Aging Begins at 30

The Surgical Treatment of Emphysema

In talking to patients one develops word pictures to explain their disease. I used to tell mine, "If you smoke a pack of cigarettes daily for a year, that's one pack-year. If you smoke two packs a day for a year that's two pack-years. When you've smoked 50 pack-years you'll get smoker's lung, called emphysema, which is irreversible, and after 100 you can expect lung cancer. It's that simple!"

Because of the possible crowding out of healthy lung air sacs, surgical removal of the ballooned useless air sacs has become fashionable. It is called lung volume reduction surgery. Now we have reached the testing time although that should have come first. In a National Trial, 538 emphysema patients were assigned randomly to surgical treatment and 540 were assigned to standard non-surgical treatment. Only about one third of patients screened for this trial were found to be eligible. About 1,500 participating physicians are listed. It was a big expensive trial, but necessary.

First the overall death rate in the two groups was the same at the 29-month follow-up. It was apparent, however, that some surgical patients benefited, so further analysis was done. They were divided into upper and lower lobe disease and into patients who could exercise and those that could not. The ones helped most by the surgery were those with upper lobe disease, who also at the time of randomization had lost their ability to exercise. They had a 20 percent mortality rate compared to 40 percent in the medical treatment group. If they had upper lobe disease but could exercise or had lower lobe disease there was no benefit to having the surgery. If patients had lower lobe disease and were able to exercise the risk of death for the surgery patients was significantly higher (twice) than in those who were treated without surgery.

Two editorials accompanying this study caution against "data mining" for so-called secondary findings, which means reaching conclusions not outlined in the original plan. If a suggestion of an effect is found it must be separately retested. To do otherwise is to commit statistical heresy. A correction called Bonferroni's is used and if the results are still promising you have a new hypothesis to test; that is, you do not have a positive result.

What about cost? In a separate article this is examined. Compared to non-surgical medical treatment the cost is $190,000 per good year of life gained but in the best responders the figure is $60,000 per quality year gained. For comparison, dialysis or coronary artery bypass grafting cost about $60,000 per quality year. If the benefits obtained at three years in the lung surgery group can be sustained for 10 years the cost will be reduced to $53,000 per quality year.

In one of the editorials, Drs. Drazen and Epstein state, "Good Research separates what we think should happen from what we actually know does work." This important research will tell us how and when to use this surgery to help our emphysema patients.

Section Top | Title Page

See related Patient Topics COPD (Chronic Obstructive Pulmonary Disease), Emphysema or Lungs and Breathing.

See related Provider Topics COPD (Chronic Obstructive Pulmonary Disease), Emphysema or Lungs and Breathing.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

http://www.vh.org/adult/patient/internalmedicine/aba30/2003/emphysema.html