thirty-day and 90-day post-treatment mortality rates were calculated and compared using Cox regression and propensity score-matched analyses. Results We identified 76,623 patients who underwent surgery (78% lobectomy, 20% sublobar resection, 2% pneumonectomy) and 8,216 patients who received SBRT. In the unmatched cohort, mortality rates were moderately increased with surgery versus SBRT (30 days, 2.07% v 0.73% [absolute difference (Δ), 1.34%]; P < .001; 90 days, 3.59% v 2.93% [Δ, 0.66%]; P < .001). Among the 27,200 propensity score-matched patients, these differences increased (30 days, 2.41% v 0.79% [Δ, 1.62%]; P < .001; 90 days, 4.23% v 2.82% [Δ, 1.41%]; P < .001). Differences in mortality between surgery and SBRT increased with age, with interaction P < .001 at both 30 days and 90 days (71 to 75 years old: 30-day Δ, 1.87%; 90-day Δ, 2.02%; 76 to 80 years old: 30-day Δ, 2.80%; 90-day Δ, 2.59%; > 80 years old: 30-day Δ, 3.03%; 90-day Δ, 3.67%; all P ≤ .001). Compared with SBRT, surgical mortality rates were higher with increased extent of resection (30-day and 90-day multivariate hazard ratio for mortality: sublobar resection, 2.85 and 1.37; lobectomy, 3.65 and 1.60; pneumonectomy, 14.5 and 5.66; all P < 0.001). Conclusion Differences in 30- and 90-day post-treatment mortality between surgery and SBRT increased as a function of age, with the largest differences in favor of SBRT observed among patients older than 70 years. These representative mortality data may inform shared decision making among patients with early-stage NSCLC who are eligible for both interventions.

Cost/efficacy evaluation of the technologies applied to video-assisted thoracoscopic surgery lobectomy

Superior outcomes after video-assisted thoracoscopic surgery (VATS) pulmonary lobectomy have been demonstrated, compared with thoracotomy, for patients affected by early-stage non-small cell lung cancer (NSCLC). However, in an era of rising health care costs and controlled resources, the overall medical cost of surgical procedures is measured by the hospitals' marketing offices. Several factors such as surgical technique, conversion rate, length of stay, post-operative complications occurrence and mainly the introduction of new surgical technologies (disposables and devices) could influence the cost-effectiveness of VATS procedures. However, increased operating room costs are counteracted by shorter hospital stay and reduced ward bed stays providing further resources for other patients. Thus, choosing a surgical approach and assessing whether a specific technique is cost-effective is mandatory for a modern thoracic surgeon to justify its expenses. This review tries to reach a conclusion by comparing all recent studies reporting a cost analysis for VATS lobectomy, especially for new technologies used for VATS lobectomy. Nevertheless, no sufficient evidences are published to assess VATS new technologies sustainability and further cost analyses are necessary before VATS lobectomy expense is deemed justified.

Complete video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy

BACKGROUND

To explore the effectiveness of video-assisted thoracoscopic surgery (VATS) bronchial sleeve resection and reconstruction.

METHODS

The clinical data of patients who had received VATS bronchial sleeve lobectomy in our center from January 2008 to February 2015 were retrospectively analyzed.

RESULTS

Totally 118 patients (105 men and 13 women) received the VATS bronchial sleeve lobectomy. The procedures included sleeve resection of right upper lobe (n=59), right middle lobe (n=7), right lower lobe (n=8), left upper lobe (n=34), and left lower lobe (n=10). The lesions were confirmed to be squamous cell carcinoma (n=68), adenocarcinoma (n=16), mucoepidermoid carcinoma (n=8), adenosquamous carcinoma (n=7), large cell carcinoma (n=1), carcinoids (n=5), and others (n=13; including small cell carcinoma, pleomorphic carcinoma, and inflammatory myofibroblastic tumor). Operations lasted 118-223 min [mean ± standard deviations (SD): 124.00±31.75 min]. The length of removed bronchus was 1.50-2.00 cm (mean ± SD: 1.75±0.26 cm). The duration of bronchial anastomosis (from the first puncture to the completion of knotting) was 15-42 min (mean ± SD: 30.20±7.97 min). The number of dissected lymph node stations (at least three mediastinal lymph node stations, including station 7) was 5-9 stations (mean ± SD: 6.50±1.18 min). The number of dissected lymph nodes was 10-46 (mean ± SD: 26.00±10.48). The intraoperative blood loss was 20-400 mL (mean ± SD: 71.00±43.95 mL), and no blood transfusion was performed. All patients were observed in intensive care unit (ICU) for 1 day. Postoperative drainage was performed for 3-8 days (mean ± SD: 5.00±1.49 days). Postoperative hospital stay was 3-8 days (mean ± SD: 5.10±2.07 days).

CONCLUSIONS

VATS bronchial sleeve resection and reconstruction is a safe and feasible technique.

Complete video-assisted thoracoscopic lobectomy of the left lower lobe and lung lymph node dissection

We describe herein a case of complete video-assisted thoracoscopic lobectomy of the left lower lobe and lung lymph node dissection. The patient was a 67-year-old man. A physical examination revealed a nodule in the left lower lobe that had been present for 7 years. According to the chest computed tomography (CT) report recently, a diagnosis of lung cancer was not excluded. Due to the surgical indications, he was underwent complete video-assisted thoracoscopic lobectomy of the left lower lobe and lung lymph node dissection. The frozen pathology report was consistent with adenocarcinoma. He recovered smoothly, without any perioperative complications.

Cost and effectiveness of video-assisted thoracoscopic surgery for clinical stage I non-small cell lung cancer: a population-based analysis

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive alternative to conventional surgery (CS). We aimed to estimate the short-term cost-effectiveness of VATS vs. CS for clinical stage I non-small cell lung cancer (NSCLC-c-stage-I) patients from the payer's perspective (National Health Insurance).

METHODS

We identified NSCLC-c-stage-I patients diagnosed and received surgery within 2007-2009 through a comprehensive population-based database containing cancer and death registries, and reimbursement data. The duration of interest was 1 year. We included potential confounding covariables through literature searching and our own experience, and used a propensity score to construct a 1:1 population for adjustment.

RESULTS

Our study population constituted 966 patients. The mean hospital stay [days, standard deviation (SD)] were 14.4 [7] and 16.1 (7.7) for VATS and CS respectively (P=0.002). The mean cost (2013 USD) and survival (year) was $22,316 vs. $21,976 and 0.98 vs. 0.974 for VATS vs. CS. The probability for VATS to be cost-effective (i.e., positive net benefit) was 0.49 & 0.56 at willingness-to-pay (WTP) 50,000 & 100,000 USD/life-year, respectively.

CONCLUSIONS

We provide the first empirical evidence that when compared to CS, VATS was potentially cost-effective in the short term (1 year) within the common WTP levels in Taiwan.

Safety and feasibility of video-assisted thoracoscopic surgery for stage IIIA lung cancer

OBJECTIVE

The current study was prospectively designed to explore the application of video-assisted thoracoscopic surgery (VATS) radical treatment for patients with stage IIIA lung cancer, with the primary endpoints being the safety and feasibility of this operation and the second endpoints being the survival and complications after the surgery.

METHODS

A total of 51 patients with radiologically or mediastinoscopically confirmed stage IIIA lung cancer underwent VATS radical treatment, during which the standard pulmonary lobectomy and mediastinal lymph node dissection were performed after pre-operative assessment. The operative time, intraoperative blood loss/complications, postoperative recovery, postoperative complications, and lymph node dissection were recorded and analyzed. This study was regarded as successful if the surgical success rate reached 90% or higher.

RESULTS

A total of 51 patients with non-small cell lung cancer (NSCLC) were enrolled in this study from March 2009 to February 2010. The median post-operative follow-up duration was 50.5 months. Of these 51 patients, 41 (80.4%) had N2 lymph node metastases. All patients underwent the thoracoscopic surgeries, among whom 50 (98%) received pulmonary lobectomy and mediastinal lymph node dissection completely under the thoracoscope, 6 had their incisions extended to about 6 cm due to larger tumor sizes, and 1 had his surgery performed using a 12 cm small incision for handling the adhesions between lymph nodes and blood vessels. No patient was converted to conventional open thoracotomy. No perioperative death was noted. One patient received a second surgery on the second post-operative day due to large drainage (>1,000 mL), and the postoperative recovery was satisfactory. Up to 45 patients (88.2%) did not suffer from any perioperative complication, and 6 (11.8%) experienced one or more complications.

CONCLUSIONS

VATS radical treatment is a safe and feasible treatment for stage IIIA lung cancer.

Management of the pulmonary artery during video-assisted thoracoscopic left upper lobectomy

BACKGROUND

Complete video-assisted thoracoscopic surgery (c-VATS) for left upper lobectomy is difficult due to the branching pattern of the left pulmonary artery.

OBJECTIVE

Our purpose was to report outcomes of a modified technique of c-VATS left upper lobectomy.

METHODS

We retrospectively compared the outcomes of 83 patients with stage I/II non-small-cell lung cancer (NSCLC) who received left upper lobectomy between 2008 and 2011; 32 underwent conventional c-VATS and 50 received modified c-VATS. In the modified procedure, the order in which hilum of lung was treated was from the lingular segmental artery to the superior pulmonary vein to the bronchus, and then finally the pulmonary artery.

RESULTS

The mean patient age was 63.6 ± 8.4 years, and no differences were observed in age, gender, and largest tumor diameter between the two groups. No conversion occurred in either group. The surgical time for modified c-VATS was significantly shorter than that for conventional c-VATS (210 vs. 270 min, p < 0.001). Drainage time after surgery and length of hospitalization for the modified c-VATS group were significantly less than those for the conventional group (drainage 3 vs. 4 days, respectively, p = 0.041; length of hospitalization 7 versus 12 days, respectively; p < 0.001). Surgical margins were clear in all cases. Four (8.0 %) complications occurred in the modified procedure group compared with ten (31.3 %) in the conventional group (p = 0.015).

CONCLUSION

This new technique offers shorter surgical and postoperative drainage time, shorter hospital stays, and fewer complications than conventional c-VATS upper left lobectomy.

Comparative study of systematic thoracoscopic lymphadenectomy and conventional thoracotomy in resectable non-small cell lung cancer

OBJECTIVE

To assess the feasibility and safety of the video-assisted thoracoscopy surgery (VATS) systematic lymph node dissection in resectable non-small cell lung cancer (NSCLC).

METHODS

The clinical data of patients with NSCLC who underwent VATS or thoracotomy combined with lobectomy and systematic lymphadenectomy from January 2001 to January 2008 were retrospectively analyzed to identify their demographic parameters, number of dissected lymph nodes and postoperative complications.

RESULTS

A total of 5,620 patients were enrolled in this study, with 2,703 in the VATS group, including 1,742 men (64.4%), and 961 women (35.6%), aged 59.5±10.9 years; and 2,917 in the thoracotomy group, including 2,163 men (74.2%), and 754 women (25.8%), aged 58.5±10.4 years. Comparing the VATS with the thoracotomy groups, the mean operative time was 146 vs. 157 min, with a significant difference (P<0.001); and the average blood loss was 162 vs. 267 mL, with a significant difference (P<0.001). Comparing the two groups of patients data, the number of lymph node dissection: 18.03 in the VATS group and 15.07 in the thoracotomy group on average, with a significant difference (P<0.001); postoperative drainage time: 4.5 days in the VATS group and 6.37 days in the thoracotomy group on average, with a significant difference (P<0.001); postoperative hospital stay: 6.5 days in the VATS group and 8.37 days in the thoracotomy group on average, with a significant difference (P<0.001); proportion of postoperative chylothorax: 0.2% (4/2,579) in the VATS group and 0.4% (10/2,799) in the thoracotomy group, without significant difference (P>0.05).

CONCLUSIONS

For patients with resectable NSCLC, VATS systematic lymph node dissection is safe and effective with fewer postoperative complications, and significantly faster postoperative recovery compared with traditional open chest surgery.

Chinese multi-institutional registry (CMIR) for resected non-small cell lung cancer: survival analysis of 5,853 cases

BACKGROUND

Concerns on surgical treatment of non-small cell lung cancer (NSCLC) have been increasing recent years. However, the significance of previous studies based on single center or regional experience in China was impaired by small sample size. Here we described a Chinese Multi-institutional Registry (CMIR) to address this disadvantage and proposed a further collaboration project.

METHODS

Information of patients diagnosed with stage I to III NSCLC who underwent radical resection between 2001 and 2008 in seven institutions from the People's Republic of China was collected using a blinded standardized data form. Survival outcomes were calculated by Kaplan-Meier curves and Life-table method.

RESULTS

A total of 5,853 patients who met the inclusion criteria were entered into the database. The average age was 58.9±10.7 years. Males (59.5%) and adenmocarcinoma (53.0%) represented the majority of all cases. Lobectomy (87.9%) was the major operation type in practice. The 5-year overall survival rates were 81.9% for stage IA, 71.6% for IB, 55.0% for IIA, 45.2% for IIB, 34.9% for IIIA and 23.3% for IIIB (P<0.001).

CONCLUSIONS

This is the first and the largest clinical database for resected NSCLC in China with optimal data quality. Future collaboration to expand and share this database nationwide is warranted.

Feasibility of complete video-assisted thoracoscopic surgery following neoadjuvant therapy for locally advanced non-small cell lung cancer

OBJECTIVE

To explore the feasibility of complete video-assisted thoracoscopic surgery (c-VATS) following neoadjuvant therapy (chemotherapy, targeted therapy and radiotherapy, either alone or in combination) for the treatment of patients with non-small cell lung cancer (NSCLC).

METHODS

The clinical data of 43 NSCLC patients undergoing c-VATS following neoadjuvant therapy were retrospectively analyzed, including the preoperative functional indicators, staging, concurrent diseases, surgical techniques, operation time, number of lymph nodes dissected and postoperative drainage time and quantity, postoperative hospital stay, postoperative complications, and survival.

RESULTS

From January 2006 to March 2012, a total of 43 patients with stage IIA-IIIB NSCLC were included in this study (IIIA: 27 cases, 62.8%; IIIB: 11 cases, 25.6%), including 32 males (74.4%) and 11 females (25.6%). Forty-two patients were operated successfully, 28 underwent pulmonary lobectomies (including 9 bronchial sleeve resections), 5 had double lobectomies, 5 had wedge resections, and 4 had total pneumonectomies. Seven patients were referred to undergo Hybrid VATS (7/42, 16.7%). The mean length of the operation was 160.48±16.52 min (range, 130-180 min); the intraoperative blood loss was 253.57±117.08 mL; the number of lymph nodes dissected was 16.88±10.93; the postoperative drainage time was 1-7 d (mean: 2.62±0.96 d); and the postoperative hospital stay was 3-7 d (mean: 5.45±1.30 d). The incidence of postoperative complications was 9.5% (4/42), and the perioperative mortality was 2.4% (1/42). The 1-, 2-, and 3-year overall survival rates were 94%, 79%, and 65%, respectively.

CONCLUSIONS

c-VATS following neoadjuvant therapy is safe and feasible for the treatment of locally advanced NSCLC.

Hybrid video-assisted thoracic surgery with segmental-main bronchial sleeve resection for non-small cell lung cancer

BACKGROUND

The purpose of the current study is to present the clinical and surgical results in patients who underwent hybrid video-assisted thoracic surgery with segmental-main bronchial sleeve resection.

METHODS

Thirty-one patients, 27 men and 4 women, underwent segmental-main bronchial sleeve anastomoses for non-small cell lung cancer between May 2004 and May 2011.

RESULTS

Twenty-six (83.9%) patients had squamous cell carcinoma, and 5 patients had adenocarcinoma. Six patients were at stage IIB, 24 patients at stage IIIA, and 1 patient at stage IIIB. Secondary sleeve anastomosis was performed in 18 patients, and Y-shaped multiple sleeve anastomosis was performed in 8 patients. Single segmental bronchiole anastomosis was performed in 5 cases. The average time for chest tube removal was 5.6 days. The average length of hospital stay was 11.8 days. No anastomosis fistula developed in any of the patients. The 1-, 2-, and 3-year survival rates were 83.9%, 71.0%, and 41.9%, respectively.

CONCLUSION

Hybrid video-assisted thoracic surgery with segmental-main bronchial sleeve resection is a complex technique that requires training and experience, but it is an effective and safe operation for selected patients.

The feasibility of a Two-incision video-assisted thoracoscopic lobectomy

Background

This study is to evaluate the feasibility and safety of video-assisted thoracoscopic (VATS) lobectomy with two incisions.

Methods

A total of 73 patients (male 47, female 26; mean age 61.2 ± 12.00 years old) who underwent major pulmonary resection, through VATS, using two incisions were included in this study. The thoracoscopy port was placed at the 7th or the 8th intercostal space in the mid-axillary line, and the working port, 3~5 cm long, at the 5th intercostal space, on the operator’s side.

Results

The preoperative diagnosis was benign lung disease in 8 patients (11.0%) and malignant lung disease in 65 (89.0%). Two patients (3.1%) needed a third port during surgery due to severe pleural adhesion, and conversion to thoracotomy was needed in 5 (6.8%), due to bleeding at pulmonary arterial branch (n = 3), anthracofibrotic lymph nodes around pulmonary artery (n = 1), and severe pleural adhesion (n = 1). The mean duration of the operation in the 66 patients, completed by a two-incision VATS lobectomy, was 163.4 ± 30.40 minutes. In 56 cases, which were completed by a two-incision VATS lobectomy for primary lung cancer, a total number of dissected lymph nodes per patient were 20.2 ± 11.2. The chest tube was removed on postoperative day 5.4 ± 2.8, and there was no occurrence of major perioperative morbidity and mortality.

Conclusions

Two-incision VATS lobectomy is applicable in the selected cases, and may obtain similar results with the conventional VATS lobectomy, through a certain period of learning curve.

History and current status of mini-invasive thoracic surgery

Mini-invasive thoracic technique mainly refers to a technique involving the significant reduction of the chest wall access-related trauma. Notably, thoracoscope is the chief representative. The development of thoracoscope technique is characterized by: developing from direct peep to artificial lighting, then combination with image and video technique in equipments; technically developing from diagnostic to therapeutic approaches; developing from simpleness to complexity in application scope; and usually developing together with other techniques. At present, the widely used mini-invasive thoracic surgery refers to the mini-open thoracic surgery performed mainly by using some instruments to control target tissues and organs based on the vision associated with multi-limb coordination, which may be hand-assisted if necessary. The mini-invasive thoracic surgery consists of three approaches including video-assisted thoracic surgery (VATS), video-assisted Hybrid and hand-assisted VATS. So far the mini-invasive thoracic technique has achieved great advances due to the development in instruments of mini-invasive thoracic surgery which has the following features: instruments of mini-invasive thoracic surgery appear to be safe and practical, and have successive improvement and diversification in function; the specific instruments of open surgeries has been successively developed into dedicated instruments of endoscopic surgery; the application of endoscopic mechanical suture device generates faster fragmentation and reconstruction of organ tissues; the specific delicated instruments of endoscopic surgery have rapid development and application; and the simple instruments structurally similar to the conventional instruments are designed according to the mini-incison. In addition, the mini-invasive thoracic technique is widely used in five aspects including diseases of pleura membrane and chest wall, lung diseases, esophageal diseases, mediastinal diseases and heart diseases. However, there remain many problems in specifications and trainings, economic cost, conservation and innovation. Therefore, particular attention should be paid to these problems. Nevertheless, the promotion of thoracic surgery appears promising in the future.