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Ann Thorac Surg 2008;86:2008-2018. doi:10.1016/j.athoracsur.2008.07.009
© 2008 The Society of Thoracic Surgeons
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Review

Surgery for Early-Stage Non-Small Cell Lung Cancer: A Systematic Review of the Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Approaches to Lobectomy

Bryan A. Whitson, MD, PhDa, Shawn S. Groth, MDa, Susan J. Duval, PhDb, Scott J. Swanson, MDc, Michael A. Maddaus, MDa,*

a Department of Surgery, Division of Thoracic and Foregut Surgery, University of Minnesota, Minneapolis, Minnesota
b School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
c Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York

* Address correspondence to Dr Maddaus, University of Minnesota Department of Surgery, MMC 207, 420 Delaware St. SE, Minneapolis, MN 55455 (Email: madda001{at}umn.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Video-assisted thoracoscopic surgery (VATS) for lobectomy has been touted to provide superior outcomes, compared with thoracotomy, for patients with early-stage non-small-cell lung cancer (NSCLC). However, supporting data are limited to case series and small observational studies. We hypothesized that a systematic review of the literature would enable a more objective evaluation of the evidence in order to determine the potential superiority of the VATS approach, compared with thoracotomy, in terms of short-term morbidity and long-term survival. To identify relevant articles for inclusion in our analysis, we performed a systematic review of the MEDLINE database. We looked for randomized controlled trials, observational studies, and case series that reported outcomes after VATS or thoracotomy lobectomy for NSCLC. For statistical testing, we used a two-sided approach ({alpha} = 0.05) under the hypothesis that VATS lobectomy is superior to thoracotomy lobectomy. We screened 17,923 studies. After independent review of the abstracts by 2 reviewers, we included 39 studies (only one randomized controlled trial) in our analysis. In aggregate, these 39 studies involved 3256 thoracotomy and 3114 VATS patients. The characteristics of the two groups were not significantly different. Compared with thoracotomy, VATS lobectomy was associated with shorter chest tube duration, shorter length of hospital stay, and improved survival (at 4 years after resection), all statistically significant. Compared with lobectomy performed by thoracotomy, VATS lobectomy for patients with early-stage NSCLC is appears to favor lower morbidity and improved survival rates.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
The variety of procedures that can be performed using minimally invasive surgical approaches is expanding. In the 1990s, surgeons began using video-assisted thoracoscopic surgery (VATS) to perform lobectomies. As experience grew, VATS lobectomy began to be used to treat patients with early-stage (ie, stage I and II) non-small cell lung cancer (NSCLC). Proponents of the VATS approach have touted several potential advantages compared with a thoracotomy: less morbidity, shorter convalescence, and superior survival rates. Critics of the VATS approach have argued that it may not be an equivalent oncologic operation. Unfortunately, prospective multi-institutional randomized trials have not been performed; the evidence in the literature to guide surgical management of early-stage NSCLC is limited to single institution case series and small observational studies.

We used a systematic review of the literature to enable a more objective assessment of the published evidence available and permit a more accurate comparison of VATS vs thoracotomy lobectomy for early-stage NSCLC in terms of short-term morbidity and long-term survival rates. This was intended to help resolve uncertainty and efficacy between the two approaches. We formulated four hypotheses: compared with open lobectomy, patients who undergo VATS lobectomy have (1) a lower overall complication rate, (2) a shorter duration of chest tube drainage, (3) a shorter length of stay, and (4) a superior overall survival rate during the first 5 years after NSCLC resection.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 Acknowledgments
 References
 
Data Collection
To identify relevant articles for inclusion in our analysis, we performed a structured literature retrieval of the MEDLINE database. We looked for randomized controlled, trials, observational studies, and case series that reported outcomes after either VATS or thoracotomy lobectomy for NSCLC. Our MEDLINE search algorithm (Fig 1) began by querying for non-small cell lung carcinoma (medical subject heading) and for non-small cell lung cancer (mapping term). This query yielded article abstracts from 17,923 studies. We excluded articles with the medical subject headings of antineoplastic combined chemotherapy protocols, neoadjuvant therapy, chemotherapy, and drug evaluation. Of the remaining articles, we included only those containing lobectomy as a mapping term, leaving 446. We then excluded case reports, letters, comments, editorials, and reviews. Finally, we limited our final analysis to articles written in English, involving humans, and published from January 1, 1992 (the year the first VATS lobectomy was performed), through April 30, 2007.


Figure 1
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  		Fig 1. The algorithm of the systematic review's MEDLINE search schema demonstrates the criteria for limiting and excluding articles as well as the number of articles identified at each step.

 
Using these search criteria, we identified 282 potential articles for inclusion in our analysis. The abstracts of these articles were reviewed by 2 independent reviewers, using the inclusion criteria of (1) at least 10 patients in the study underwent either VATS or open lobectomy and (2) the abstract specifically indicated that the article contained data on complication rates, chest tube duration, length of hospital stay, or survival rates. After independent review of the abstracts, 61 articles were included. After we reviewed those 61 articles, we included 39 in our analysis. The other 22 articles were excluded because they did not contain the specific data mentioned in the abstract or because they did not subdivide their results by disease stage or by surgical approach (ie, they only presented aggregate data). For our analysis, we looked at articles which reported data for clinical stage I and those that reported data on pathologic stage I.

Statistical Analysis
Because variability of continuous outcomes (length of stay and chest tube duration) from individual studies was typically unavailable, pooled estimates were calculated by weighting according to the sample size of the study from which they was taken. Proportions were transformed to the logit scale before pooling. Statistical comparison of the two surgical approaches was performed using a random effects meta-regression model with surgical approach as the covariate. Heterogeneity was assessed with I2 [1]. In studies where the complication rate was not reported, we calculated it as the sum of the individual complication rates. If the overall survival rates were not explicitly stated, we extracted them from survival curves (when provided). Results are reported as mean and 95% confidence interval. Data on length of stay and complications from McKenna (1998) [2], which potentially were duplicated in a subsequent publication [3], were excluded from the analysis. All statistical analyses were performed using Stata 10.0 software (StataCorp, College Station, TX) and using a two-sided approach ({alpha} = 0.05).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 Acknowledgments
 References
 
Study Characteristics
Of the 39 articles included in our analysis, 22 provided data on the VATS approach and 27 on thoracotomy. Twenty-nine manuscripts provided data on a single approach, 10 on both approaches. In aggregate, the studies involved 3256 thoracotomy lobectomy patients and 3114 VATS lobectomy patients. The two groups were not significantly different with regards to patient characteristics or tumor histology (Table 1) [4–30]. The demographics of the two groups were not significantly different in terms of age, gender, and the proportion of adenocarcinoma (Table 1). The thoracotomy group did have a higher proportion of squamous cell carcinoma. Between the VATS and thoracotomy study groups there were no statistical differences between the proportions of patients with clinical stage I (p = 0.35), and pathologic stage I (p = 0.27), II (p = 0.17), and III (p = 0.30) disease. Only four manuscripts described tumor size. From those that did, there was no statistical difference (p = 0.46) between tumor size (VATS: 2.61 ± 0.55 cm, n = 107 [4, 5]; thoracotomy: 2.43 ± 0.78 cm, n = 448 [7, 14, 17, 30]).


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  		Table 1 Study Characteristics
 
Perioperative Morbidity
In our analysis of the complication rates in the two groups, 12 VATS and 9 thoracotomy articles reported data that could be extracted and 11 VATS studies were analyzed (Table 2). The overall complication rate after VATS lobectomy of 16.4% was significantly lower (p = 0.018) than that after thoracotomy lobectomy of 31.2% (Table 3).


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  		Table 2 Overall Complication Rates
 

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  		Table 3 Univariate Comparison of Surgical Approach to Lobectomy
 
Chest tube duration data were reported in 9 VATS and 7 thoracotomy articles (Table 4). The VATS approach was associated with a significantly shorter (p = 0.025) chest tube duration (4.2 days) than the thoracotomy approach (5.7 days) (Table 3).


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  		Table 4 Chest Tube Duration
 
Hospital length of hospital stay data were reported in 15 VATS and 12 thoracotomy articles (Table 5). Only 14 VATS studies were analyzed due to duplicate data. The VATS approach was associated with a significantly shorter (p = 0.016) overall hospital length of stay (8.3 days) than thoracotomy lobectomy (13.3 days; Table 3).


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  		Table 5 Overall Hospital Length of Stay
 
We also determined rates of atrial fibrillation, pneumonia, and persistent air leak from the limited number of studies that reported them. For all three of these complications, we noted nonsignificant, lower rates after VATS compared with thoracotomy (summary data in Table 3).

Overall Survival Rates
The pooled data on the overall survival rates of VATS and thoracotomy lobectomy patients are highlighted in Tables 3 and 6.Go Annual overall survival rates (postoperative year 1 through 5) from the time of surgical resection were lower in the VATS studies at all years. At 4 years after surgical resection, the VATS approach demonstrated a 17% higher survival than the thoracotomy approach, which was significant (p = 0.003).


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  		Table 6 Overall Survival Rates
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 Acknowledgments
 References
 
Systematic Review Analysis
Level I data directly comparing VATS with thoracotomy lobectomy for the treatment of early-stage (I or II) NSCLC are not available. Rather, the literature is limited to case series and small retrospective cohort studies. Previous attempts at performing multi-institution trials to compare the outcomes of thoracotomy vs VATS lobectomy were impaired by poor accrual rates.

Speculation about one of the reasons for poor accrual was a lag in the dissemination of the technical skills necessary to perform VATS lobectomy among practicing surgeons, many of whom did not receive instruction in the VATS approach as part of their fellowship training. Another speculation is that attempts at randomized trials were inhibited by limited compliance with the approach to which patients were randomly assigned. For instance, surgeons capable of performing VATS lobectomy often rebuffed the treatment assignment when their patients in whom a VATS approach was feasible were randomly assigned to undergo thoracotomy lobectomy, citing their conviction that the thoracotomy in such patients was a more morbid operation. In addition, the patients themselves may have played a role by requesting the less invasive approach. We believe that the data in the current analysis can objectively evaluate the question since the groups did not differ between cell type, gender, age, stage, or size of the lesions resected.

Given such poor accrual, and the very low likelihood that such level I data will ever be available, our intent was to critically examine the data available in the literature. Through our structured search of the literature, subsequent review, and systematic review analysis, we answered these four questions:

1 Is VATS lobectomy associated with a lower complication rate than thoracotomy lobectomy?
2 Do patients who undergo VATS lobectomy have shorter chest tube duration than thoracotomy lobectomy patients?
3 Is VATS lobectomy associated with a shorter hospital length of stay than thoracotomy lobectomy? and
4 Does VATS lobectomy confer a superior overall survival advantage compared with the thoracotomy lobectomy?

Using the best available data in the literature, we found that the answer to these questions favored the VATS approach (survival was significant at 4 years only; Table 3).

In an attempt to answer these questions prospectively, the Cancer and Leukemia Group B (CALGB) sponsored the trial CALGB 140501: VATS Lobectomy vs Open Lobectomy, a registry study to examine and to compare the outcomes after VATS and open lobectomy for stage I NSCLC. Unfortunately, despite receiving initial support from the National Cancer Institute's Cancer Therapy Evaluation Program, the trial was never opened, because of funding limitations.

Data have been gleaned from other CALGB trials, such as CALGB 39802 (Phase II Study of Video-Assisted Thoracic Surgery [VATS] Lobectomy in Patients with Small, Peripheral, Non-Small Cell Lung Cancer), and has been published in the Journal of Clinical Oncology [41].

In the future, data may potentially be extractable from CALBG 140503, titled "A Phase III Randomized Trial of Lobectomy Versus Sublobar Resection for Small (≤2 CM) Peripheral Non-Small Cell Lung Cancer." CALGB 140503 has a projected enrollment of 1297 patients and will compare sublobar resections and lobectomies for NSCLC. Data are being collected on VATS and thoracotomy lobectomy approaches, and post hoc analysis comparing the 2 approaches may be possible.

Morbidity
We found that the overall rate of complications after VATS vs thoracotomy lobectomy favored the VATS approach. The statistically significant improvement in overall complication rates in the VATS approach (p = 0.018) suggests that VATS lobectomy, despite its technical challenges, is as safe as the gold standard operation of open lobectomy for patients with early-stage NSCLC. When analyzing the rates of specific postoperative outcomes, we noted some distinct advantages of VATS lobectomy, including shorter chest tube duration (absolute difference, 1.5 days) and hospital length of stay (absolute difference, 5 days). For both of these outcomes, the differences between the two groups were statistically significant.

Variations in practice patterns between different countries (commented on under Limitations) may have contributed to these differences. Moreover, the practice patterns of surgeons who predominately use the VATS approach vs those who favor thoracotomy lobectomy may also account for the differences. Anecdotally, the threshold for drainage that is acceptable for chest tube removal among minimally invasive surgeons (300 mL/d) [42] is usually higher than among nonminimally invasive surgeons (200 mL/d) [43, 44]. In general, contemporary practices have accepted higher volume of chest tube output at the time of removal than was previously accepted (up to 400 mL/d) [45, 46]. From the articles we reviewed, uniform detailed data on criteria for chest tube removal could not be collated.

Overall Survival
In our analysis of overall annual survival rates, the VATS approach was better than thoracotomy lobectomy. The absolute survival advantage ranged from 5% at 1 year to 17% at 4 years. A VATS lobectomy must be performed in the same oncologic fashion with attention to lymph node assessment and removal.

We advocate VATS lobectomy for patients with early-stage NSCLC if the surgeon can provide an equivalent oncologic operation as a thoracotomy lobectomy with minimal morbidity. In particular, a complete mediastinal lymphadenectomy (10 or more lymph nodes from 3 or more lymph node stations) [47] should be performed to accurately stage the mediastinum, which has important therapeutic and prognostic implications [48–51]. In the articles included in our study, data on the extent of lymph node dissections were not uniformly available, but other studies have demonstrated that complete mediastinal lymph node dissection through a VATS approach is feasible and that results are equivalent to those of a thoracotomy approach [51–53].

One may ask, given the purported oncologic equivalence of these seemingly identical operations when a mediastinal lymph node dissection is performed, to what is the survival advantage attributed? One could speculate that the open approach, the thoracotomy lobectomy, is more immunosuppressive than the minimally invasive approach, VATS lobectomy. This inhibition could potentially decrease the patient's ability to scavenge residual tumor cells or cells shed at the time of resection from tumor manipulation (both microscopic disease). Although unclear, the effects of the extent of immunosuppression may also contribute to tumor growth [54].

This analysis lends data to support the expanded use of the VATS lobectomy for anatomically appropriate early-stage NSCLC lesions. To disseminate the practice, training should be encouraged and expanded to fellows, as visiting professorships, and as continuing medical education. In general, approximately 90% of lobectomies can be performed by VATS [55]. Elderly or high-risk patients can tolerate VATS resection better than a thoracotomy [55]. Tumors of sufficient size such that ribs need to be spread, potentially unsafe dissection conditions, and extrapulmonary invasion or spread are the major contraindications to attempted VATS resection [55].

Limitations
Our structured search of the literature, subsequent review, and analysis has several limitations related to the lack of raw data and of comprehensive follow-up. This analysis is, by virtue of the studies included, an observational study. Only one randomized study (Kirby, 1995) [8] met our inclusion criteria. Most of the studies included in our analysis were case series and small observational studies. Had there been more randomized controlled trials published and available for inclusion, the strength of our results would have increased. However, there is a concern for publication bias in the studies included. Those surgeons with less than optimal experiences or outcomes inferior to a thoracotomy would likely be less than enthusiastic about publishing their data, if they were accepted for publication at all. There is a bias for English language papers; however, this allowed for uniformity in translation. The data are not uniform in their presentation. Articles not indexed in MEDLINE would be an example of database bias.

In addition, we included studies representing patient care data from 1992 (when VATS was in its infancy and when complication rates were higher) to 2007 (when VATS lobectomy has become widely accepted). The care of NSCLC patients has evolved during this 15-year period, but our inclusion of both VATS and thoracotomy articles spanning this time period minimized confounding. Some studies reported their results as means and others reported medians, making it difficult to make between-study comparisons.

Our results were also influenced by the practice patterns of the authors whose studies we included. For instance, the hospital length of stay presented in Table 5 varied widely (from 3 to 25 days). In general, the hospital length of stay in Asian institutions is longer than in North American institutions, a difference that could skew any determination of an average hospital length of stay after VATS and thoracotomy lobectomy. However, this regional variation was consistent for both approaches. Therefore, we believe that bias was minimized; the average hospital stay after VATS and thoracotomy lobectomy is slightly longer with studies from Asia and North America included than if only North American studies had been included. In the analysis, we used the definition of a VATS lobectomy that was used by the individual component articles' authors. As such, the size of the incision, spreading of ribs or not, and technique (eg, number of ports) was likely variable.

Finally, our survival analysis has at least two limitations. First, we extracted the survival rates for some studies from their survival curves, raising the possibility of measurement error. Second, (and perhaps more important) disease-free survival, a surrogate marker for oncologic efficacy, was not reported in most of the articles we included.

Conclusion
In our systematic review of the available world's English language literature, we found that VATS lobectomy for patients with early-stage NSCLC, compared with thoracotomy lobectomy, was associated with less morbidity and improved overall survival rates.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
Acknowledgments
 References
 
DR THOMAS A. D'AMICO (Durham, NC): I have no conflicts to disclose. I congratulate Dr Whitson and his colleagues for the excellent analysis of the available published studies that report the outcomes of thoracoscopic and open lobectomy. After completion of CALGB [Cancer and Leukemia Group B] 39802 demonstrating feasibility of thoracoscopic lobectomy and suggesting advantages in quality of life outcomes, it was generally expected that a randomized trial to investigate outcomes, including oncologic outcomes, would follow. However, the accrual target of nearly 1000 patients discouraged various funding agencies from supporting this trial, especially in light of the environment of waning equipoise among thoracoscopic surgeons. A proposed registry trial seemed to answer both concerns but failed to achieve funding as well.

In the interval, however, several large series, including those of 500 to 1000 patients, have been reported with favorable outcomes compared to published series of lobectomy by thoracotomy, in terms of quality of life outcomes and oncologic outcomes. Nevertheless, some surgeons remain skeptical about these numerous demonstrated advantages, and the estimated fraction of lobectomies performed thoracoscopically using the STS [Society of Thoracic Surgeons] database still is less than 20%. Thus, a collective analysis of the available data is extremely valuable, especially considering that a prospective randomized trial will not be forthcoming. Although we recognize the inherent limitations of the meta-analysis, there are valuable points to be made by this analysis, and, Dr Whitson, I have three questions regarding the design and analysis of your study.

First, it is my belief that one of the most important advantages of thoracoscopic lobectomy is the lower complication profile, as shown today. While your analysis demonstrated a significantly lower overall complication rate, the rate of individual complications may be numerically lower but statistically insignificant. Yet, your analysis yielded rates for atrial fibrillation, pneumonia, and persistent air leak for the open approach that are lower than many published series, including your own, and the number of studies included in your analysis of these variables was only four, three, and five studies respectively. In two recently published series that directly compared complications of the thoracoscopic approach to the open approach, the atrial fibrillation rate for thoracotomy was 16% and 19%, yet your analysis yielded a rate of less than 9%. So is it possible that the restrictions posed by your inclusion and exclusion criteria were too strict, and have you considered an analysis that provides more statistical weight to studies with direct comparisons as the way for the number of patients in the study has done?

Secondly, regarding survival, the analysis includes patients with stage I or stage II lung cancer, yet the survival results are not stage-specific. Are you confident that this analysis is accurate in terms of survival, and have you attempted to compare survival by stage?

Finally, your analysis convincingly demonstrates aspects of superiority associated with the thoracoscopic approach, suggesting that this procedure should be more widely adopted for the treatment of early stage lung cancer, especially in light of the development of nonsurgical strategies to treat such patients. What obstacles remain to offering this operation and its potential benefits to more patients in North America, Europe, and Asia?

I would like to thank the Society for the opportunity to discuss this paper.

DR WHITSON: Thank you, Dr D'Amico, for your very thorough review of our manuscript. I will try to answer your comments in order. With regards to our inclusion criteria and our different analysis, our criteria may have been a bit strict, but we did this intentionally to try to get as homogeneous a group as possible and what we thought was a relevant clinical question.

In terms of the atrial fibrillation, I think this is an excellent example of what could be termed publication bias, where only the most favorable results are published. In some of the early series where results were reported, some authors were undoubtedly trying to tout their excellent outcomes. In others where they were not, we do not know the reason; perhaps a higher rate or perhaps it was not felt to be relevant to the topic of that particular manuscript. In later series, however, we would expect that we would see results reported in both arms. Some of the more contemporary series, as you have alluded to, have reported their data for both the thoracotomy and the VATS [video-assisted thoracic surgery] approach, and there is appearing to be very minimal differences in the rate of atrial fibrillation, if any, at all.

We were, again, also limited somewhat by the morbidity data that were available in the published studies. Fewer studies reported data and so fewer were included in the analysis for the secondary aims of pneumonia, atrial fibrillation, and persistent air leak. This may possibly be due to a perception by the authors of the early studies that those data were not relevant to their clinical point and therefore were not published. However, this is speculation. Attempting to somehow extract this data from the original data would be a very good way to answer this question.

As far as a different analysis, I think that in an ideal world, as you alluded to, a randomized controlled trial would be the best way to answer these questions. However, that will very likely not be performed or completed. If we limit our study to just the 10 studies that had a thoracotomy and a VATS arm, we have a decreased number in patients by that limitation alone. In those studies, the number of potential patients is then subdivided further due to a nonuniform reporting of complications or atrial fibrillation. If we were to try to go back and identify just those studies that focused on complications instead of length of stay and survival, we might have a different result, and that is something we are going to look into.

In terms of our survival analysis, we feel that this is accurate. Again, we wanted a disease that was primarily treated surgically and we wanted early-stage disease. Some of the manuscripts that were reviewed were not uniform in what data they reported. One might either have an entirely clinical stage I series or a pathologic stage I series, and some may not break out their individual survival data. However, when we have looked at that, the results by stage are very similar to the aggregate but they are underpowered; some of the years are not statistically different but the trends are the same.

What are obstacles to expansion? I think primarily this would be termed as training. I think training needs to be expanded as fellows, as visiting professorships, and as continuing medical education. Personally, as an applicant when I go to interview at programs, I am looking for those places that have minimally invasive training as a large component of their surgical practice. It is something very analogous to laparoscopic training in general surgery, it is becoming disseminated in the training programs and then in the real world. That is the time and place to learn it. In addition, we need to make sure that there is adequate and standardized preoperative screening of patients so that those patients who are eligible for a VATS lobectomy are identified and are given the opportunity for that treatment and not a thoracotomy. Thank you.

DR JOSEPH B. SHRAGER (Stanford, CA): Dr Whitson, this was a very nice presentation. This is obviously an important question, and therefore it is a worthwhile undertaking to do this study, and obviously it required a lot of work.

However, as you know, meta-analyses typically pick the highest quality randomized, controlled trials to analyze. I think the reason for this is that if you include observational studies in a meta-analysis, you are simply going to magnify the biases that those observational studies contain. For example, the vast majority of retrospective studies of VATS lobectomy are going to include a higher percentage of patients with smaller tumors within each individual stage grouping. For example, within stage I, the patients getting VATS lobes are typically going to be those with less than 2-cm tumors. So there is an obvious selection bias, which is going to create the appearance of a higher survival in those studies—a higher survival after VATS vs open lobectomy—even when grouped by stage.

I happen to believe in VATS lobectomy for tumors I am really convinced are stage IA, and preferably small IAs, but because I am not convinced of the quality of the lymph node dissection that I can do thoracoscopically. I won't do it for higher stage tumors. I think I'll stick by that practice at least until ACOSOG [American College of Surgeons Oncology Group] Z30 shows me that lymph node dissection doesn't matter.

So my question I guess is the following: on the issue of survival, why should I be more convinced from a meta-analysis of biased studies than I would be by the individual biased studies themselves?

DR WHITSON: I think you have touched on a lot of the very good points regarding limitations of meta-analyses in general. The two big limitations of this analysis are the publication bias that goes along with some authors potentially only publishing their very favorable results and the very limited amount of the either armed observational trials or randomized trials. In our study there was only one randomized control trial, published out of Cleveland, and this is a significant point of concern. However, these are the only data that are available. By looking at all of the literature and trying to glean from it what we can in order to attempt to make practice guidelines and recommendations, this is what we are left with. We also anxiously await Dr Allen's results of ACOSOG Z0030.

As far as your question of looking at is this a better oncologic operation and should we put weight in these biased results, each individual surgeon would have to look at their survival and their outcomes in their own hands, as well as these data, and make that decision for themselves. I think the data are starting to mount. Even though it is somewhat biased data, limited by what has been published, you could make the same argument that the thoracotomy data are biased as well if you look at them just in isolation. There does appear to be a survival advantage with the VATS lobectomy, especially in the early stage non-small cell lung cancer. So we advocate in those people who are trained and feel comfortable doing it with a mediastinal lymph node dissection, that it should be the procedure of choice for early stage non-small cell lung cancer.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
References
 
We would like to acknowledge Mary Knatterud, PhD, for her editorial assistance with this manuscript.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 

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