Article and Video CATEGORIES

Cancer Journey

Search By

Dr. Jack West is a medical oncologist and thoracic oncology specialist who is the Founder and previously served as President & CEO, currently a member of the Board of Directors of the Global Resource for Advancing Cancer Education (GRACE)

 

Lobectomy vs. Limited Resection: Different Approach Based on Age?
Author
Howard (Jack) West, MD

While the prevailing standard of care for resectable lung cancer is a lobectomy or pneumonectomy, we want the surgery to be as appropriate as possible for patients. That means not short-changing patients by doing a lesser surgery than they need to do as well as possible with the cancer, but also not overtreating patients with a more aggressive surgery than they need. There are two main variables that potentially alter the equation and may make a sublobar resection a more appropriate consideration. The first is in cases in which the patient has competing risks of survival and/or medical problems that make a more aggressive surgery less necessary or more morbid (side effect-ridden, longer time for recovery, etc.) than average, or both. The second situation is when the cancer has more favorable features than most, so even in healthier patients it may not be necessary to do a more extensive surgery. I'll explore the first scenario now.

As I mentioned in a previous post introducing the different types of lung surgery, an influential trial by the now defunct Lung Cancer Study Group indicated that survival is superior in patients who receive a pneumonectomy or lobectomy compared to those who receive a segmentectomy or wedge resection (abstract here). However, there was actually no difference in survival in the first three years, with improvement only emerging with longer follow-up. This suggests that patients with competing health risks may not be as well served by a more aggressive surgery. Thoracic surgeons have therefore asked whether elderly patients may do as well or better with a sub-lobar resection that involves less blood loss and recovery time without a significant compromise of cancer-related survival. One important study suggest that's the case.

The study by Mery and colleagues from Brigham & Women's Hospital in Boston (abstract here) was a retrospective review of the survival of over 14,000 patients in the Surveillance, Epidemiology, and End Results (SEER) database, a collection of information from cancer registries from all over the country, and covering about 14% of the US population. These patients had all undergone surgery for stage I or stage II NSCLC. The investigators divided patients in the database into three age groups: under 65, 65-74, and 75 and older. Not surprisingly, survival was significantly better in younger patients than older patients, and the 17% of patients with stage II NSCLC had a significantly worse survival than patients with stage I NSCLC. Overall, patients who underwent a pneumonectomy had a significantly worse survival than other patients, but it's unclear whether this is due to the peri-operative mortality (deaths within 30 days of surgery, which are much higher after a pneumonectomy than a lobectomy), the loss of pulmonary capacity after surgery, or characteristics of the tumors that required a pneumonectomy (larger, more central). Patients who underwent a wedge resection also had a lower survival overall than other patients.

When evaluating the differences between different types of surgery as a function of age, however, it wasn't the case that patients of all ages did better with lobectomies than "limited resections" (sub-lobar surgeries). In fact, patients under 75 had a significant survival advantage after a lobectomy, but the patients 75 and older did every bit as well after a wedge resection or segmentectomy as they did after a lobectomy:

Lobe vs. Limited Surg Younger Pts

(Click to enlarge image)

Lobe vs. Limited, 5 and Older

They evaluated the age difference using a different cut-off of 71 years and found that patients 71 and younger had a significant benefit from lobectomy, while those older than 71 did not. There was a modest separation of the curves after about two years even in older patients, but the difference in survival was not significant even with longer follow-up.

Lobectomy difference at 71

Despite sub-lobar resections not being considered the standard of care, older patients were more than twice as likely to have undergone this surgery than younger ones (17% vs. 8% of curative surgeries).

This article leaves us with a few important conclusions. First, it provides further corroborating evidence that younger patients have a superior survival with a lobectomy than a limited resection (at least the overall population). Second, it suggests that the overal population of patients over 71 have an equivalent survival following a sub-lobar resection compared to a lobectomy. This conclusion only applies, however, to older patients who have a complete resection with negative surgical margins.

This is not the final word on the issue, but these data come from a very large database and make sense to consider carefully in weighing the risks and benefits of a more aggressive vs. less aggressive surgery. The age cutoff is not necessarily the gospel, but rather speaks to the idea that patients with competing health problems should have the risks of the cancer weighed against the risks of their other issues. For some remarkably healthy patients with no competing health problems and an anticipated survival of many, many years, it may be very appropriate to pursue the most aggressive approaches against lung cancer.

Next, I'll discuss the other issue of cancers that may be favorable enough that they don't require as aggressive a surgery as most others, even in younger and healthier patients.

Next Previous link

Previous PostNext Post

Related Content

Article
Advance directives are a powerful way to take control of healthcare choices. These documents allow you to outline preferences for medical care and specify end-of-life wishes. These documents can also be a way to appoint loved ones who you would like to help with these decisions, such as a healthcare proxy (someone to make decisions on your behalf, if you cannot). As cancer treatments can involve aggressive treatments and/or complex medical management, having advance directives ensures that your desires regarding treatment options and end-of-life care are clearly communicated. 
Image
2024-25 patient perspectives header
Article
Tell your story and help us help others! Apply online now for this paid opportunity. This program gives a voice to those who have experience in participating in a clinical trial for a cancer diagnosis. Your voice helps to educate and advocate for others who are in or who may be considering a clinical trial.  We want to hear from you!
Image
Foro de Pacientes de Terapias Dirigidas de Cáncer de Pulmón
Video
¡El vídeo completo bajo demanda está disponible para verlo!

Forum Discussions

Hello Linda, my name is Alexandra Beneke, I'm the Outreach Manager for GRACE. Your willingness to share your experiences and knowledge with the cancer community is truly inspiring. Your dedication to...

Hi Bluebird,  Welcome to GRACE.  I'm sorry you're going through this scare and hope it's just inflammation or from an infection you didn't know you had. 

 

A CT would be...

Radiation + Brain Operation has just been discarded due to high risk. They will double Tagrisso dosis and then wait to see if it works, then try traditional Chemo. I would...

Hi and welcome to GRACE.  I'm sorry to know you are entering a new stage.  I'm not about to comment just now but wanted to let you know I see your...

Edit to say, we can't give advice but we can comment with views and facts.  :)

 

My first thought is to ask if she has been seen at a large...

Hi Barbro, Welcome to GRACE. I'm sorry you're worrying about this. We aren't able to give feedback on scan reports. Interpreting scan reports in this setting is not only unethical but...

Recent Comments

JOIN THE CONVERSATION
Tagrix FDA Approval
By mariachristian on
Hi Judy! It is so good to…
By JanineT GRACE … on
Tagrix vs Tagrisso
By Dipakchavan on
Hello Linda, my name is…
By AlexandraGBeneke on