**7. Surgery**

Surgery remains the mainstay of treatment for early stage NSCLC. Unfortunately, according to most published reports, elderly have a significant lower resection rates compared to younger patients and age is one of the factor influencing the decision for surgical treatment. Sigel retrospectively analyzed 27 850 patients with stage I lung cancer. The rate of lung surgery was 95% for patients less than 60 years and 79% in patients > 80 years (Sigel et al., 2009). An analysis of Riquet showed that patients older than 70 years of age represents 21.7% of patients who had surgery for lung cancer, patients of 75 years and older represents 8.8% and older than 80 years old are only 1.9% in proportion (Riquet et al., 2001).

These observations are still true, even considering the significant improvement in anesthesia, in technical procedures of lung resection and post-operative care that greatly enhanced the security of the surgery, even in a frail population. In patients with stage I and II, surgical option is still the prefer treatment option. The 5-year overall survival rates for pathological stage I range between 67% for pT1pN0 and 57% for pT2pN0 tumors. The corresponding values based on clinical stage are 61% for cT1cN0 and 37% for cT2cN0.

recent French study it was shown that comprehensive geriatric evaluation did significantly influence treatment decisions in 82% of the older cancer patients. In this 161 patients group, with a median age of 82.4 years, cancer treatment was change in 79 patients (49%), including delayed therapy in 5 patients, less intensive therapy in 18% and more intensive therapy in

It is interesting to notice that even a simplified geriatric assessment, adapted to cancer and quicker to perform than a CGA was recently demonstrated effective in patients with thoracic cancer. It is an important aid to decision-making in the management of elderly

Social evaluation Place of residence: home, type of residence for

Nutritional status Loss of weight over the previous 3 months

Cognitive functions Mini Mental State Examination (MMSE), Clock

State of mind Mini-Geriatric Depression Scale (mini-GDS)

Autonomy Instrumental Activities of Daily Living (IADL) Table 1. Simplified Geriatric Assessment of patients with bronchial cancer (Cudennec et al.,

Surgery remains the mainstay of treatment for early stage NSCLC. Unfortunately, according to most published reports, elderly have a significant lower resection rates compared to younger patients and age is one of the factor influencing the decision for surgical treatment. Sigel retrospectively analyzed 27 850 patients with stage I lung cancer. The rate of lung surgery was 95% for patients less than 60 years and 79% in patients > 80 years (Sigel et al., 2009). An analysis of Riquet showed that patients older than 70 years of age represents 21.7% of patients who had surgery for lung cancer, patients of 75 years and older represents

These observations are still true, even considering the significant improvement in anesthesia, in technical procedures of lung resection and post-operative care that greatly enhanced the security of the surgery, even in a frail population. In patients with stage I and II, surgical option is still the prefer treatment option. The 5-year overall survival rates for pathological stage I range between 67% for pT1pN0 and 57% for pT2pN0 tumors. The corresponding values based on clinical stage are 61% for cT1cN0 and 37% for cT2cN0.

8.8% and older than 80 years old are only 1.9% in proportion (Riquet et al., 2001).

Iatrogenic risk Number and classes of drugs

Risk of fall Timed "Get up and go" test

Sense organs Vision and hearing

around the home

other cancer

drawing task

(≥5%), albuminemia levels

an elderly, dependent patient Helpers, aids

Dementia, confusion, depression, incontinence, falls, malnutrition, progressive heart failure,

28% of patients (Chaïbi et al. 2010).

patients with bronchial cancer (Cudennec et al., 2010).

Aim Method

Existence of ≥3 co-morbidities significant

in geriatrics

2010).

**7. Surgery** 

#### **7.1 Evaluation and selection of patients**

Patients must have a very good evaluation and adequate scrutiny is necessary to evaluate those who will really benefit from surgery. Preoperative assessment of cancer in the elderly (PACE) incorporates validated instruments including the CGA, an assessment of fatigue and performance status and an anaesthesiologist's evaluation of operative risk. It is considered to be a valuable tool in enhancing the decision process concerning the candidacy of elderly patients for surgical intervention. It also reduce inappropriate age-related inequity in access to surgical intervention (PACE, 2008).

#### **7.2 Different types of surgery are used for the elderly. But which one is better?**

Survival data from the SEER database with patient of all ages shown that survival for lung cancer stage I and II were 56 and 34% respectively (Chang et al., 2007). The most important question regarding surgical resection for lung cancer is how aggressive should it be? The choice of the type of surgery is particularly important in the elderly. Right pneumonectomy is likely to be avoided in octogenarians (Broks et al., 2007; Port et al., 2004; Van Meerbeeck et al., 2002), but low rate of pneumonectomy in different series make this difficult to assess. As an indication, the British Thoracic Society Guidelines indicates that pneumonectomy is associated with higher risk of mortality.

The sublobar pulmonary resection remains controversial in patients of any age. In a SEER analysis of 14,555 patients with stage I or II NSCLC, it was showed that benefit of a lobectomy was not evident for patients older than 71 years compared with limited resection (Meryet al., 2005). Okami did a non-randomized study to evaluate the different types of surgery in the elderly patients. A total of 764 patients, including 133 elderly and 631 younger patients had lobectomy or sublobar resection. The survival after sublobar resection was significantly lower than that after standard lobectomy in the younger group (64% vs 90.9%). Comparatively, no difference was seen in the elderly (67.6% vs 74.3%). However, locoregional recurrences were higher in patients with sublobar resection than lobectomy in young and older patients (Okami et al., 2009). A phase III study regarding this specific topic would be necessary to confirm this information.

Another study done in Pittsburg has compared lobectomy to the segmentectomy for stage I lung cancer. In a subgroup of 99 octogenarian patients, the segmentectomy was associated with an improvement of the 3-year survival (p=0.02) (Schuchert et al., 2009).

#### **7.3 The impact of comorbidities on surgical outcomes**

A review of 10,761 patients with lung cancer stage IA showed the age of 67 years or more as an independent factor associated with long-term survival worse after surgery. One of the major criticisms of this study is that patients were not stratified based on their functional status or their comorbidities. It is known that these two factors are associated with advanced age and are predictors of mortality in elderly patients suffering from lung cancer (Maione et al., 2005; Frasci et al., 2000; Asmis et al., 2008; Schuchert et al., 2009).

In another study of 126 patients 70 years of age or older with lung cancer, the Charlson Comorbidity Index has been performed in patients for lung surgery. A low score was a predictor of major complications after surgery (Birim et al., 2003). Some studies in patients older than 80 years of age were also conducted (Brokx et al., 2007; Okami et al., 2009; Wada et al., 1998). At the Mayo Clinic, 294 patients aged between 80 and 94 years underwent pulmonary resection and their 1-year survival was 80% and 2-year survival was 62% (Dominguez-Ventura et al., 2007).

Lung Cancer in Elderly 233

few conclusive results available from studies of adjuvant chemotherapy in elderly, it is difficult to conclude that it should be a standard treatment for older people. However, we can possibly extrapolate from studies done with younger patients and use it in selected

It was demonstrated that nearly 25% of patients with disease stage I or II did not have surgery, most often because of significant comorbidities, patient preferences or poor lung functions (Bach et al., 1999; Spiro et al., 2002). For elderly who are not candidates for surgery, radiation therapy is possible. Unfortunately, it usually gives poor results with a 5 year survival estimated at between 6 to 14% (Razet al., 2007; Wisnivesky et al., 2005). In this

Radiation therapy has been shown to improve outcomes compared to best supportive care alone (Raz et al., 2007). A subgroup analysis, in the study of Morita, assessed the impact of age in relation with survival in irradiated patients. One hundred and forty-nine patients older than 80 years with stage I lung cancer were included in this analysis. The survival was lower in older patients compared with younger. The 3- and 5-years actuarial survival was 15.4% and 7.7% in octogenarians versus respectively 38.2% and 25.2% in younger (p=0.035) (Morita et al., 1997). Similar results were found by Sibley (Sibley et al., 1998). However, a retrospective study from 6 studies of EORTC with 1,208 patients has shown no difference in overall survival between patients older or younger of 70 years (Pignon et al., 1998). Other retrospective studies compared treatment outcomes in younger and older patients. The North Central Cancer Treatment Group studied the impact of age (≥ 70 years versus younger) with two different schedules of radiation, either daily or twice per day, combined with concurrent chemotherapy. The 2-year survival rates were 39% in younger and 36% in the elderly and at 5-year, it was 18% versus 13% in patients ≥ 70 years (p=0.4). Toxicity of grade 4 or more were significantly higher in older patients (81%) than in younger ones (62%). The conclusion of this study was that toxicity is higher in elderly, but the survival is

section, the curative as well as palliative indication for radiation will be discussed.

similar. Thus for fit patients this treatment can be proposed (Schild et al., 2003).

90.9% and 69.3%, respectively (Atagi et al., 2000).

In the treatment of locally advanced NCSLC, the standard of care is radiation with chemotherapy based on cisplatin. Two major trials demonstrated a survival advantage for the use of induction chemotherapy prior to radiation therapy (Dillman et al., 1990; Sause et al., 2000). After the publication of these results, studies have been done to test the combined treatment. These studies shown that combined chemoradiotherapy is more effective compared to radiation alone (Dillman et al., 1990; Furuse et al., 1999). Elderly were in general excluded from these studies and few trials have been done about the role of combined chemoradiation in this particular population. A phase II study in 40 elderly patients with unresectable stage III or medically inoperable stage I and II lung cancer treated with concurrent carboplatin and radiation was done. For stage IIIA/IIIB patients, the median survival time was 15.1 months and 1-and 2-year actuarial survival rates were 52.6% and 20.5%, respectively. For stage I/II patients, 1- and 3-year actuarial survival rates were

A phase III trial was performed by Atagi in 2005 with patients older than 70 years with stage III NSCLC. Patients were randomly assigned to either radiation therapy (dose of 60 Gy) with concurrent carboplatin or radiation therapy alone. 4 patient's death may have resulted

patients aged less than 75 years of age.

**9. Radiotherapy** 

A review of 297 articles was done by Chambers (2010) to consider the impact of lung resection on morbidity, mortality and postoperative quality of life for patients aged over 70 years. They found twelve articles to answer this question. The collective analysis of these 12 articles showed a five-year survival following surgery for early stages in those under age 70 between 69 and 77%, for those over 70 years, the five-year survival ranges from 59 to 78%. The 30-day mortality rate was 5.7% in patients younger than 70 years against 1.3 to 3.3% in those over 70 years, length of hospital stay after thoracoscopy was respectively 4.6 and 4.9 to 5.2 days. The post-operative lung functions were also equivalent between the two groups. FEV1 decreased 13% compared to 18% in patients older than 70 years (p=0.34) comparing the functional vital capacity decrease were equivalent between both groups (9% vs 14%). Lung function was also compared among young and elderly patients after lobectomy for early stage NSCLC. Changes in FEV1 and functional vital capacity were not significant although postoperative complications occurred in 32% of younger patients and 48% in the elderly (Sullivan et al., 2005).
