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Jelle E Bousema,1 Fieke Hoeijmakers,2 Marcel GW Dijkgraaf,3 Jouke T Annema,4 Frank JC van den Broek,1 M Elske van den Akker-van Marle5 On behalf of the MEDIASTrial Study Group1Department of Surgery, Máxima MC, Veldhoven, 5500 MB, the Netherlands; 2Department of Surgery, Leiden University Medical Center, Leiden, 2300 RC, the Netherlands; 3Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, 1100 DE, the Netherlands; 4Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, 1100 DE, the Netherlands; 5Department of Biomedical Data Sciences, Unit Medical Decision Making, LUMC, Leiden, 2300 RC, the NetherlandsCorrespondence: Frank JC van den BroekDepartment of Surgery, Máxima MC, Veldhoven, P.O. BOX 7777, Veldhoven, 5500 MB, the NetherlandsEmail lung.resurge@mmc.nlBackground: Variability in practice and ongoing debate on optimal invasive mediastinal staging of patients with resectable non-small cell lung cancer (NSCLC) are widely described in the literature. Patients’ preferences on this topic have, however, been underexposed so far.Methods: An internet-based questionnaire was distributed among MEDIASTrial participants (NTR6528, randomization of patients to mediastinoscopy or not in the case of negative endosonography). Literature, expert opinion and patient interviews resulted in five attributes: the risk of a futile lung resection (oncologically futile in case of unforeseen N2 disease), the length of the staging period, resection of the primary tumor, complications of staging procedures and the mediastinoscopy scar. The relative importance (RI) of each attribute was assessed by using adaptive conjoint analysis and hierarchical Bayes estimation. A treatment trade-off was used to examine the acceptable proportion of avoided futile lung resections to cover the burden of confirmatory mediastinoscopy.Results: Ninety-seven patients completed the questionnaire (57%). The length of the staging period was significantly the most important attribute (RI 26.24; 95% CI: 25.05– 27.43), followed by the risk of a futile surgical lung resection (RI 23.44; 95% CI: 22.28– 24.60) and resection of the primary tumor (RI 22.21; 95% CI: 21.09– 23.33). Avoidance of 7% (IQR 1– > 14%) futile lung resections would cover the burden of confirmatory mediastinoscopy, with a dichotomy among patients always (39%) or never (38%) willing to undergo confirmatory mediastinoscopy after N2 and N3-negative endosonography.Conclusion: Although a strong dichotomy among patients always or never willing to undergo confirmatory mediastinoscopy was found, the length of the staging period was the most important attribute in invasive mediastinal staging according to patients with resectable NSCLC.Trial Registration: Not applicable.Keywords: patients’ preferences, non-small cell lung cancer, mediastinal nodal staging, endosonography, mediastinoscopy, thoracic surgery