Lobectomy Best for Elderly Early-Stage NSCLC Patients

Lobectomy offers the highest overall survival and disease-specific survival for elderly patients with node-negative NSCLC

medwireNews: Lobectomy should not be dismissed in elderly patients with early-stage non-small-cell lung cancer (NSCLC), suggest US researchers who found the benefits of sublobar resection did not outweigh the survival advantages of the more extensive procedure.

Data for 9093 US patients, aged a median of 75 years, who underwent definitive treatment between 2003 and 2009 indicated that lobectomy had a higher 90-day rate of mortality than sublobar resection and a significantly higher rate than stereotactic ablative radiotherapy (SABR; 4.0 vs 3.7 and 1.3%, respectively).

After 3 years of follow-up, however, lobectomy resulted in a significantly lower rate of mortality than sublobar resection or stereotactic ablative radiotherapy (25.0 vs 35.3 and 45.1%, respectively), reports the team from the University of Texas MD Anderson Cancer Center in Houston.

“The assumption was that for an elderly patient with a number of co-morbidities, the smaller surgery would be better than a whole lobectomy because there would be fewer surgical complications”, explained lead author Shervin Shirvani in a press release.

“Yet, it appears that the ability to eradicate the cancer with the bigger surgery may be more important than minimizing surgical risk”, he said.

Multivariate analysis showed that overall survival in the NSCLC patients was significantly predicted by sublobar resection, with an adjusted hazard ratio (HR) of 1.32 versus lobectomy.

Increasing tumour stage also significantly predicted poorer overall survival (T1b and T2a vs T1a, HR=1.22 and 1.47), while adenocarcinoma histology (HR=0.38 vs not otherwise specified) and receipt of mediastinal sampling (HR=0.82) were associated with improved survival.

Women had significantly better overall survival than men (HR=0.75) but patients with comorbid chronic obstructive pulmonary disease (COPD) were less likely to survive than those without (HR=1.25). And older patients were less likely to survive than younger patients, with a HR of 1.93 for those aged 80 years or older at baseline compared with patients aged 66 to 69 years.

Lung cancer-specific survival was also significantly and negatively associated with sublobar resection (HR=1.50 vs lobectomy), increasing age (HR=1.66 for ≥80 years vs 66–69 years), comorbid COPD (HR=1.25) and rising tumour stage (T1b and 2a vs 1a, HR=1.30 and 1.60, respectively).

Meanwhile, female gender (HR=0.75) and mediastinal sampling (HR=0.78) were associated with significantly better lung cancer-specific survival.

Writing in JAMA Surgery, the researchers report that overall survival was significantly better for patients given SABR versus lobectomy in the first 6 months of follow-up (HR=0.45) but after this time, SABR was associated with a higher risk of death (HR=1.66). SABR also offered poorer lung cancer-specific survival (HR=1.44).

But the team notes that SABR patients rarely underwent pathological staging. Further analysis accounting for the possibility of occult mediastinal disease in this patient population did not find a significant difference in the survival outcomes of SABR patients compared with those who underwent lobectomy when the groups were carefully matched for advanced age or the presence of multiple comorbidities.

“The use of this analysis to rationalize SABR use instead of lobectomy in the general population of elderly patients with early-stage NSCLC is not justified”, write the researchers, emphasising the need for clinical trial findings.

Nevertheless, they conclude: “Our findings regarding the comparative effectiveness of SABR in frail patients with very advanced age are also promising because this technology appears to offer a lower risk for periprocedural mortality and encouraging long-term survival.”


Shirvani S, Jiang J, Chang J, et al. Lobectomy, sublobar resection, and sterotactic ablative radiotherapy for early-stage non-small cell lung cancers in the elderly. JAMA Surg; Advance online publication 15 October 2014 doi:10.1001/jamasurg.2014.556

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