Studies have shown that surgery provides the best outcome for patients with early-stage lung cancer. However, up to 20% of these patients are classified as high risk or inoperable, and thus undergo non-operative treatments. Factors traditionally linked to high risk for pulmonary resection include age older than 75, tobacco abuse, or extensive medical comorbidities. “Many high-risk patients with early-stage lung cancer are deemed inoperable based on current criteria,” says Manu S. Sancheti, MD. “However, a consensus on the definition of risk currently does not exist and these patients may be consequently denied surgery.”
Dr. Sancheti and colleagues have published a study in Annals of Thoracic Surgery that compared outcomes of patients who underwent lung cancer surgery considered to be high risk with those of standard risk. The investigation involved 490 patients with clinical stage I lung cancer who underwent pulmonary resection at Emory University between 2009 and 2013. Major criteria for high risk included a forced expiratory volume in one second (FEV1) or diffusion capacity of carbon dioxide (DLCO) of less than 50%. Minor factors included two of the following: age older than 75, or a FEV1 or DLCO of 51% to 60%.
In the cohort, 180 were classified as high-risk. These patients were older than standard-risk patients (70 vs 65 years) and had worse FEV1 and DLCO levels. High-risk patients also had more smoking pack-years, a greater incidence of COPD, and were more likely to undergo sublobar resection.
The length of stay was longer for the high-risk group with a slight increase in perioperative complications. “However, we did not observe a statistically significant difference in postoperative mortality, indicating that patients recovered well despite the increased risk,” says Dr. Sancheti. The study reported a 3-year survival rate of 59% for high-risk patients and 76% for standard-risk patients.
“Importantly, about 20% of patients had cancer in their lymph nodes on surgical pathology, a finding that was unexpected based on the preoperative imaging tests,” says Dr. Sancheti. “These patients were able to undergo chemotherapy, which is an important adjunct treatment at this cancer stage. Without surgery, the spread of cancer to the lymph nodes would not have been discovered.”
Dr. Sancheti notes that the findings of the study should encourage physicians to employ a multidisciplinary approach to determine the best treatment plan for individuals with stage I lung cancer. “Our results show that patients should not be automatically deemed inoperable based on a collection of traditional risk factors,” he says. “We need to reexamine the risk stratification for stage I lung cancer patients because surgical resection appears to be an acceptable option with good results for many patients previously considered inoperable. These individuals have a new treatment avenue that may have been previously denied to them.”
Sancheti MS, Melvan JN, Medbery RL, et al. Outcomes after surgery in high-risk patients with early stage lung cancer. Ann Thorac Surg.2015 Nov 9 [Epub ahead of print]. Available at: http://www.annalsthoracicsurgery.org/article/S0003-4975(15)01501-5/abstract.
Donington J, Ferguson M, Mazzone P, et al. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management of high-risk patients with stage I non-small cell lung cancer. Chest. 2014;142:1620-1635.
Donington JS, Blasberg JD. Management of early stage non-small cell lung cancer in high-risk patients. Thorac Surg Clin. 2012;22:55-65.