Correspondence

Operation for lung cancer in the elderly: What about octogenarians?

To evaluate postoperative outcome and quality of life (QOL), comparing patients <80 years old to patients ≥ 80.

EORTC questionnaires, QLQ-C30 and QLQ-LC13 was used to assess QOL, in patients after surgery. Results were evaluated according to 3 age groups: <70, 70 to 79, and ≥80.

106 patients were enrolled with 33 (<70), 25 (70-79), and 48 (≥80) patients per group. The median age was 74 years. 79% of patients had minimally invasive procedures, including 91% of those ≥80. Fifteen patients underwent wedge resections. Complication rates (18%, 32%, and 29%, P = .4) and median length of stay (4, 6, and 5 days, P = .2) were similar in all age groups, with no hospital mortality. One hundred one patients completed the questionnaires. Global QOL was highest among octogenarians. Overall functional and role QOL was higher among octogenarians than 70- to 79-year-olds, with emotional QOL higher than those <70 (P < .05). Social QOL in octogenarians was marginally lower than younger patients. Lung-specific symptom scores were at least 1.5 times lower than those <80 (P = .052). Patients aged 70 to 79 had the worst symptomatic and emotional effect on QOL. Surgical access and preoperative performance status did not affect final QOL across all age groups (P = .9 and P = .065). Among anatomical lung resections, QOL was higher in octogenarians than those 70 to 79 in all domains, and similar or higher than those <70 in most domains.

Quality of life among octogenarians after surgery remains similar to younger patients even after anatomical lung resection. Surgery in octogenarians is safe, with minimal impact on postoperative QOL.

L’oncogériatrie est une spécialité en plein essor du fait des modifications épidémiologiques profondes liées au vieillissement de la population. La prise en charge des sujets âgés de 75 ans et plus atteints de cancer bronchopulmonaire est devenue une question majeure en oncologie thoracique. La chirurgie à visée curative reste le traitement offrant les meilleures possibilités de survie au patient, et ce, quel que soit son âge. La grande variabilité observée parmi les patients âgés oblige à prendre en compte leurs spécificités, notamment du point de vue de la physiologie du vieillissement mais également des comorbidités qu’ils peuvent présenter. Le bilan préopératoire permettant de déterminer la résécabilité de la tumeur mais également l’opérabilité du patient est donc d’autant plus essentiel qu’il doit être adapté au terrain particulier du sujet d’âge avancé. La morbi-mortalité associée au traitement chirurgical est à présent mieux évaluée grâce aux données de la littérature et est considérée comme acceptable vu le bénéfice sur la survie à moyen et long termes. Les efforts de recherche clinique doivent néanmoins être poursuivis et notamment en ce qui concerne les traitements multimodaux pour lesquels nous ne disposons que de très peu de données.

Geriatric oncology is a rapidly expanding domain because of the deep epidemiological changes of the last decades related to the ageing of the population. Lung cancer treatment in patients 75 years and over is a major issue of thoracic oncology. Curative surgery remains the treatment offering the best survival rates to the patient whatever his age. The important variability observed within the elderly forces us to take into account their specificities, in particular for ageing physiology and associated comorbidities. Thus, preoperative workup permitting to assess the resectability of the tumor but also the operability of the patient is all the more essential in the advanced age that it must be adapted to the particular characteristics of the elderly. Thanks to recent data of the literature, morbidity and mortality associated to surgical treatment are now better characterized and considered as acceptable in accordance with long-term survival. Clinical investigation remains essential to acquire a better knowledge of potential benefit of multimodal treatments in the elderly, for which very few data are available.

Recent reports indicate that age is not a contraindication to pulmonary resection for octogenarians with nonsmall cell lung cancer (NSCLC), but other data are lacking. The purpose of this study was to determine outcomes in these patients, particularly short- and long-term survival with stage I disease.

A retrospective cohort of 68 octogenarians with NSCLC who underwent curative resection from 1980 to 2002 was followed-up for outcomes.

Median age was 82 years old (range, 80–87 years old) consisting of 44 males (65%), with a mean follow-up of 32 months (range, 1–178 months). Operations included: 47 lobectomies (69%), 11 wedge resections (16%), 5 segmentectomies (8%), 4 bilobectomies (6%), and 1 pneumonectomy (1%). There were 31 adenocarcinomas (46%), 18 squamous carcinomas (26%), 12 bronchioalveolar carcinomas (18%), 4 large cell carcinomas (6%), and 3 miscellaneous malignant neoplasms (4%). Median hospital stay was 7 days (range, 3–53 days). Thirty-day mortality was 8.8% (n = 6) with 83% developing cardiopulmonary complications. Overall actuarial survival at 1, 3, and 5 years was 73%, 51%, and 34%, respectively. Of 41 patients (60%) with stage I disease, 23 were T1 lesions. Five-year survival was significantly different between stages Ia and Ib patients (61% and 10%, respectively, p = 0.001). Patients in more advanced stages had a 5-year survival of 3/27 (11%). Multivariate analysis identified advanced tumor stage, lower ASA physical status, and low FEV₁ as factors associated with poorer long-term survival.

The 5-year survival, particularly in patients with stage Ia tumors with favorable ASA and FEV₁, supports the notion that health status and tumor stage outweigh chronologic age in determining surgical candidates.

There is a general trend worldwide of an increasing incidence of elderly population. Age is the greatest risk factor for cancer; therefore, this demographic shift is the main reason for an increase of cancer incidence. Lung cancer is a typical disease of the elderly patients. This review summarizes the issues of treatment of non-small cell lung cancer (NSCLC) in the elderly. Early stage NSCLC is usually treated with radical surgery, locally advanced NSCLC with radiotherapy (RT) and/or chemotherapy (CHT) and metastatic disease with CHT, but the evidence for these approaches is based on studies which are usually performed with highly selected patients while elderly patients are under-represented. We used the data from studies addressing particularly elderly or providing subgroup information on age to analyse the feasibility of current standard approaches for elderly and discuss alternative approaches. Surgery is an effective method in elderly patients with early stage NSCLC although some approaches bear a somewhat higher risk of operative morbidity and mortality. RT for early stage may be an alternative with curative potential. For locally advanced stage RT alone, or combined radiochemotherapy in selected cases, is feasible for elderly patients with locally advanced NSCLC when a careful assessment of pre-therapeutic status is made and appropriate drugs are selected. Advanced age alone also should not preclude CHT, although the risk of adverse effect may be higher in certain cases. New generation drugs seem to be particularly feasible and efficient in elderly patients. In general, age itself does not seem to preclude patients from standard treatments although in some cases co-morbidity forces to alternative approaches. Currently, single-agent CHT should be considered as the standard treatment of advanced NSCLC elderly patients.

Background. Octogenarians often present with potentially resectable bronchogenic carcinoma. Older reports noting prohibitive mortality and recent surveys documenting continued substantial risk raise concerns about the applicability of operation in this age group.

Methods. We reviewed the short-term and long-term results of pulmonary resection for intended cure of lung cancer in patients 80 years and older operated on from 1980 through 1995. Our surgical philosophy favored lobectomy over lesser resection and generally avoided pneumonectomy in the elderly.

Results. Fifty-four octogenarians underwent resection: 43 lobectomies, 2 extended lobectomies, 2 bilobectomies, 3 segmentectomies, 3 wedge excisions, and 1 pneumonectomy. There were two perioperative deaths (3.7%). The overall nonfatal complication rate was 42%, with a major complication rate of 11%. Postoperative stay decreased from 8.1 days overall to 6.3 days in the last 3 years. Only 3 patients required temporary convalescent care after discharge. Actuarial survival at 1, 3, and 5 years was 86%, 62%, and 43%, respectively, for all discharged patients (n = 52) and 97%, 78%, and 57% for stage I cases (n = 39). Patients with tumors beyond stage I fared poorly.

Conclusions. Advanced age per se is neither a contraindication to curative resection nor a routine indication for nonanatomic operations in healthy octogenarians with stage I lung cancer. With proper selection, acute risk should be low. Pneumonectomy, extended resection, and operation for stage II or III disease should be considered only in exceptional cases.