Lung cancer surgery

Study objectives: Quality of life (QOL) following video-assisted thoracic surgery (VATS) major lung resection has not been systematically studied. This study was designed to evaluate the intermediate to long-term QOL in patients with lung cancer following resection, comparing VATS with thoracotomy.

Design: Cross-sectional study, telephone survey.

Methods: Of 136 disease-free surviving patients with non-small cell lung cancer operated on between 1994 and 2000, 45 patients were excluded because of large tumors (> 5 cm) or locally advanced disease, and another 27 patients were excluded because of adjuvant therapy, coexisting cancer from another source, or psychiatric illness. At the time of the survey, 13 patients were found to be either unsuitable or unwilling to participate. This left a total of 51 patients, with 27 patients in the VATS group and 24 patients in the thoracotomy group (open group), for the final analysis. QOL was assessed using Chinese versions of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 and the EORTC QLQ-LC13, supplemented with nine self-developed surgery-related questions.

Results: Mean follow-up time was 33.5 months in the VATS group (median, 20.8 months; range, 6.0 to 84.2 months) and 39.4 months in the open group (median, 37.7 months; range, 7.0 to 75.1 months). Both groups had good QOL and high levels of functioning despite a fairly high incidence of symptoms. There was a trend for VATS patients to score higher on the QOL and functioning scales and to report fewer symptoms. However, these differences did not lead to statistical significance.

Conclusions: This study showed that lung cancer patients with resectable disease following surgical treatment without recurrence have good QOL and high levels of functioning on intermediate to long-term follow-up, with no significant differences between the VATS and open groups.

Key words: lung cancer; quality of life; thoracotomy; video-assisted thoracic surgery

Abbreviations: EORTC = European Organization for Research and Treatment of Cancer; NSCLC = non-small cell lung carcinoma; QLQ = Quality of Life Questionnaire; QOL = quality of life; VATS = video-assisted thoracic surgery

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Surgical resection continues to be the mainstay of treatment for early non-small cell lung carcinoma (NSCLC). (1) Traditionally, this is done through a thoracotomy. However, with the introduction of minimal access techniques, major pulmonary resections can now be performed with video-assisted thoracic surgery (VATS).

The fact that access trauma is lessened in VATS has been well documented. Studies on lobectomy comparing VATS with thoracotomy have suggested that the former is associated with short-term benefits such as decreased postoperative pain, (2-5) decreased perioperative morbidity, (4-7) better postoperative pulmonary function, (8,9) reduced length of hospital stay, (3,6,10) lower hospital costs (5,10) and earlier return to normal activities. (3,11) However, the effect of these early benefits on the patient's long-term quality of life (QOL) remains uncertain. With the building evidence that survival after VATS lobectomy is similar to the survival after lobectomy by thoracotomy, (5-8,12) QOL assessments become increasingly important in the evaluation of these treatment options. Sugiura et all (11) attempted to assess the long-term QOL in lung cancer patients after lobectomy, comparing VATS (n = 20) with thoracotomy (n = 15); they suggested that VATS lobectomy was associated with improved long-term QOL. However, they used a limited questionnaire containing only six questions. No studies have been undertaken to our knowledge on postoperative long-term QOL in patients undergoing VATS using standardized questionnaires. We conducted a cross-sectional study to assess the intermediate to long-term QOL in patients with early NSCLC after major lung resection, comparing VATS with the standard posterolateral thoracotomy approach, the results of which form the basis of this publication.

MATERIALS AND METHODS

Patients

All surviving patients with resectable NSCLC who underwent surgical resection at the Prince of Wales Hospital, Hong Kong, between March 1994 and October 2000, with no evidence of recurrence were considered for this study. All patients underwent surgery at least 6 months previously. One hundred thirty-six patients were initially regarded as potential candidates. In order to make both groups comparable, patients with tumor size > 5 cm or locally advanced tumor requiring extended resection were excluded from the study (n = 45), as these patients would not be candidates for VATS. Patients who received adjuvant therapy (n = 14) or had other forms of cancer (n = 11) or psychiatric illness (n = 2) were also excluded from the study. At time of the telephone survey, two patients were hospitalized for stroke and were unable to participate. Three patients were unavailable for follow-up, and six patients were unable to understand the questionnaires due to old age or senile dementia. Two patients refused to participate in the study. As a result, a total of 51 patients were available for analysis, including 27 patients who underwent VATS lobectomy (VATS group) and 24 patients who underwent lobectomy by thoracotomy (open group).

Operative Technique

Our technique for VATS lobectomy has been described in detail elsewhere. (2,7) We emphasize on avoiding rib spreading and torquing of the thoracoscope at all times. For open lobectomy, we perform the standard posterolateral thoracotomy with division of the latissimus dorsi and serratus anterior muscles.

QOL Assessment

QOL was assessed using three different questionnaires: the Chinese version of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 (cancer core questionnaire), the Chinese version of the EORTC QLQ-LC13 lung cancer-specific questionnaire module, and a self-developed module containing nine additional surgery-related questions. The questionnaires were sent to the patients, accompanied by a letter with general information and aim of' the study. All QOL data were collected thereafter by a trained research nurse through telephone interviews. In order to avoid bias, the operating surgeons were not involved at any point in the questioning.

EORTC QLQ-C30

The EORTC QLQ-C30 (version 3.0) is a self-rating questionnaire composed of 30 questions/items and incorporates nine multi-item scales: five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, nausea/vomiting), a global health/QOL scale, and several single items assessing additional symptoms (dyspnea, sleep disturbance, constipation, and diarrhea). A final item evaluates the perceived economic consequences of the disease. Reliability and validity of the English and Chinese versions of the EORTC QLQ-C30 questionnaire have been confirmed in international studies. (13-15)

EORTC QLQ-LC13

The EORTC QLQ-LC13 is a supplemental questionnaire module that was designed for use among patients receiving treatment with chemotherapy and/or radiotherapy. It contains 13 questions/items assessing lung cancer-associated symptoms (cough, hemoptysis, dyspnea, and site-specific pain), chemotherapy/radiotherapy-related side effects (sore mouth, dysphagia, peripheral neuropathy, and alopecia), and pain medication. The dyspnea scale was aggregated into a four-item scale by including the single dyspnea item of the EORTC QLQ-C30 core questionnaire. (16) Chemotherapy/radiotherapy-related side effects were not included in the analysis. Reliability and validity of the EORTC QLQ-LC13 module have been confirmed in international studies. (15,16)

Additional Questions