EComment. The role of thoracic surgery in octogenarians with non-small cell lung cancer

Abstract

We have read with interest the paper by Guerra et al. [1] reviewing the most recent literature on surgical treatment of non-small cell lung cancer (NSCLC) in octogenarians. Nowadays, this is a notable topic since life expectancy is increasing. In a recent study of the UK population, it has been shown that the greatest population increasing is amongst those aged 85 and over; in 2013 the number is estimated to reach 2.5 million (4% of all population). Moreover, octogenarians are more often considered for lung resection because the number of those who have a diagnosis of lung cancer is growing (from 7.5% to 17% of new diagnoses) [2]. In evaluating the role of thoracic surgery in octogenarians, it must be underlined that also in this group of patients, lung resection is the best chance of cure, especially in early stages. However, published data report that 30% of elderly patients are excluded from surgery, in contrast to 8% of younger patients — and this is often due only to chronological age [3]. The main reason is the belief that age per se is a risk factor for perioperative morbidity and mortality. Other important factors opposing surgery are the shorter life-expectancy and worse postoperative quality of life in the elderly. We would like to focus on two relevant indications emerging from Authors' paper. The first one is that age per se is not related to an increasing of morbidity and mortality and the surgical risk is related only to comorbidities and poor physical performance. It must be considered that octogenarians have at least one associated disease in 80% of cases, and two or more severe comorbidities in 50%. This means that treatment decision must be tailored on a case by case basis and based on associated diseases and performance status evaluation, independent of age. Focusing on pulmonary function, the Authors reported that this was not a significant predictive factor for complications. On the contrary, Berry et al., in a recent paper, reported that worsening pulmonary function was the only preoperative variable independently predicting complications in octogenarians [4]. The second topic is the kind of resection. Many authors have found no differences in 3- and 5-year survival in octogenarians who underwent lobectomy compared with wedge resection and reported a lower mortality in the latter group. Furthermore, in 2008, Igai et al. showed that VATS reduced morbidity and mortality in elderly patients [5]. Therefore, the chance to adopt a mini-invasive approach and to perform a reduced lung resection could further expand the list of surgical indications in this group of patients. Conflict of interest: none declared.