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J Thorac Cardiovasc Surg 2003;126:1935-1942
© 2003 The American Association for Thoracic Surgery

General thoracic surgery

Optimal management when unsuspected N2 nodal disease is identified during thoracotomy for lung cancer: cost-effectiveness analysis

^a Department of Surgery, The University of Chicago, Chicago, Ill, USA

Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.

Received for publication April 21, 2003; revisions received July 24, 2003; accepted for publication July 30, 2003.

^* Address for reprints: Mark K. Ferguson, MD, Department of Surgery, The University of Chicago, 5841 S. Maryland Avenue MC5035, Chicago, IL 60637, USA
mferguso{at}surgery.bsd.uchicago.edu

OBJECTIVES: Whether to proceed with lung resection when N2 nodal disease is identified at the time of thoracotomy for lung cancer is controversial. A decision analysis model was developed to address this question.

METHODS: A meta-analysis was performed on data from reports published between 1990 and 2002 evaluating survival for (1) patients who were treated by initial resection for clinically unsuspected N2 nodal disease (initial resection) and (2) survival for patients undergoing resection after neoadjuvant therapy for N2 nodal disease (no initial resection). Hospital cost data for surgery were derived from our institution, and cost data for chemotherapy and radiation therapy were obtained from current literature. A decision model was developed to compare initial resection to no initial resection from the perspective of the medical center using survival, quality-adjusted life years survival, and cost-effectiveness as outcomes.

RESULTS: The no initial resection option provided better median survival (2.1 versus 1.7 years), quality-adjusted life years (1.8 versus 1.3), and cost-effectiveness, with an incremental cost-effectiveness ratio of $17,119/quality-adjusted life year. Outcomes were influenced by survival estimates for each treatment option.

CONCLUSIONS: When N2 nodal disease is discovered during thoracotomy, the approach of delaying resection until after neoadjuvant therapy provides the best survival and is more cost-effective. This is likely due to the beneficial effects of neoadjuvant therapy and the exclusion of patients with more aggressive disease from the surgical candidate pool.

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