Win ratio analysis of surgical approaches for lung cancer: a nationwide observational study using the French national hospital discharge database

Abstract

Minimally invasive surgical approaches have gained widespread adoption, yet comparative evidence integrating multiple hierarchical endpoints remains limited. Our objective was to compare the surgical approaches for lung cancer resection (thoracotomy, VATS, robot-assisted surgery) using a four-level hierarchical composite endpoint of postoperative morbidity and mortality, and the Win Ratio (WR) method, which respects the clinical priority of outcomes, and offers a novel framework for such comparisons. A nationwide retrospective cohort study including all patients undergoing pulmonary resection for lung cancer were included (N = 62,670; 169 hospitals, French National Hospital Discharge Database 2020–2024). The primary endpoint was a four-level hierarchical composite: 90-day mortality > Dindo–Clavien complication score > 30-day readmission > length of stay. Inverse probability of treatment weighting (IPTW) was used for confounding adjustment. WR and Net Benefit (NB) were reported. Both minimally invasive approaches demonstrated statistically significant superiority over thoracotomy: VATS vs. thoracotomy WR = 1.47[1.44–1.50] (p < 0.0001, NB = 18.4%); robot-assisted vs. thoracotomy WR = 1.52[1.47–1.56] (p < 0.0001, NB = 20.1%). The comparison between robot-assisted surgery and VATS showed a modest advantage for the robotic approach (WR = 1.03[1.00–1.06], p = 0.025, NB = 1.5%) which is clinilly marginal. Dindo–Clavien complication was the main driver of differences. Results were robust across multiple sensitivity analyses, including alternative hierarchies, IPTW truncation thresholds, and restriction to lobectomies. This large-scale Win Ratio analysis suggests that minimally invasive approaches (VATS and robot-assisted surgery) are associated with better short-term postoperative outcomes compared with thoracotomy for lung cancer resection, mainly due to a reduction in the severity of complications rather than a fall in mortality.These findings should be interpreted with caution given the observational design and the potential for residual confounding by unmeasured clinical factors.