(Chest. 2005;128:2671-2676.)
© 2005
American College of Chest Physicians
Advanced Age Does Not Exclude Lobectomy for Non-small Cell Lung Carcinoma*
Vita Sullivan, MD;
Tao Tran, MD;
Amy Holmstrom, RN;
Michael Kuskowski, PhD;
Paul Koh, MD;
Jeffrey B. Rubins, MD, FCCP and
Rosemary F. Kelly, MD, FCCP
* From the Division of Cardiovascular and Thoracic Surgery (Drs. Sullivan, Tran, Koh, and Kelly), University of Minnesota, Minneapolis, MN; and the Departments of Research (Ms. Holmstrom), Geriatric Research (Dr. Kuskowski), and Medicine (Dr. Rubins), Education & Clinical Center, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN.
Correspondence to: Rosemary F. Kelly, MD, Minneapolis VA Medical Center (112) One Veterans Dr, Minneapolis, MN 55417; e-mail: kelly071{at}umn.edu
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Abstract
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Study objectives: Localized non-small cell lung carcinoma (NSCLC) is best treated by complete surgical resection, commonly requiring lobectomy. The impact of lobectomy on the health status of the elderly patient is not well-characterized. The aim of this study was to compare the effect of lobectomy in elderly patients (
70 years of age) and younger patients (< 70 years of age) on their pulmonary function and functional status 1 year following surgery.
Design: One hundred forty patients underwent lobectomy for NSCLC at the Minneapolis Veterans Affairs Medical Center from January 1999 to December 2003. All patients underwent pulmonary function tests (PFTs) and functional status assessment using Karnofsky scores (KS) that were assessed preoperatively. Sixty-three of 140 lobectomy patients were available 1 year postoperatively for reevaluation by PFTs and KS.
Results: There was no statistical difference between groups in either the pulmonary function or functional status testing results at 1 year after undergoing lobectomy. FVC decreased by 14% in the elderly patient and by 9% in the younger patient group. FEV1 decreased by 19% in elderly patients and by 13% in younger patients. Functional status declined for two older patients (8%), who dropped their KS from 80 to 100% (normal activity without limitation) to 40 to 70% (unable to work, but able to care of self at home). Nine of the younger patients (24%) had KS drop from 80 to 100% to 40 to 70%. There was one perioperative death (30-day mortality rate for the study groups, 1.5%).
Conclusions: Elderly patients 70 years of age undergoing lobectomy for NSCLC had similar PFT results and functional status as younger patients < 70 years of age 1 year after undergoing surgery. Curative resection should not be denied based on age alone.
Key Words: elderly • lobectomy • Karnofsky score • non-small cell lung carcinoma • pulmonary function tests • surgery
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Introduction
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Bronchogenic carcinoma continues to be a substantial health concern in the United States. There were approximately 172,000 newly diagnosed lung cancers in the year 2003.1 Lung cancer remains the leader of cancer-related deaths in both men and women, accounting for 31% and 25%, respectively, of all cancer-related deaths in 2002.1 The majority of bronchogenic carcinomas (75 to 80%) are due to non-small cell lung carcinoma (NSCLC). When these carcinomas are diagnosed in the early stages, as defined by the TNM staging system of the American Joint Committee on Cancer, complete resection can be curative. It is estimated that only 20% of the newly diagnosed lung carcinomas meet operable criteria.
The incidence of lung carcinoma diagnosed in elderly patients is rising, and the overall population in the United States is aging. In the United States in 1990, there were 341 million individuals who were 65 years of age, a population that had increased to 360 million by 2003.23 Of individuals > 65 years of age, the most rapid growth occurred in the oldest age groups (individuals > 85 years old). With NSCLC generally considered to be a disease of aging, a result of cumulative tissue injury and damage, the majority of lung carcinomas will be diagnosed in the elderly population. Even now, the peak incidence of NSCLC diagnoses are made in individuals in the age range of 70 to 74 years at a rate of 550 per 100,000 for men and 300 per 100,000 in women.4
Deciding the appropriate treatment of NSCLC in the elderly patient remains a difficult problem. It has been demonstrated that for early NSCLC (stages I/II) the optimal strategy is complete resection with either lobectomy or pneumonectomy, as procedures such as wedge resections or segmentectomies have been shown to have higher local recurrence rates.5 Without a doubt, the best impact on the overall 5-year survival rate occurs when NSCLC is diagnosed and aggressively treated in the early stages, and the survival rate drops precipitously with progression of the disease into stages IIB to IIIA.6 Elderly patients may be less likely to be offered surgery as previous studies have demonstrated that elderly patients ( 70 years of age) are more likely to have complications following surgical resection for NSCLC.78 This practice may deny the older patient the optimal therapeutic intervention.
Preoperative surgical planning for the elderly patient involves special considerations. The quality of life following any therapeutic intervention is a major component in the decision-making process for any patient. This becomes even more critical as patients age since surgery often impacts the ability to live and function independently. The 1-year impact of lobectomy on lung function and quality of life has not been well-studied in elderly patients. The purpose of this study was to evaluate the 1-year impact of lobectomy performed for the treatment of early-stage NSCLC on the elderly patient ( 70 years of age) compared to the younger patient (< 70 years of age) with respect to pulmonary function test (PFT) outcomes and functional status assessment using the Karnofsky score (KS).
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Methods and Materials
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Patient Selection
Inclusion criteria for this study were patients undergoing lobectomy at the Veterans Affairs Medical Center, Minneapolis, MN, from January 1999 through December 2003 with preoperative clinical stage I and II NSCLC. The patients were reevaluated objectively with PFTs and subjectively using the KS to assess functional status at 1 year. The patients who received neoadjuvant therapy or were undergoing resection for infectious etiologies were excluded from this study. The study was approved by the Institutional Review Board of the Minneapolis Veterans Affairs Medical Center.
The preoperative assessment included a chest CT scan, positron emission tomography imaging with radiolabeled 18Ffluorodeoxyglucose, PFTs, and, when clinically indicated, a bone scan and head CT scan. The CT scan determined the clinical tumor stage, and both CT scanning and 18Ffluorodeoxyglucose positron emission tomography scanning determined clinical node and metastasis stages preoperatively. Each patient was determined to be an appropriate candidate for surgical intervention. If indicated by history or physical examination, a cardiac evaluation was also done. At the time of lobectomy, a complete mediastinal lymphadenectomy was performed as well.
During the study period, 140 patients underwent lobectomy for NSCLC with a curative intent. Of those patients, 63 were able to be followed up at 1 year postoperatively for evaluation and were included in the study. There were 77 patients who underwent lobectomy during the study period but were excluded from this analysis (younger group, 43 patients; elderly group, 34 patients). Sixty patients were excluded from the study because they were unable or unwilling to undergo PFT at 1 year. Ten patients underwent neoadjuvant chemotherapy prior to resection. Seven patients underwent lobectomy for the treatment of malignancies other than NSCLC (metastasis that required lobectomy for complete resection) or for infection.
To confirm that our data were not biased by including only lower risk older patients, risk factors that can impact perioperative and 1-year morbidity and mortality rates were also included in the statistical modeling. The risk factors that were considered included a known history of coronary artery disease, hypertension, diabetes mellitus, peripheral vascular disease, cerebral occlusive vascular disease, congestive heart failure, elevated cholesterol level, arrhythmia, and other primary malignancy. The statistical modeling also included perioperative complications to ensure that the older and younger patient groups were similar. Complications included pneumonia, pneumothorax, persistent air leak (for > 7 days), arrhythmia, cerebral vascular accident (CVA), myocardial infarction, effusion requiring intervention, chylothorax, return to the operating room (OR), and laryngeal nerve paresis. Only complications that may impact functional status as well as pulmonary function at 1 year were included in this analysis.
PFT
Patients underwent spirometry testing, which included the evaluation of total lung capacity, FVC, and FEV1. Bronchodilator treatment was used to evaluate optimal lung function only in patients requiring bronchodilators daily as part of their medical management of emphysema.
KS
Patients rated their functional status preoperatively during their initial evaluation with the thoracic surgery nurse coordinator using the KS system (Table 1
).9 The KS is a clinician’s appraisal of the level of the patient’s functioning. The same nurse coordinator asked patients to self-rate their quality of life with the KS at their 1-year follow-up evaluation. For ease of comparison in this analysis, the KS was organized into broader categories of function. The broad categories consist of those patients who lived independently, those who required frequent medical care/assistance, and those who were dependent on the care of others. Changes considered to be significant were changes from one broad functional level to another.
Statistical Analysis
Data were analyzed using a statistical software package (SPSS, version 11.0; SPSS; Chicago, IL). Analysis of covariance was used to determine whether there were any changes between the elderly group ( 70 years of age) and the younger group (< 70 years of age) in the change of their measured FEV1 and FVC (preoperative – 1 year postoperative). Risk factors and perioperative complications, as defined above, were included in the analysis as covariates of equal weighting. KS of the elderly and younger groups were compared using 
2 analysis. A change in a broad category of function was considered to be significant, whereas remaining in the same category as the preoperative KS was considered to be unchanged (Table 1).
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Results
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At the time of the study, 113 of 140 patients were alive at 1 year postoperatively, giving a 1-year survival rate of 81%. The overall perioperative mortality rate for the 140 patients (deaths occurring within 30 days of the lobectomy) was 0.7% due to one death. Of the 113 patients who were alive at 1 year, 63 were available for analysis. Of the 63 patients, all were men, with 38 patients in the younger group and 25 patients in the elderly group. The mean (± SD) patient ages were 62.6 ± 6.1 years for the younger group and 74.5 ± 3.6 years for the elderly group. The final surgical histopathology status for all resections is listed in Table 2
. Anatomic location and stage by age groups are listed in Tables 3
and 4
, respectively.
Complications occurred in 24 of 63 patients (younger group, 12 patients [32%]; elderly group, 12 patients [48%]), with complications defined as one or more adverse events requiring additional intervention or treatment. Complications included pneumonia, prolonged air leak, arrhythmia, CVA, effusion, return to the OR, chest wall abscess, recurrent laryngeal nerve paresis, and chylothorax. Five patients required a return to the OR (younger group, three patients; elderly group, two patients). Three patients were taken back to the OR for bleeding immediately (younger group, two patients; elderly group, one patient). One patient underwent ligation of the thoracic duct for persistent chylothorax (younger group). The fifth patient (older group) required delayed evacuation of a hemothorax at 10 days postoperatively. None of these complications resulted in a perioperative death.
PFT
In the younger patient group, the mean preoperative FVC was 3.81 ± 0.81 L (range, 2.02 to 5.33 L) and the mean FEV1 was 2.33 ± 0.76 L/s (range, 0.97 to 3.84 L/s). One year following lobectomy, the mean FVC was 3.47 ± 0.80 L (range, 1.87 to 5.31 L) and the mean FEV1 was 2.02 ± 0.67 L/s (range, 0.87 to 3.37 L/s). This resulted in a mean change at 1 year postoperatively in FVC and FEV1 of 9% and 13%, respectively, for those patients < 70 years old. In the elderly patient group, the mean preoperative FVC was 3.39 ± 0.66 L (range, 1.9 to 4.71 L) and the mean FEV1 was 2.23 ± 0.67 L/s (range, 1.13 to 3.75 L/s). One year following lobectomy, the mean FVC was 2.91 ± 0.81 L (range, 1.08 to 4.64 L) and the mean FEV1 was 1.81 ± 0.60 L/s (range, 0.92 to 2.74 L/s). This resulted in a mean change in FVC and FEV1 of 14% and 19%, respectively, for elderly patients 1 year postoperatively.
The change in FEV1 and FVC (preoperatively to 1 year postoperatively) between the younger and elderly groups was examined using analysis of covariance. Risk factors and postoperative complications were analyzed as potential factors impacting pulmonary function at 1 year postoperatively. All covariates were equally weighted. The covariates considered were risk factors (defined as a known history of coronary artery disease, hypertension, diabetes mellitus, peripheral vascular disease, cerebral occlusive vascular disease, congestive heart failure, elevated cholesterol level, arrhythmia, and other primary malignancy) and complications (defined as pneumonia, pneumothorax, persistent air leak for > 7 days, arrhythmia, CVA, myocardial infarction, effusion requiring intervention, chylothorax, return to the OR, and laryngeal nerve paresis). This analysis demonstrated no significant difference between the age groups for FEV1 (F1,59 = 1.06; p = 0.31) or for FVC (F1,59 = 0.94; p = 0.34). The study design of younger vs elderly patients did not allow age to be viewed as a continuous variable. However, given the clear lack of relationship between age and pulmonary function at 1 year postoperatively based on the scatter plots, the analysis would have been the same (Fig 1
).
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Figure 1. Top: scatter plot of the percentage change in FEV1 (preoperative – 1 year postlobectomy) vs age. Bottom: scatter plot of the percentage change in FVC (preoperative – 1 year postlobectomy) vs age.
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KS
In those patients < 70 years of age, the mean preoperative KS was 90 ± 13.8% and the mean postoperative KS was 84 ± 13.8%. Nine of the 38 patients (24%) <70 years of age decreased in a broad category of function. All of these decreases were from the highest category (scores of 80 to 100% [defined as able to carry on normal activity and no special care needed]) to the middle category (scores of 50 to 70% [defined as unable to work, able to live at home, and cares for most personal needs]). Five of these nine patients dropped from a KS of 80% to a KS of 70% (Table 1).
In the elderly group, the mean preoperative KS was 90 ± 12.4% and the mean postoperative KS was 85 ± 12.3%. The KS of 2 of 25 patients (8%) decreased in a broad category of function. All of these decreases were from the highest category to the middle category (Table 1).
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Discussion
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Historically, surgical intervention in the elderly for NSCLC has been approached with much apprehension. Age and associated comorbidities have been relative contraindications for surgery. This has been disproved in multiple studies that have found that rates for 30-day mortality, long-term survival, and morbidity in the elderly undergoing resection for NSCLC are comparable to those in their younger counterparts.1011121314 However, pervasive customs and beliefs that advanced age and associated comorbidities automatically exclude an aggressive surgical approach may still prevent elderly patients from benefiting from such intervention.15
An increasing number of elderly patients who meet the operative criteria for curative resection are presenting with early-stage lung carcinoma. The benefit of surgery and its impact on survival following surgery are unquestionable. The median survival time for patients with nonresected lung carcinoma has been found to be 7.7 months.16 The long-term survival rate can range from 25 to 80% up to 5 years following resection, depending on the stage. Cykert et al17 have shown that in a population of patients considering curative thoracotomy for NSCLC the perception and anticipation of physical debility postoperatively can deter surgery. However, the impact of lobectomy on long-term lung function and quality of life is not often studied. Therefore, the identification of preoperative predictors of physical debility and a realistic expectation of the impact of resection on lung function and quality life are invaluable in counseling patients.
Previous studies have shown that there is an early functional deficit both in FEV1 and FVC (Nezu et al18: FEV1, 11.2%; FVC, 11.6%; Nugent et al19: FEV1, 15%; FVC, 14%) after lobectomy that is followed by later functional recovery at 6 months. They also found no significant decrease in exercise capacity following resection. These studies, however, include patients with an average age of only 64.2 years, and the follow-up time extended only to 6 months postoperatively. Our study demonstrates that there is no difference in the impact of lobectomy on lung function in both younger and older patients at 1 year postoperatively.
The expected lung function following resection is also intricately associated with quality of life. In patients who have limited lung reserve prior to resection secondary to aging and other lung pathologies (eg, COPD or emphysema), a small percentage change in lung function may have a significant impact on quality of life. We found that there was in fact no significant change in subjective quality of life at 1 year postoperatively following resection for the treatment of early-stage NSCLC, as determined using the KS. This was true in both younger and elderly patients, as both groups were able to continue to live and function at the same capacity following resection as they had prior to undergoing surgery.
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Conclusion
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Elderly patients ( 70 years of age) with good pulmonary function and KS should not be denied operative therapy for NSCLC based on age alone. In this study, age did not affect outcomes of morbidity, pulmonary function after recovery from surgery, and quality of life after lobectomies for the treatment of early-stage NSCLC. These results may improve the discussion with elderly patients in regard to expectations of survival and quality of life following lobectomy for early-stage NSCLC. There is not a statistically significant age-related difference for long-term lung function recovery and quality of life between elderly patients and younger patients who undergo lobectomies as definitive therapy for the treatment of early-stage NSCLC.
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Footnotes
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Abbreviations: CVA = cerebral vascular accident; KS = Karnofsky score; NSCLC = non-small cell lung carcinoma; OR = operating room; PFT = pulmonary function test
Received for publication February 10, 2005.
Accepted for publication April 11, 2005.
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References
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- United States Census Bureau. Resident population estimates of the United States by age and sex: April 1990 to July 1, 1999 with short-term projection to November 1, 2000. Available at: www.census.gov. Accessed November 10, 2004
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- National Cancer Institute. Surveillance, epidemiology and end results (SEER) Program: SEER statistical database; incidence—SEER 9 registry public use. Available at: www.seer.cancer.gov. Accessed November 10, 2004
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Abstract
Introduction
