Video-assisted thoracoscopic surgery (VATS) is one of the leading approaches to performing lobectomy in early-stage non-small cell lung cancer. It offers advantages such as fewer complications, faster recovery, and an improved quality of life.
However, no single randomized trial has demonstrated whether VATS improves overall survival (OS) or disease-free survival (DFS) compared to open lobectomy.
To address that gap, a first-of-its-kind meta-analysis was conducted. Jacie Jiaqi Law, MB BCh, presented the results during Presidential Symposium 2 with Lectureship Award Presentations at the 2025 World Conference on Lung Cancer (WCLC) on Monday, September 8.
Presidential Symposium 2 with Lectureship Award Presentations
Watch Jacie Jiaqi Law, MB, BCh, and other experts from the Presidential Symposium 2—available on-demand for registered WCLC 2025 attendees. Learn More
Dr. Law described the methods for the meta-analysis, which included a comprehensive literature search to find eligible trials, excluding those with bias and inconsistencies. Subgroup analyses were conducted for pre-specified prognostic and potential treatment effect modifiers, including age, FEV1, pathological T, and N stage.
The literature search identified three randomized trials that met eligibility criteria: Bendixen et al. from Denmark,1 Long et al. from China,2 and Lim et al. from the United Kingdom.3 Together, these studies included data from 1,185 patients, with 586 randomized to VATS and 599 to open lobectomy. The median follow-up times were 9.5 years, 5.2 years, and 3.8 years, respectively.
“Here is where the true challenges begin. Imagine trying to obtain randomized trial data sets across three separate countries—the headaches and legalities we had to deal with. But I am here with you, presenting on stage, which means that we have succeeded in obtaining patient data with a minimum dropout of five participants,” Dr. Law said.
Across the three trials, baseline characteristics were generally well balanced, with age emerging as the only modifier meeting the pre-specified threshold for imbalance. In the pooled analysis, VATS was associated with significantly improved OS compared with open lobectomy, corresponding to a 21% lower risk of death (hazard ratio [HR] 0.79; 95% confidence interval [CI]: 0.65–0.96). However, DFS did not differ between the two groups (HR 0.91; 95% CI: 0.75–1.12).
Sensitivity analyses that excluded patients with benign disease showed similar pooled hazard ratios: 0.78 for OS (95% CI: 0.64–0.95) and 0.89 for DFS (95% CI: 0.73–1.09). Subgroup analyses showed the survival benefit was consistent across age groups (p = 0.83 for OS and p = 0.43 for DFS).
“You can see that this survival benefit with VATS was consistently observed across all three individual randomized trials with no heterogeneity,” Dr. Law said.
Dr. Law stated that for the first time in history, this study provides evidence that in the context of early-stage lung cancer, a seemingly simple change in surgical access to VATS leads to a 21% reduction in overall risk of death, with no evidence of compromise to DFS.
“As I’m sure you all will agree, VATS should be prioritized as a surgical approach when it comes to resection in lung cancer,” Dr. Law concluded.
References
- 1. Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016;17(6):836-844. doi:10.1016/S1470-2045(16)00173-X
- 2. Long H, Tan Q, Luo Q, et al. Thoracoscopic Surgery Versus Thoracotomy for Lung Cancer: Short-Term Outcomes of a Randomized Trial. Ann Thorac Surg. 2018;105(2):386-392. doi:10.1016/j.athoracsur.2017.08.045
- 3. Lim E, Harris RA, McKeon HE, et al. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT. Health Technol Assess. 2022;26(48):1-162. doi:10.3310/THBQ1793
