May 20, 2003 (Seattle) -- Simple things like taking a shower or getting dressed can leave someone with emphysema breathless. Now, however, a landmark study reports that some emphysema patients can increase their exercise tolerance by having diseased sections of their lungs removed -- called lung volume reduction surgery.
The controversial surgery works best for patients whose emphysema is confined to the upper parts of the lung and who have very low exercise tolerance, says Keith Naunheim, MD, a surgeon at Washington University in St. Louis who presented his research at a meeting of lung specialists. "We estimate that about 100,000 patients could benefit from the surgery," he tells WebMD. That is a relatively small number compared to the estimated 2 million Americans who have emphysema.
The study enrolled 1,218 patients with severe emphysema. Each patient received either lung volume reduction surgery or optimal medical treatment after they completed a lung rehabilitation program to get them "as healthy as possible," says co-researcher Andrew Ries, MD, MPH, of the University of Southern California.
Ries says that in general, surgical patients fared better than medical patients.
The real benefit says Ries, are lifestyle gains: 16% of surgery patients have improved exercise tolerance compared with just 3% of the medically treated patients.
There was no survival benefit when all surgery patients were considered together. But a small group of patients who had damage confined to the upper areas of the lungs -- the most typical emphysema pattern seen in smokers -- and who have very limited exercise tolerance "will live longer if they have this surgery," says Naunheim.
When lung volume reduction surgery was first introduced in late 1980s, it rapidly became a popular treatment for emphysema patients based on a series of small studies showing the surgery could improve exercise tolerance and prolong life. But there were wide variations in outcomes: Some surgeons said death from the surgery itself occurred 4% of the time while others reported death rates of 15%. Medicare pulled the plug on lung volume reduction surgery when a review of medical claims indicated that 17% of patients died within six months of surgery.
At that point, Medicare and the government decided to jointly fund research to determine once and for all if lung volume reduction surgery was worth the risk. Naunheim and others unveiled the results before a standing-room-only crowd at the American Thoracic Society meeting. The study also appears in the May 22 issue of The New England Journal of Medicine.
Though the quality-of-life improvements can be considered good news for emphysema patients, the benefit has a high price. The cost for lung volume reduction surgery and six months of postoperative treatment averaged just under $63,000 per patient, while six months of medical treatment costs $13,000. Naunheim says surgical costs are so high because patients are often hospitalized for long periods or are sent to rehab facilities before returning home. There is no doubt that recovery is long and requires a lot of work on the part of the patient and doctors, he says.
Medicare stopped paying for lung volume reduction surgery in late 1995, says Steven Sheingold, PhD, who represented Medicare at a news conference where the results were discussed. He tells WebMD that Medicare is already considering reinstating payment but says that it will take about three months before a decision is made.