TUESDAY, May 20, 2003 (HealthDayNews) -- Surgery to help people with emphysema breathe easier can be better than drug treatment for the condition, but not for every patient, according to a new comparison of the two therapies.
The costly operation, called lung-volume-reduction surgery (LVRS), works best for people with isolated areas of lung damage and whose ability to exercise is greatly impaired by their disease. For others, the procedure may be only modestly better than conventional care, and in one group -- those with diffuse airway injury but relatively good exercise function -- it seems to cause more harm than good, the study found.
Researchers reported their results May 19 at a meeting in Seattle of the American Thoracic Society. A report on the findings appears in the May 22 issue of the New England Journal of Medicine.
"The study sharpens up our ability to tell who should get the surgery and who shouldn't," says study co-author Dr. Steven Piantadosi, a statistics expert at Johns Hopkins University in Baltimore. Unfortunately, emphysema patients for whom the operation isn't warranted "are flying by the seat of their pants," Piantadosi says. "If it's not clearly indicated, it's probably not a good idea for them to be operated on."
Between 1 million and 2 million Americans suffer from emphysema, a chronic and deadly lung condition caused by smoking. The disorder is marked by the gradual erosion of tiny airways, starving patients of oxygen and hobbling their ability to perform even the most minimal activities. It kills 100,000 people a year in this country alone, and even with surgery the long-term outlook is grim.
Dr. Robert Wise, a lung specialist at Johns Hopkins University School of Medicine and a co-author of the study, says roughly 10 percent of people with severe emphysema might be good candidates for surgery. Perhaps 40 percent to 50 percent of the rest could be considered for the operation, Wise says.
LVRS was pioneered in the 1950s, though questions about its effectiveness have limited its use. In the procedure, doctors remove sections of scarred airways, with the hope that doing so will free up airflow in the remaining organ.
The National Emphysema Treatment Trial (NETT) sought to learn if the benefits of the lung surgery outweighed its potential risks. The work was sponsored in part by Medicare, which has stopped covering the procedure outside the trial.
NETT included 1,218 men and women with severe emphysema at 17 clinics across the country. All received "medical therapy," including drugs (such as steroids) to open their airways, as well as oxygen, encouragement to exercise, and other lung rehabilitation. In addition, half underwent LVRS.
For the average patient, the surgery led to an immediate improvement in lung function, which tapered off by about two years after the procedure. Those in the other group saw their lung function continue to wane.
By the end of the study, death rates in the two groups were the same, yet people who had the operation were about eight times more likely to die within the first 90 days of starting the trial (7.9 percent versus 1.3 percent). However, when the researchers excluded 140 patients at high risk of dying from the lung surgery, that gap narrowed somewhat and by the end of the study mortality in the two groups was no different.
LVRS was most effective in people with localized lung damage and poor ability to exercise, halving the risk of death compared with medical management alone. That makes sense, experts say, because removing the injured tissue has a good chance of allowing healthy airways to take over. Meanwhile, people with bad exercise capacity are more likely to die in the absence of treatment. For this group, even a small increase in the ability to move around improves their overall quality of life.
On the other hand, LVRS was least effective in the group with widespread lung damage but good exercise ability. They had a higher risk of death compared with medical management only, yet reaped no benefits from the procedure.
After accounting for plus-minus of these two groups, the long-term effects of surgery were essentially neutral.
Dr. Gail Weinmann, project officer on the study for the National Heart, Lung, and Blood Institute, which helped fund the research, says the trial provides "the best quality data" that now exist on LVRS. Without the work "we could not have known who would benefit, we could not have known the probability that they would benefit or the duration" of the effectiveness, says Weinmann, a co-author of the journal article.
In a related study, researchers analyzing the same data conclude that LVRS isn't cost-effective in the short run, but may be so over many years. "It's very expensive in the short-run. Its best value is for the sub-group that has the best outcome," says Dr. Scott Ramsey, a physician and economist at the University of Washington and a co-author of the study.
Medicare, the government's insurance program for the elderly, is now reviewing its coverage of lung reduction surgery based on the NETT results. A decision is expected soon.
Ramsey's group estimates that if 1 percent of the nation's emphysema patients were eligible for LVRS, costs to the health-care system would run between $100 million and $300 million a year. "It's a big hit for their budget," he says, referring to Medicare. "That's why they're going to look very carefully at who is eligible for the procedure."