Combined bronchoscopy, mediastinoscopy, and thoracotomy for lung cancer: Who benefits?

Objectives: Surgical staging and resection of lung cancer may be done as 1 operation (combined) or 2 (staged). This study evaluates the safety and efficiency of these treatment strategies. Methods: From 1998 to July 2001, 343 patients underwent bronchoscopy, mediastinoscopy, and thoracotomy without induction chemoradiotherapy by 3 surgeons. Fifty-seven patients were staged and 286 combined. Staged patients had higher clinical stage (P < .001). Propensity-matched groups were compared to adjust for this and other differences. Factors associated with safety and efficiency were identified by propensity-adjusted multivariable analysis. Results: Mortality and morbidity were similar for both strategies. Efficiency, measured by shorter operative time (1.2 hours) and lower cost (25%), was better for combined strategy (P < .001). Hospital stay was similar, but revenue was 12% higher for the staged strategy (P < .001). In propensity-matched comparisons excluding surgeon, results were similar to the above. Comparisons including surgeon demonstrated similar cost and revenue for both strategies. Increased mortality and morbidity were associated only with patient and tumor characteristics: male gender, worsening Eastern Cooperative Oncology Group performance status, and increasing pathological node classification. All measures of efficiency worsened with increasing pathological classifications. Staged strategy was associated with increased operative time and revenue, while one surgeon and patient smoking history were associated with increased hospital stay and costs. Conclusions: The combined strategy provides efficient, safe health care for clinically operable lung cancer patients, but it may not be as financially rewarding as the staged strategy. Treatment strategy is only 1 of many determinants of efficiency.