Surgical resection remains the gold standard for patients diagnosed with early-stage lung cancer, and since the early 1990s, video-assisted thoracoscopic surgery (VATS) lobectomy has been acknowledged as an effective – and preferred — minimally invasive approach for lung cancer surgery.
However, VATS requires specialized training and equipment meaning adoption of this technique has not been globally uniform.
At the 2021 World Conference on Lung Cancer, Maria Teresa Tsukazan, MD, of Pontifícia Universidade Católica do Rio Grande do Sul, Brazil, presented data from the Brazilian Society of Thoracic Surgeons (BSTS) showing that in 2020, 88.7% of lung resections were minimally invasive surgeries (MIS).1
In Brazil, Dr. Tsukazan noted, the disposable devices for this type of surgery are not default for the public healthcare system, and this has prolonged the learning curve for VATS. With this analysis, Dr. Tsukazan and colleagues wanted to evaluate the reality of the MIS approach in a middle-lower income country.
The study included all lung resections from the Brazilian Thoracic Society (SBCT) prospective database since 2015. Of the 3,024 lung resections identified, the researchers included 935 oncologic lobectomies. From 2015 to 2020, 60.8% of the lobectomies used a minimally invasive approach. MIS had a hospital mortality rate of 1.5% compared with 4.5% for open thoracotomy (P = 0.006).
The proportion of MIS increased during the study period from 53.9% in 2015 to 88.7% in 2020 (P < 0.001), “despite the longer learning curve”, Dr. Tsukazan and colleagues wrote in their presentation.
However, these results should be interpreted with caution, without generalizing to all of Brazil, said Ricardo Sales dos Santos, MD, PhD, staff thoracic surgeon of Hospital Israelita Albert Einstein, São Paulo and Professor of SENAI CIMATEC University Center, Bahia, both in Brazil.
“Currently the BSTS has nearly 800 associated surgeons,” Dr. dos Santos said.2 “The database used was restricted to under 10% of these surgeons; therefore, the work represents centers where MIS has been more widely used.”
According to Dr. dos Santos, who is also a member of the ILCN Editorial Group, the reality of MIS adoption may be different from the one shown.
Putting Data into International Context
The growth of the BSTS in the last 20 years has allowed the advancement of MIS techniques in Brazil; however, the access of patients in a homogenous way to such benefits depends on social and economic changes in several areas that are not directly or exclusively related to thoracic surgery. Specifically, Dr. dos Santos noted, less than 20% of the Brazilian population has private medical insurance, where there is higher access and availability of MIS disposable materials than in the public health scenario.
“More recently, a few academic public hospitals started to offer MIS tools for lobectomy,” Dr. dos Santos said. “The high importation costs to obtain staplers is still a significant problem in Latin American countries.”
Indeed, adoption of VATS procedures is strictly dependent on the income status of the region or country due to the relatively high costs of VATS procedures and disposable equipment compared to open thoracotomy, explained Witold Rzyman, MD, of Medical University of Gdansk, Poland.
“The vast majority of reports analyzing this problem clearly show a huge shift in surgical technics from open thoracotomy to VATS procedures, which is clearly visible in Polish, American, and European registries,” Dr. Rzyman, member of the ILCN Editorial Group, said.3 ,4 ,5 “Middle- and low-income countries are less likely to implement MIS in depth, but these techniques will nonetheless become more widespread.”
VATS was introduced in Poland in the late 1990s, Dr. Rzyman said. After several years of slow development, progress in adoption of VATS has been more clearly visible since 2007. Poland launched the National Lung Cancer Registry in 2007 and since then has kept detailed clinical information on lung cancer surgical procedures from all 29 thoracic surgery departments, Dr. Rzyman said.
“Since 2010, there has been a real increase in the number of MIS procedures,” Dr. Rzyman said. “From 2012, the number of VATS lobectomies compared to all lung cancer resections grew by 50% each year until 2017. Since then it has been fairly stable and accounts for 35% to 40% of all lung cancer resections nationwide.”
Dr. Rzyman noted though that eight thoracic departments perform over 80% of all VATS procedures in Poland. In the best eight units, the percentage exceeds 50%, but not 65%.
The rates in Poland are similar to those estimated in the United States. In a study published in 2017 using data from the United States Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2009 to 2012, VATS accounted for 35% of procedures among 27,451 lobectomy patients.4 Another study published that year used data from the National Cancer Data Base in the United States and showed that crude hospital VATS used varied widely, with an average of 25.5% but a range from 4.4% to 42.3%.6
“This variation couldn’t be explained by patient or tumor characteristics or by a shortage of VATS equipment in the United States,” Dr. dos Santos noted. “But similar to Brazil, the authors recommended the dissemination and implementation of novel training techniques and learning opportunities for surgeons.”
VATS rates are also variable in China, according to data from 17 tertiary hospitals across all six geographic regions. The VATS rate was 47.6% nationwide but varied from 14.0% to 74.5% across regions.7
“The trend of VATS procedures is inevitable in the coming age of lung cancer screening, producing a large proportion of early lung cancer cases, ideal for VATS resection,” Dr. Rzyman said. “As these techniques become more widespread, companies that produce one-off VATS products should consider adjusting prices to local opportunities in different parts of the world.”
- 1. Tsukazan M, et al. Lobectomy for lung cancer, what is the Brazilian reality? Brazilian Society of Thoracic Surgeons Analysis. P06.09. Presented at: 2021 World Conference on Lung Cancer.
- 2. Verbal communication to dos Santos from Drs. Daniel Bonomi and Mario Cláudio Ghefter. Scientific Director of the Brazilian Society of Thoracic Surgery and Founding Member, respectively, for the information provided for the above comments
- 3. Polish National Lung Cancer Registry [Available from: Krajowa Baza Raka Płuca wersja 2 (igichp.edu.pl).
- 4. Desai H, Natt B, Kim S, Bime C. Decreased in-hospital mortality after lobectomy using video-assisted thoracoscopic surgery compared with open thoracotomy. Ann Am Thorac Soc. 2017;14(2):262-6.
- 5. Falcoz PE, Puyraveau M, Thomas PA, et al. Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-matched analysis of outcome from the European Society of Thoracic Surgeon database. European Journal of Cardio-Thoracic Surgery. 2016;49(2):602-9.
- 6. Abdelsattar ZM, Allen MS, Shen KR, et al. Variation in hospital adoption rates of video-assisted thoracoscopic lobectomy for lung cancer and the effect on outcomes. Ann Thorac Surg. 2017;103(2):454-460.
- 7. Cai J, Zhou J, Yang F, Wang J. Adoption rate of video-assisted thoracic surgery for lung cancer varies widely in China. Chest. 2018;153(4):1073-1075.