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Too old for lung resection for NSCLC? In France, the answer is "Non!"
The elderly have been largely excluded from clinical trials on non-small cell lung cancer (NSCLC), as their surgical risks have been perceived as too high to benefit as a group from lung resection. Many people believe that in practice, elderly people with NSCLC have often been excluded from consideration for lung resection solely based on age, although surgeons may be becoming more amenable to operating on them in recent years.
Rivera et al of the Bordeaux region challenge that dogma in this registry analysis of 1,969 people over 70 years old with NSCLC stage I or II who were operated on between 2004 and 2008. They then matched them to 1,969 younger patients with similar factors (FEV1, gender, ASA score, performance status, BMI, and number of comorbidities). The elderly cohort's average age was 75; the younger cohort, 58. The elderly had a BMI of 25.7 vs. the youngers' 24.9, and the older group had more adenocarcinomas, but the groups were otherwise well-matched.
Interesting findings included:
Surprisingly, the older and younger patients got sublobar resections in equal frequency (historically these were more favored for the elderly).
Postoperative complications were similar in older and younger patients.
90-day mortality was almost twice as high for older patients (4.6% vs. 2.5%, p=0.02). However, this is an improvement from earlier series in which 30-day mortality was 7% in the elderly after lung resection.
Major limitations in drawing conclusions from the data included:
No information on long-term survival or morbidity in either group. Perhaps it could be inferred for the younger patients, but due to older patients' exclusion from trials, their 1-to-5 year survival -- the most important in recommending for or against lung resection -- isn't clear. Nor is it clear what happened after discharge -- if they went home to independent living, or wound up in a nursing home soon after surgery.
No insight into the surgical selection process in the elderly. FEV1 was only characterized as >60% or <60%. Exercise testing -- a major predictor of survival postoperatively -- wasn't included. Without a clear picture of the preop assessment of these patients, it's hard to extrapolate to our own. (Not to mention, these patients were French, and thin. Could we expect these outcomes for our corn-fed, Marlboro-smoking countrymen in the U.S.?)
Overall, there's good evidence to support resection of early NSCLC in the generally healthy elderly, even the very old. For instance, five-year survival after resection of stage IA NSCLC in 21 well-selected patients over 80 years old was an encouraging 82% in a 2004 series. In another 2004 series of 23 stage IA patients, five-year survival was 61%.
Rivera C et al. Surgical Management and Outcomes of Elderly Patients With Early Stage Non-small Cell Lung Cancer. A Nested Case-Control Study. CHEST 2011;140(4):874-880.