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Ann Thorac Surg 2000;69:678-679
© 2000 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, England, UK
Address reprint requests to Dr Goldstraw, Department of Cardiothoracic Surgery, Royal Brompton National Heart and Lung Hospital, Sydney St, London SW3 6NP, England
People are living longer, a trend that is most marked in developed countries. In 1998 in the UK 7.3% of the population were over 75 years of age compared to only 4% in 1961. It is estimated that this figure will rise to 15% by 2021 [1]. Men in this cohort have the highest incidence of lung cancer [2], and it is only a matter of time before women join them. In one district in the UK 43% of patients diagnosed with lung cancer over a 30 month period starting in 1990 were over 75 years of age [3]. In this issue of The Annals of Thoracic Surgery, Bernet and colleagues [4] make the point that age alone does not rule out successful surgical treatment for lung cancer. They have shown that perioperative mortality and 5-year survival are not statistically different for a group aged over 70 years when compared to a group younger than 50 years. There are several reports, including our own [5], that have shown that pulmonary resection can be undertaken for lung cancer in patients aged over 70 years, even over 80 years [6], with mortality only slightly higher than that in younger people. There is no evidence that lung cancer in the elderly is any less lethal than the disease in the younger population. The effectiveness of pulmonary resection at all ages depends upon stage, and this is unaffected by age. While we as surgeons must continue to emphasize this message to those who control patient referral and decide health care priorities, we must be aware of the shortcomings in our case. The report by Bernet and colleagues [4] can be used to illustrate many of these deficiencies, although other studies, including our own, are equally flawed. Such studies are not population-based and we do not know the denominator from which operable cases are selected. Surgeons must be selective in choosing patients on whom to operate, especially when patients are of advanced years. It would be folly to do otherwise. But in what way does such selection influence perioperative mortality and postoperative survival?
The overall perioperative mortality in this study is creditable, 2.2% in the patients who were less than 50 years of age and 2.5% in those over 70 years. The figures even more creditable for those in each group who underwent pneumonectomy (2.6% and 3.8% respectively). The mortality of pneumonectomy in most studies is around 6% [7], and this rises to almost 10% in patients over 70 years of age [5]. The surgeons in Switzerland must be operating on much fitter patients or else have much to teach us as to perioperative management! However, patients undergoing "open-and-close" thoracotomy or incomplete resections were excluded from their study, and we do not know the impact of this on the statistics. Proportionately fewer pneumonectomies were performed in patients over 70 years (22% vs 42%, p = 0.002), especially in patients with stage IIIa disease (41% vs 71%). It is probable that the surgeons were reluctant to undertake pneumonectomy in patients over 70 years and who can blame them for this. They undoubtedly would strive to perform more conservative resection, and if this was not possible may well have chosen to accept an incomplete resection or "open-and-close" thoracotomy. The morbidity associated with pulmonary resection in patients over 70 years was very high in this study, especially that attributed to cardiovascular problems and dysrythmias (27%). This suggests that Bernet and colleagues [4] are expert at preventing complications from becoming lethal.
Surely no one really believes that the mortality of any operation is unaffected by age. The best we can hope to do is to assess biologic age independent of chronologic age. The proportion of people who are "fit" will fall as age advances. In one study in the UK the proportion of patients with lung cancer who underwent thoracotomy fell from 18% in the population under 65 years to only 2.1% for those over 75 years [3].
The only certainty in life is that with age we get closer to death! Overall survival after surgery must reflect this truism. It may seem reasonable to correct for this by considering only those deaths because of lung cancer, but this may introduce bias and we should be given overall survival as well as actuarial. It is possible that the family doctor is more disposed to accept sudden neurological deterioration as being because of a "stroke" in those over 70 years while considering the possibility of cerebral metastases in the younger age group. The surgeon may judge the success of such surgery by assessing the proportion of patients in whom death from lung cancer has been prevented. The sociologist, the economist, and indeed the patient are more concerned with the timing of death than its cause!
Other factors may influence the tumor-related survival in the two populations. The proportion of women is higher in the younger group. Women have not yet been smoking long enough to catch up with men! Female gender is a favorable prognostic indicator for all cell-types at all stages. However, the far higher proportion of adenocarcinoma it brings to the younger group (44% vs 22%) offsets this favorable bias in the younger age group. In addition, the proportion of patients who were asymptomatic at presentation favored the older group (38% vs 53%). The proportion of patients in stage IIIa (the old classification that included T3N0) was higher in the younger group (31% vs 19%, p = 0.057), the number undergoing pneumonectomy was higher in this group and yet the 5-year survival and median survival was the same in both groups. This might signify that conservative resection could have been possible in a high proportion of the younger patients undergoing pneumonectomy. However, it is more likely that it is further indication of the surgeons’ reluctance to undertake pneumonectomy in patients over 70 years of age, thus unintentionally excluding those patients from the study.
As Bernet and colleagues point out, the lesson from this and similar studies is that "surgeons are capable of compensating for increased age by greater selection of patients coming to surgery." Undoubtedly our radiotherapy and chemotherapy colleagues are equally skilled. As such, chronologic age should not be a contraindication to offering patients effective treatment for their disease.
References
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