Lung cancer screening with low-dose CT appears to boost the use of minimally invasive thoracic surgery, underscoring the importance of coupling CT screening programs with a dedicated video-assisted thoracic surgery (VATS) program, according to an article detailing results from the Danish Lung Cancer Screening Trial published in the June issue of the Journal of Thoracic Oncology.
While much research has been devoted to lung cancer screening, the study authors, led by Rene H. Petersen, MD, of Copenhagen University Hospital, noted that few previous articles have examined the implications of early lung cancer detection for the utilization of minimally invasive thoracic surgery.
VATS is a minimally invasive surgery performed by introducing a thoracoscope and surgical tools through a pair of 5 cm incisions. Use of VATS has evolved over the last 20 years and brings with it certain advantages over open lobectomy, according to the authors. These benefits include reduced perioperative pain, shorter hospital stay, more rapid resumption of normal daily activities, less impairment in pulmonary function postoperatively, less impairment in shoulder function, reduced cytokine release, improved delivery of adjuvant chemotherapy, lower incidence of complications and economic advantages. Although there is a lack of randomized controlled trials comparing open lobectomy and VATS lobectomy, Petersen et al noted reports of equivalent long-term survival between the two procedures.
The results of the National Lung Screening Trial, which demonstrated 20 percent fewer lung cancer deaths among high-risk patients who received screening with low-dose CT compared with standard chest radiograph, are expected to increase utilization of low-dose CT screening, according to the authors. Widespread use of CT screening brings its own concerns, however, as overdiagnosis and the prevalence of false-positive nodules is an issue.
“Bearing in mind the risk of overdiagnosis and given the nature of screening patients, who differ from an average patient in a thoracic surgical department, we find a minimally invasive approach of utmost importance in these patients,” wrote the authors.
Similar to the National Lung Screening Trial, the Danish Lung Cancer Screening Trial is a randomized trial looking at screening outcomes in current and former smokers. In the Danish trial, a total of 4,104 patients were randomized from 2004 to 2006 to receive either annual low-dose CT screening for five years or no screening. Diagnostic and treatment interventions were monitored prospectively for one to three years after the last round of screening.
Sixty-eight cases of lung cancer were detected in the screening group by March 1, 2011, compared with 24 in the unscreened group, according to the authors. Fifty-one of the patients with cancer in the screened group were candidates for surgery, of which 84 percent underwent VATS versus 50 percent of the unscreened population. Another seven patients with a suspicion of malignancy underwent surgical treatment, though their lesions were found to be benign after they were removed. There were no major complications in the removal of benign lesions.
VATS does have a bit of learning curve, noted Petersen et al, and while the surgeons involved in this trial were experienced before enrolling patients, the authors wrote, “it is of utmost importance for future low-dose CT screening trials to have thoracic surgeons involved in the early detection program and that the thoracic surgeons should have a dedicated VATS program.”
Despite the benefits of VATS outlined by the authors, they wrote that there is still a role for traditional thoracotomy when resecting tumors larger than 6 cm, central tumors requiring a bronchial or vascular sleeve resection, or in cases featuring chest-wall involvement.