Endosonography followed by surgical staging improves quality of life, according to ASTER study

Patients who underwent endoscopic testing prior to surgery for lung cancer had significantly better quality of life at the end of the staging process, with no significant difference in costs between the two strategies, according to data presented at the 14th World Conference on Lung Cancer in Amsterdam, hosted by the International Association for the Study of Lung Cancer (IASLC).

"Given that assessment of lymph glands using the endoscopic approach was more effective, better tolerated by patients and no more expensive than the surgical approaches, we recommend that investigation should commence with the endoscopic tests, reserving the surgical tests as a backup if the endoscopic approaches do not show any evidence of cancer," said principal investigator Dr. Robert Rintoul of Papworth Hospital in Cambridge, United Kingdom. "We anticipate that this data will change the way in which the mediastinum is assessed in the future."

Before performing lung cancer surgery, it's important to determine whether the cancer has spread to the lymph glands in the middle of the chest, or mediastinum. If it has done so, then a surgical operation to attempt to remove the tumor may not be appropriate, Dr. Rintoul said.

Historically, biopsy of these lymph glands has required an exploratory surgical operation such as a mediastinoscopy. But new approaches to reach the lymph glands via the airway or the esophagus using flexible telescopes have been developed; these techniques are called endobronchial and endoscopic ultrasound.

Results of ASTER, a randomized clinical trial to compare the surgical biopsy approach with the endoscopic approaches, were published in the Journal of the American Medical Association in November 2010. They showed that assessing the lymph glands with the endoscopic approaches, using mediastinoscopy as a backup if the endoscopic approach did not show any evidence of cancer, was more effective than using mediastinoscopy alone.

At the end of staging, patients who underwent endosonography reported better quality of life than those randomized to surgical staging, researchers said at the World Conference on Lung Cancer. There was little difference between the two groups at 2 months and 6 months.

Mediastinal staging with endosonography was cost-effective compared with surgery alone, saving £746 (approximately $1,210 U.S./€845 euros) per patient. The savings rose to £2,124 (approximately $3,450 U.S./€2,400) per patient among those who had endosonography but did not undergo surgical staging.