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Integrating Health Status and Survival Data

The Palliative Effect of Lung Volume Reduction Surgery

¹ Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; ² Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; ³ Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; ⁴ Internal Medicine, Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, Michigan; ⁵ Department of Health Services, University of California, Los Angeles, California; ⁶ Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; ⁷ Division of Pulmonary & Critical Care Medicine, Temple University, Philadelphia, Pennsylvania; ⁸ Division of Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland; ⁹ Division of Pulmonary Sciences, National Jewish Medical Center and Research Center, Denver, Colorado; ¹⁰ Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; ¹¹ Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Correspondence and requests for reprints should be addressed to Roberto P. Benzo, M.D., M.Sc., Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Gonda 18-440, Rochester, MN 55902. E-mail: benzo.roberto{at}mayo.edu

Rationale: In studies that address health-related quality of life (QoL) and survival, subjects who die are usually censored from QoL assessments. This practice tends to inflate the apparent benefits of interventions with a high risk of mortality. Assessing a composite QoL-death outcome is a potential solution to this problem.

Objectives: To determine the effect of lung volume reduction surgery (LVRS) on a composite endpoint consisting of the occurrence of death or a clinically meaningful decline in QoL defined as an increase of at least eight points in the St. George's Respiratory Questionnaire total score from the National Emphysema Treatment Trial.

Methods: In patients with chronic obstructive pulmonary disease and emphysema randomized to receive medical treatment (n = 610) or LVRS (n = 608), we analyzed the survival to the composite endpoint, the hazard functions and constructed prediction models of the slope of QoL decline.

Measurements and Main Results: The time to the composite endpoint was longer in the LVRS group (2 years) than the medical treatment group (1 year) (P < 0.0001). It was even longer in the subsets of patients undergoing LVRS without a high risk for perioperative death and with upper-lobe-predominant emphysema. The hazard for the composite event significantly favored the LVRS group, although it was most significant in patients with predominantly upper-lobe emphysema. The beneficial impact of LVRS on QoL decline was most significant during the 2 years after LVRS.

Conclusions: LVRS has a significant effect on the composite QoL-survival endpoint tested, indicating its meaningful palliative role, particularly in patients with upper-lobe–predominant emphysema.

Key Words: chronic obstructive pulmonary disease • outcome assessment • palliative care • quality of life • survival • emphysema

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Lung volume reduction surgery (LVRS) improves the chances of survival in some patients with advanced emphysema. The effects of LVRS on patients' health-related quality of life adjusted for the survival time has received less attention. What This Study Adds to the Field This study demonstrates the beneficial effect of LVRS on a composite endpoint consisting of the occurrence of death or a clinically meaningful decline in quality of life. The benefit was even stronger in LVRS subsets of patients without high risk for perioperative death and with upper-lobe–predominant emphysema. The results indicate that LVRS provides a meaningful palliative effect beyond the survival benefit.