“Surgery remains the mainstay of treatment for early-stage [non-small cell lung cancer (NSCLC)], regardless of age,” researchers wrote in the Journal of Th oracic Oncology. “Although there are no formal practice guidelines for octogenarians, several earlier studies supported surgery; nevertheless, they are frequently dated, drawn from a single center, and included highly selected populations. An updated and more detailed understanding of surgical outcomes in this population can motivate further research and the development of interventions designed to mitigate the age-related risks for elderly patients who choose surgical treatment.”

This is especially relevant as life expectancy rises. Further, octogenarians now account for 20% to 25% of all lung cancer diagnoses and deaths, study investigators noted.

Ian C. Bostock, MD, MS, and colleagues examined patients with stage IA NSCLC using data from the Surveillance, Epidemiology, and End Results and Medicare. All patients were aged 65 years and older.

Age-Specific Survival For Octogenarians With Early NSCLC

The study included 22,126 patients, with 18.4% aged at least 80 years.

The researchers reported that patients in their eighties were more than twice as likely to experience a high comorbidity burden compared with the youngest patients (33.3% vs 17.9%; P<0.001). Following surgery, octogenarians showed more than double the rate of in-hospital mortality compared with the youngest patients (2.4% vs 0.9%; P<0.001), as well as more than twice the rate of 90-day mortality (7.2% vs 2.9%; P<0.001).

Octogenarians also experienced more than twice the rate of 1-year mortality compared with the youngest group of patients (65 to 69 years), according to Dr. Bostock and colleagues (15.2% vs 7.3%; P<0.001). Approximately half of octogenarian patients (48.7%) were still alive at the 5-year mark compared with about two-thirds (68.0%) of patients aged 65-69 years (P<0.001).

Lung Cancer Surgery in Octogenarians

Patients aged 80 to 89 years underwent minimally invasive surgery slightly more often than patients aged 65 to 69 years (53.1% vs 49.5%; P=0.002) and had sublobar procedures more often (31.5% vs 20.7%; P<0.001), the researchers reported.

Octogenarians had nearly double the rate of post-surgical complications compared with patients aged 65-69 years (11.0% vs 6.7%; P<0.001) and a significantly greater rate of 30-day readmissions (11.7% vs 8.4%; P<0.001).

Older Patients Face Different Challenges

Octogenarians were discharged to skilled nursing facilities almost three times as often as patients aged 65 to 69 years (19.9% vs 6.3%; P<0.001). Patients staying in skilled nursing facilities for more than 30 days experienced a 36.0% increased mortality risk compared with patients discharged to home or home healthcare.

An adjusted analysis determined that patients aged 80 to 89 years experienced a 62.0% greater mortality risk at 1 year than patients aged less than 80 years (risk ratio, 1.62; 95% CI, 1.48-1.78). Th ese patients were also 52.0% more likely to die within 5 years (HR, 1.52; 95% CI, 1.42-1.62).

Male sex, higher comorbidity burdens, residing in a county with a low median income, open surgical approach, and sub-lobar resection were also linked with 1-year mortality.

Barriers to Successful Outcomes in Octogenarians

Dr. Bostock and colleagues cited these discrepancies as “substantial gaps” in age-related outcomes. Further, the study also involved patients in the lowest lung cancer risk group—3-centimeter, stage 1A tumors and may, therefore, represent “optimistic outcomes” for the surgical management of lung cancer in octogenarians.

The researchers continued that one possible factor behind these outcomes may be related to the quality of care that patients receive.

“Potential reasons for the observed outcomes in octogenarians remain unclear. One possibility is poor quality care,” Dr. Bostock and colleagues wrote. “When compared with outcomes from nationally representative data sources, outcomes after lung resection among those cared for by surgeons and hospitals participating in the Society of Th oracic Surgeons General Thoracic Surgery Database [did] better.”

Future research should focus on developing strategies to decrease the age-related survival gap, the researchers noted, but added that the findings have more immediate clinical relevance.

“Th ese results could also be used clinically to aid in discussions of mortality risk and loss of independence in older patients with early-stage [lung cancer] and could prompt quality improvement interventions that focus on reducing risk along the continuum of care, from preoperative evaluation to postoperative care pathways,” Dr. Bostock and colleagues wrote.