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A new meta-analysis provided high-quality evidence demonstrating that video-assisted thoracoscopic surgery (VATS) significantly reduces the risk for death by 21% compared with open lobectomy in patients with early-stage lung cancer.

Jacie Jiaqi Law, MD, of the Royal Brompton Hospital in London, England, characterized the study as the largest and most comprehensive analysis to date comparing survival outcomes between VATS and open surgery for lung cancer resection.

Law, the lead author of the meta-analysis, highlighted that the minimally invasive approach offers more than quality-of-life benefits, according to her study findings, which she presented at World Conference on Lung Cancer (WCLC) 2025.

“For the first time, our study provides evidence that in the context of early-stage lung cancer, a seemingly simple change in surgical access to VATS, we can expect a 21% reduction in overall risk of death with no evidence of compromise to disease-free survival,” Law said during her presentation.

Rationale and Study Design

Law noted that VATS has become the most common method for pulmonary lobectomy in patients with early-stage lung cancer. She explained, however, that its widespread adoption is based primarily on nononcological benefits such as reduced postoperative pain, fewer complications, shorter hospital stays, and improved quality of life. However, clinical equipoise has remained regarding the oncological adequacy of VATS compared with open surgery.

“There has been no single randomized controlled trial published to date that has been sufficiently powered to detect a difference in survival outcomes between VATS and open surgery,” she said.

To address this knowledge gap, the research team conducted an individual patient data meta-analysis combining three high-quality randomized controlled trials: the PLEACE trial (NCT01278888) by Morten Bendixen, MD, and colleagues from Denmark, a trial by Hao Long and colleagues from China (NCT01102517), and the VIOLET trial (NCT03521375) by Eric Lim and colleagues from the UK.

The analysis included 1185 patients (586 randomized to VATS and 599 to open lobectomy) with median follow-up times ranging from 3.8 to 9.5 years across the three trials. All analyses were conducted on an intention-to-treat basis using a one-stage random effects Cox proportional hazards model.

Key Findings

The analysis revealed that patients randomized to VATS had significantly better overall survival than those who underwent open lobectomy, with a pooled hazard ratio (HR) of 0.79 (95% CI, 0.65-0.96), representing a 21% reduction in the risk for death. This survival benefit was consistent across all three individual trials.

Law noted that the 21% relative improvement in overall survival meets the generally accepted threshold for clinically meaningful survival differences. She emphasized that this magnitude of benefit is comparable to what is considered clinically important for adjuvant chemotherapy recommendations.

Despite the significant differences in overall survival between VATS and open lobectomy, the study showed no evidence of a difference in disease-free survival, with a pooled HR of 0.91 (95% CI, 0.75-1.12).

“The overall survival benefit observed in VATS may be driven by improvements in noncancer specific outcomes rather than enhanced cancer control,” Law noted during her talk. She referenced data showing lower hospital readmission rates and significant reductions in adverse events over the first year, primarily renal and infective complications.

Data Interpretation

Ayumi Suzuki, MD, PhD, of the Cancer Institute Hospital of Japanese Foundation for Cancer Research in Tokyo, Japan, who served as the discussant for the presentation, highlighted the evolution of lung cancer surgery, noting the shift toward less invasive procedures. She also revealed that most of the surgeries for early-stage lung cancer performed in her department are done by VATS.

Suzuki acknowledged that several questions remain about the mechanisms underlying the survival benefit in patients who undergo VATS lobectomy. She proposed that reduced mortality due to comorbidities, more intensive treatments after recurrence, and maintaining anti-tumor immunological responses may be potential factors contributing to the overall survival benefit.

She also noted that the lack of data on cause-specific mortality, detailed histological data, and postoperative complications in the three trials creates the need for large and well-designed randomized controlled trials to provide more evidence regarding the superiority of VATS lobectomy over open lobectomy.

Although Suzuki encouraged surgeons to consider adopting VATS, she concluded by emphasizing the importance of technical expertise in surgical decision-making.

“We should never forget that the most important factor is to get your patients back to their families with a good R0 resection. So if you are confident in doing a perfect thoracotomy, that might be the best selection for you if you are not familiar with VATS,” she advised.

Law and Suzuki reported no relevant financial disclosures.

Christos Evangelou, PhD, is a freelance medical writer.