Ann Thorac Surg 2009;88:1099. doi:10.1016/j.athoracsur.2009.07.009
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Stephen C. Yang, MD
Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, 600 N Wolfe St, Blalock 240, Baltimore, MD 21287
(Email: syang{at}jhmi.edu).
In recent years, there has been a realization of the "epidemic" of lung cancer in the elderly. During the next 20 years, the number of people older than 65 years of age in the United States will double, and this group of people will comprise as much as 20% of the population in developed countries. The peak incidence of lung cancer, as with other cancers, has "aged" as well, with diagnosis now usually being made between the ages of 70 and 75 years. With people living longer, active, and self-sufficient lives, coupled with a relatively shrinking thoracic surgery workforce, we all must become expert in and sensitive to the needs of the older patient.
There are abundant data showing that surgical resection for lung and esophageal cancer in the appropriate octogenarian and older is associated with acceptable morbidity and mortality. Critical for a successful outcome includes careful preoperative assessment, identification of perioperative risk factors, choosing the proper operation, and judicious postoperative care.
Berry and colleagues [1] from Duke University propose a risk model for morbidity after lobectomy only (there were no lesser resections) for primary lung cancer in patients older than 70 years. In this retrospective comparison study, their primary conclusion was that the video-assisted thoracic surgical approach for lobectomy was found to be statistically better than an open thoracotomy in regard to complications, whereas a propensity scoring system was developed to minimize selection bias from confounding covariates. Unfortunately, the nonrandomization of patients and unknown subtle differences between the two groups tempers the conclusions in their final analysis. From a practical standpoint, the decision to choose a video-assisted thoracic surgical approach or an open thoracotomy approach is ultimately left to the experience and comfort of the operating surgeon and particular processes of postoperative care.
Nevertheless, this article [1] does add to the growing body of evidence on how to further personalize the surgical care of lung cancer in the elderly. Although the article describes intuitive offers of support to a more minimally invasive approach, it does not cover other equally important areas, such as the translation into long-term survival, quality of life, or ability to tolerate adjuvant therapies; however, this message is inferred. Further investigators are needed to prospectively study which factors do influence adverse postoperative events in this more fragile patient group, and the role of sublobar resection as a reasonable oncologic option. As an increasing number of older patients with curable cancers are referred for surgical resection, these issues will play a significant role into decision-making, and should be strongly evidence-based.
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References
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- Berry MF, Hanna J, Tong BC, et al. Risk factors for morbidity after lobectomy for lung cancer in elderly patients Ann Thorac Surg 2009;88:1093-1099.[Abstract/Free Full Text]
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Risk Factors for Morbidity After Lobectomy for Lung Cancer in Elderly Patients
- Mark F. Berry, Jennifer Hanna, Betty C. Tong, William R. Burfeind, Jr, David H. Harpole, Thomas A. D'Amico, and Mark W. Onaitis
Ann. Thorac. Surg. 2009 88: 1093-1099.
[Abstract]
[Full Text]
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