Évaluation gériatrique et morbidité après exérèse pulmonaire pour cancer bronchique

[Long-term results of lung cancer surgery in octogenarians]

INTRODUCTION

This retrospective study was undertaken to evaluate late results of lung cancer surgery in octogenerians.

METHODS

All patients 80years old or more who underwent a lung resection for cancer from 2000 to 2010 at Lyon University Hospital were included. No patients were treated with video-assisted surgery. Wedge resections were excluded.

RESULTS

Sixty-three patients (42 men, 21 women) were operated. The median age was 82years. Operative mortality was 4.7%. The rate of perioperative complications was 49%. The late survival was 34% at 5years. Five-year survival by nodal involvement was N0, 36%; N1, 29%; N2 20%, P<0.05. Patients with a squamous cell carcinoma (24) had a better long-term survival than patients with an adenocarcinoma (30), 33% and 25% respectively at 5years, P<0.05. The rate of recurrence was 33.9%.

CONCLUSIONS

Surgical treatment of lung cancer in selected population of octogenerians is associated with satisfactory early and long-term results. Survival is influenced by nodal involvement and by the pathologic type of the cancer.

Does comprehensive geriatric assessment improve the estimate of surgical risk in elderly patients? An Italian multicenter observational study

BACKGROUND

The evaluation of surgical risk is crucial in elderly patients. At present, there is little evidence of the usefulness of comprehensive geriatric assessment (CGA) as a part of the overall assessment of surgical elderly patients.

METHODS

We verified whether CGA associated with established surgical risk assessment tools is able to improve the prediction of postoperative morbidity and mortality in 377 elderly patients undergoing elective surgery.

RESULTS

Overall mortality and morbidity were 2.4% and 19.9%, respectively. Multivariate analysis showed that impaired cognitive function (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.15 to 4.22; P < .02) and higher Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (OR, 1.11; 95% CI, 1.00 to 1.23; P < .04) are predictive of mortality. Higher comorbidity is predictive of morbidity (OR, 2.12; 95% CI, 1.06 to 4.22; P < .03) and higher American Society of Anesthesiologists (OR, 2.18; 95% CI, 1.31 to 3.63; P < .001) and National Confidential Enquiry into Patient Outcome of Death score (OR, 2.03; 95% CI, 1.03 to 4.00; P < .04).

CONCLUSIONS

In elective surgical elderly patients, the morbidity and mortality are low. The use of CGA improves the identification of elderly patients at higher risk of adverse events, independent of the surgical prognostic indices.

[Lung cancer in the elderly: what about surgery?]

Geriatric oncology is a rapidly expanding domain because of the deep epidemiological changes of the last decades related to the ageing of the population. Lung cancer treatment in patients 75 years and over is a major issue of thoracic oncology. Curative surgery remains the treatment offering the best survival rates to the patient whatever his age. The important variability observed within the elderly forces us to take into account their specificities, in particular for ageing physiology and associated comorbidities. Thus, preoperative workup permitting to assess the resectability of the tumor but also the operability of the patient is all the more essential in the advanced age that it must be adapted to the particular characteristics of the elderly. Thanks to recent data of the literature, morbidity and mortality associated to surgical treatment are now better characterized and considered as acceptable in accordance with long-term survival. Clinical investigation remains essential to acquire a better knowledge of potential benefit of multimodal treatments in the elderly, for which very few data are available.

Sunitinib malate in previously untreated, nonsquamous, non-small cell lung cancer patients over the age of 70 years: results of a Phase II trial

BACKGROUND

Some elderly patients may have reduced tolerance the standard therapy (chemotherapy doublets) for stage III/IV non-small cell lung cancer (NSCLC). Sunitinib malate (S), an oral, multitargeted kinase inhibitor, shows promise as 2nd-line NSCLC treatment. This study explored the safety/efficacy of S in elderly patients with previously untreated NSCLC.

METHODS

PRIMARY OBJECTIVE

disease control rate (DCR) at six-weeks.

SECONDARY OBJECTIVES

overall response (OR, CR+PR), progression-free survival (PFS), time to progression (TTP), one-yr survival, quality of life (QOL), and safety.

TREATMENT

S 37.5 mg daily/42-day cycle until PD or intolerable toxicity. Key inclusion: chemo-naïve stage IIIB/IV NSCLC (nonsquamous histology); ECOG PS=0-1; ≥ 70 years; normal organ function. Exclusion: hemoptysis, anticoagulation, or clotting diathesis. Other standard S-specific criteria applied.

RESULTS

63 patients enrolled/60 treated.

DEMOGRAPHICS

51 % male, 95 % white, median age 78 years (range, 70-88), 73 % ECOG=1, 97 % Stage IV, 83 % adenocarcinoma, 44 % prior surgery, 19 % prior radiation. With a median of 2 cycles (range, 1-16), DCR=63 %, OR=7 % (0 CR, 4 PR). Median follow-up=5.8 months (all; 15.9 months survivors), median PFS =3.0 months (range, <1-25.1), median TTP=4.5 months (range, <1-25.1), and 1-year survival=26.4 % [95 % CI: 15.9, 38.2]. QOL declined initially, but improved over time. TREATMENT-related adverse events included: fatigue (48.3 %); diarrhea (38.3 %); thrombocytopenia (33.3 %), anorexia (26.7 %), mucositis (25.0 %); nausea (25.0 %), dysgeusia (20.0 %), and neutropenia (20.0 %). Conclusions The study met its primary endpoint. S produced acceptable DCR and QOL improved; however, OR was disappointing (7 %) and toxicity was greater than expected. A biomarker to identify patients more likely to benefit from S is needed.

Preoperative geriatric assessment: comprehensive, multidisciplinary and proactive

With the changing global demographic pattern, our health care systems increasingly have to deal with a greater number of elderly patients, which consequently also takes its toll on our surgical services. The elderly are not simply older adults. They represent a heterogeneous branch of the population with specific physiological, psychological, functional and social issues that require individualised attention prior to surgery. Increased acknowledgement that chronological age alone is not an exclusion criterion, along with advances in surgical and anaesthetic techniques have today lead to decreased reluctance to deny the elderly surgical treatment. In order to ensure a safe perioperative period, we believe that a comprehensive, multidisciplinary and proactive preoperative assessment will be helpful to detect the multiple risk factors and comorbidities common in older patients, to assess functional status and simultaneously allow room for early preoperative interventions and planning of the intra- and postoperative period. In this review we outline the currently available preoperative geriatric risk assessment tools and provide an insight on how a comprehensive, multidisciplinary and proactive approach can help improve perioperative outcome.