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Final Results from the National Emphysema Treatment Trial

Defined groups of patients benefited from lung-volume-reduction surgery, but the high costs of this procedure necessitate careful patient selection.

Lung-volume-reduction surgery involves resection of diseased portions of emphysematous lung, which presumably enables nondiseased portions to function more effectively. In the National Emphysema Treatment Trial, 1218 patients with advanced emphysema were randomized to undergo lung-volume-reduction surgery or medical treatment. In 2001, the researchers reported unacceptably high mortality rates in a subgroup of 70 surgically treated patients with very low FEV₁ (20% of predicted) and several other high-risk characteristics (Journal Watch Sep 25 2001). Now, the findings for the entire cohort have been published.

Mortality was significantly higher in the surgical group than in the medical group at 90 days (7.9% vs. 1.3%) but was 26% in both groups after a mean follow-up of 29 months. In post hoc subgroup analyses, patients with predominantly upper-lobe emphysema and low baseline exercise capacity had significantly lower mortality with surgery than with medical therapy (19% vs. 34%). In contrast, patients with predominantly non-upper-lobe disease and high exercise capacity had significantly higher mortality with surgery than with medical therapy (25% vs. 13%). For other combinations of disease distribution and exercise capacity, mortality rates did not differ between surgical and medical therapy. At 24 months, significantly higher proportions of surgical patients than medical patients experienced improved exercise capacity (15% vs. 3%) and health-related quality of life (33% vs. 9%).

Comment: Is lung-volume-reduction surgery beneficial? This trial did not yield a "one-size-fits-all" answer. As previously reported, the procedure is contraindicated in the highest-risk subgroup, but certain other subgroups experienced reduced mortality and improvement in symptoms during about 2 years of follow-up. Because these conclusions partly rest on post hoc analyses, editorialists call for additional trials. Finally, according to a companion article, the incremental cost-effectiveness of this procedure at 3 years averaged US$190,000 per quality-adjusted life-year gained.

— Allan S. Brett, MD

Published in Journal Watch General Medicine June 3, 2003

Citation(s):

National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003 May 22; 348:2059-73.

• Original article (Subscription may be required)
• Medline abstract (Free)

National Emphysema Treatment Trial Research Group. Cost-effectiveness of lung-volume-reduction surgery for patients with severe emphysema. N Engl J Med 2003 May 22; 348:2092-102.

• Original article (Subscription may be required)
• Medline abstract (Free)

Drazen JM and Epstein AM. Guidance concerning surgery for emphysema. N Engl J Med 2003 May 22; 348:2134-6.

• Original article (Subscription may be required)
• Medline abstract (Free)