Robotic-Assisted Surgery Shows Promise for Older Patients With NSCLC, but Questions Remain

By Cameron Kelsall, /alert Contributor
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Robotic-assisted surgery improved outcomes for older patients with resectable non-small cell lung cancer (NSCLC) when compared with open thoracotomy, according to the results of a SEER database study published in Chest.

However, the efficacy of robotic-assisted therapy when compared with video-assisted thoracoscopic surgery remained unclear, suggesting that further research is needed before the approach is widely adopted in clinical practice.

Robotic surgery. Source: Getty

“Optimal surgical management for NSCLC is critical for maximizing chances of cure and achieving good long-term outcomes,” wrote Rajwanth R. Veluswamy, MD, MSCR, professor of medicine, hematology and oncology at Mount Sinai, and colleagues. “These treatment decisions are becoming even more important given the expected increase in the proportion of tumors diagnosed at earlier stages following full implementation of lung cancer screening recommendations.”

Because NSCLC is often diagnosed in older patients with smoking-related comorbidities, it is often difficult to determine the most effective surgical approach. 

Lobectomy via open thoracotomy, the standard of care for resectable stage I to stage IIIA NSCLC, frequently results in postoperative complications and increased mortality in older patients.

Robotic-assisted surgery is increasingly used as a treatment option in this patient population. However, there is little data comparing outcomes with standard-of-care open thoracotomy, or with video-assisted thoracoscopic surgery, another minimally invasive approach.

Veluswamy and colleagues accessed the SEER–Medicare database and identified 2766 patients aged 65 years or older with resectable NSCLC, treated with robotic-assisted surgery (n = 338), open thoracotomy (n = 1198) or video-assisted thoracoscopic surgery (n = 1230).

The researchers used propensity score methods to measure postoperative complication rates, adequate lymph node staging, survival outcomes and treatment-related costs.

Results showed that receipt of robotic-assisted surgery led to lower complication rates than open thoracotomy (odds ratio [OR], 0.57; 95% CI, 0.42-0.79) and similar complication rates to video-assisted thoracoscopic surgery (OR, 1.02; 95% CI, 0.76-1.37).

When compared with open thoracotomy, robotic-assisted surgery resulted in fewer postsurgical blood transfusions (OR, 0.31; 95% CI, 0.17-0.6) and intensive care unit stays (OR, 0.58; 95% CI, 0.44-0.77), as well as shorter lengths of stay (OR, 0.59; 95% CI, 0.35-0.98). 

However, the researchers did not observe a significant difference in adequate lymph node evaluation or survival outcomes. And although costs during the operative period were significantly lower for patients undergoing robotic-assisted surgery ($28,732 vs. $32,746; P < .0001), overall costs did not significantly differ (robotic-assisted surgery vs. open thoracotomy, $54,702 vs. $57,104).

When compared with video-assisted thoracoscopic surgery, patients who underwent robotic-assisted surgery experienced similar overall complications rates, similar likelihood of undergoing adequate lymph node evaluation, and similar survival outcomes.

However, robotic-assisted surgery was associated with significantly higher overall costs ($54,702 vs. $48,729; P = .02) and preoperative costs ($3,668 vs. $2,803; P < .0001) when compared with video-assisted thoracoscopic surgery.

The researchers identified limitations to their study, including a lack of random treatment allocation and a lack of data regarding the completeness of resection. They were also unable to ascertain complete surgical costs from the available data.

“Robotic-assisted surgery is innovative, but we found no distinct advantage over video-assisted thoracoscopic surgery to support its adoption into routine care for the surgical management of patients with NSCLC,” the researchers concluded. “As technology and operator experience with robotic-assisted surgery improve with time, continued reassessment of comparative effectiveness should be undertaken to ensure patients receive the most effective and safe surgical option.”

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