Outcomes after Video-assisted Thoracoscopic Lobectomy versus Open Lobectomy for Early-Stage Lung Cancer in Older Adults

Rationale: Video-assisted thoracoscopic surgery (VATS) and open lobectomy are both standard of care for the treatment of early-stagenon small cell lung cancer(NSCLC) because of equivalent long-termsurvival. Objectives: To evaluate whether the improved perioperative outcomes associated with VATS lobectomy are explained by surgeon characteristics, including case volume and specialty training. Methods: We analyzed the Surveillance, Epidemiology, and End Results-Medicare-linked registry to identify stage I-II NSCLC in patients above 65 years of age. We used apropensity score model to adjust for differences in patient characteristics undergoing VATS versus open lobectomy. Perioperative complications, extended length of stay, and perioperativemortality among patients were compared after adjustment for surgeon's volume and specialty using linear mixed models. We compared survival using a Cox model with robust standard errors. Results: We identified 9,508 patients in the registry who underwent lobectomy for early-stage NSCLC. VATS lobectomies were more commonly performed by high-volume surgeons (P < 0.001) and thoracic surgeons (P = 0.01). VATS lobectomy was associated with decreased adjusted odds of cardiovascular complications (odds ratio [OR] = 0.65; 95% confidence interval [CI] = 0.47-0.90), thromboembolic complications (OR = 0.47; 95% CI = 0.38-0.58), extrapulmonary infections (OR = 0.75; 95% CI = 0.61-0.94), extended length of stay (OR = 0.47; 95% CI = 0.40-0.56), andperioperative mortality (OR = 0.33; 95% CI = 0.23-0.48) even after controlling for differences in surgeon volume and specialty. Long-term survival was equivalent for VATS and openlobectomy(hazard ratio = 0.95; 95% CI = 0.85-1.08) after controlling for patient and tumor characteristics, surgeon volume, and specialization. Conclusions: VATS lobectomy for NSCLC is associated with better postoperative outcomes, but similar long-term survival, compared with open lobectomy among older adults, even after controlling for surgeon experience.