VATS Lobectomy Linked to Improved Survival in Early-Stage Lung Cancer: Meta-Analysis

A new meta-analysis of randomized trials has revealed that video-assisted thoracoscopic surgery (VATS) lobectomy leads to a 21% reduction in the risk of death compared to traditional open lobectomy for patients with early-stage non-small-cell lung cancer (NSCLC). The findings, published this month, strengthen the case for prioritizing VATS when technically feasible, marking a potential shift in standard care for the disease.

For years, VATS has gained prominence due to its less invasive nature, offering patients reduced postoperative pain, fewer complications, shorter hospital stays, and faster recovery times, as demonstrated in earlier trials conducted by Bendixen and colleagues in 2016, Lim and colleagues in 2022, and Long and colleagues in 2018. However, a critical question remained: did this minimally invasive approach compromise long-term survival rates compared to open surgery?

The new research, an individual patient data meta-analysis, pooled data from three key randomized trials – the PLEACE trial from Denmark, a trial led by Long and colleagues in China, and the VIOLET trial from the United Kingdom – encompassing data from 1,185 patients. Researchers systematically searched major medical databases, including PubMed, MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform, for relevant studies published between January 1, 2000, and June 13, 2025.

The analysis focused on overall survival, defined as time from randomization to death from any cause, and disease-free survival, defined as time from randomization to recurrence or death. The study employed a rigorous statistical approach, utilizing a one-stage random-effects Cox proportional hazards model, and adhered to an intention-to-treat basis, ensuring patients were analyzed according to their originally assigned surgical group, even if they crossed over to the other procedure.

The patient population reflected a diverse, multinational experience, with a median follow-up period ranging from 3.8 to 9.5 years across the three trials. Over 91% of patients had at least three years of survival follow-up, providing substantial long-term data. Baseline characteristics were largely balanced between the VATS and open lobectomy groups, with a median age of around 64-65 years and a near-equal sex distribution. Resection quality, measured by R0 resection rates, was almost identical in both groups (98%), and the use of adjuvant chemotherapy was also comparable (around 30% in both arms).

The most significant finding was the 21% relative reduction in mortality risk associated with VATS, corresponding to a pooled hazard ratio of 0.79 (95% CI, 0.65–0.96). This benefit was consistent across all three trials, with hazard ratios of 0.90, 0.78, and 0.71 observed in the Bendixen, Long, and Lim trials, respectively. Kaplan-Meier estimates further illustrated the advantage, showing event rates for death at 5, 10, and 15 years were 26% vs. 32%, 49% vs. 54%, and 70% vs. 76% for VATS versus open surgery, respectively.

Notably, disease-free survival did not differ significantly between the two approaches, with a pooled hazard ratio of 0.91 (95% CI, 0.75–1.12). A post-hoc analysis suggested a potential, though not statistically significant, trend towards improved disease-free survival with VATS in the initial two years post-randomization.

Researchers suggest the improved overall survival with VATS is likely attributable to reduced perioperative morbidity rather than a difference in tumor recurrence rates. This aligns with previous evidence demonstrating fewer adverse events and lower readmission rates with VATS, as shown in the VIOLET trial. Higher rates of unplanned readmission after lung cancer surgery have been independently linked to increased short-term and long-term mortality, including a six-fold increase in 90-day mortality in some analyses.

The study also found minimal differences in lymph node staging between the two approaches. Rates of cN0 to pN1 upstaging were 7% in both groups, and cN0 to pN2 upstaging was 8% in both groups, suggesting VATS can achieve lymph node staging comparable to open thoracotomy when performed by experienced surgeons.

The authors acknowledge limitations, including the relatively small number of included trials (three) and their geographic concentration in Europe and China, which may limit the generalizability of the findings. Cause-specific mortality data were unavailable, and the trials predated the widespread adoption of perioperative immunotherapy and targeted therapies in NSCLC treatment.