Peri- and postoperative morbidity and mortality in older patients with non-small cell lung cancer: a matched-pair study

BACKGROUND

Reports from case series suggest that operative outcomes are comparable amongst different age groups following surgery with curative intent for non-small cell lung cancer (NSCLC). The purpose of this study was to compare morbidity and mortality after NSCLC surgery in older patients (≥ 75 years) versus younger patients (< 75 years) and identify independent predictive risk factors.

METHODS

We identified 2015 patients with postoperative stages IA to IIIA according to AJCC/UICC 7th edition who had undergone NSCLC surgery with curative intent at a single specialized lung cancer center from January 2010 to December 2015. A matched-pair analysis was performed on 227 older patients and corresponding 227 younger patients. Short-term surgical outcomes were postoperative morbidity, length of hospital stay, 30-day and 90-day mortality. Long-term operative outcomes were disease-free and overall survival.

RESULTS

454 patients were included in the matched-pair analysis. 36% of younger patients developed postoperative complications versus 42% in older patients (p = 0.163). Age was not significantly associated with the occurrence of postoperative complications. Median length of hospital stay was 14 days in older patients and 13 days in younger patients (p = 0.185). 90-day mortality was 2.2% in younger patients compared to 4% in older patients (p = 0.424). In patients aged 75 and older impaired performance status (ECOG ≥ 1) was associated with decreased overall survival (HR = 2.15, CI 1.34-3.46), as were preoperative serum C-reactive protein / albumin ratio ≥ 0.3 (HR = 1.95, CI 1.23-3.11) and elevated preoperative serum creatinine levels ≥ 1.1 mg/dl (HR = 1.84, CI 1.15-2.95). In the younger cohort male sex (HR = 2.26, CI 1.17-4.36), postoperative stage III disease (HR 4.61, CI 2.23-9.54) and preoperative anemia (hemoglobin < 12 g/dl) (HR 2.09, CI 1.10-3.96) were associated with decreased overall survival.

CONCLUSIONS

Lung resection for NSCLC in older patients is associated with postoperative morbidity and mortality comparable to those of younger patients. In older patients, physical activity, comorbidities and nutritional status are related to survival and should influence the indication for surgery rather than age alone.

Postoperative chemotherapy significantly improves survival of elderly patients with stage IB-II non-small cell lung cancer: A population-based study

BACKGROUND

There is scant evidence-based information about survival benefits of postoperative chemotherapy in elderly patients with early-stage non-small cell lung cancer (NSCLC). The purpose of this study is to compare the overall survival (OS) and cancer-specific survival (CSS) rates of surgery alone versus postoperative chemotherapy in patients aged ≥70 years with stage I-II NSCLC.

METHODS

Elderly patients aged ≥70 years diagnosed with stage I-II NSCLC were selected from the Surveillance, Epidemiology, and End Results (SEER) database from January 1, 2010 to December 31, 2015. OS and CSS were compared between the two groups utilizing overlap weighting analysis, inverse probability of treatment weight (IPTW), and propensity score matching (PSM).

RESULTS

Of the 7193 included patients with stage I-II NSCLC who are more than 70 years old, 681 patients (9.5%) received postoperative chemotherapy and 6512 patients (90.5%) received surgery-alone. Median OS was 77 months in postoperative chemotherapy group versus 79 months in surgery-alone group (p = 0.89). The result of IPTW analysis showed the similar results. The probability of patients choosing chemotherapy increased with the AJCC stage and Grade increasing (p < 0.001) and decreased with the growth of age (p < 0.001). The results of subgroup analysis showed that the survival rate of stage IA patients decreased significantly after postoperative chemotherapy (p < 0.01) while the survival rate of stage IB-II patients increased significantly (p < 0.01). At the same time, we found that patients in the postoperative chemotherapy group tended to have better OS than those in the surgery-alone group with the grade and tumor size increasing.

CONCLUSION

The results of this study indicated that postoperative chemotherapy could significantly improve the survival of stage IB-II NSCLC patients aged ≥70 years, and decrease the survival of stage IA patients.

[Treatment of early and locally advanced stages of non-small cell lung cancer]

Treatment concepts for patients with localized and locally advanced non-small cell lung cancer (NSCLC) are based on local treatment, surgery and/or radiotherapy, with curative intent. An adjuvant systemic treatment is added after primary resection of an operable NSCLC primarily to reduce the systemic risk of relapse. Locally advanced stages with mediastinal lymph node involvement carry a substantial risk of local and distant recurrence and require multimodal treatment strategies in an interdisciplinary approach. Recently, immunotherapy with programmed cell death 1 (PD-1)/programmed cell death 1 ligand 1 (PD-L1) checkpoint inhibitors is increasingly being integrated into adjuvant, neoadjuvant or perioperative treatment concepts.

Major clinical benefit from adjuvant chemotherapy for stage II-III non-small cell lung cancer patients aged 75 years or older: a propensity score-matched analysis

BACKGROUND

Data are currently insufficient to support the use of adjuvant chemotherapy (ACT) after surgical resection for stage II or III non-small cell lung cancer (NSCLC) in patients aged ≥ 75 years. In this study we evaluated efficacy and safety profile of ACT in this population.

METHODS

We retrospectively evaluated 140 patients ≥ 75 years who underwent curative surgical resection for stage II-III NSCLC from 2010 to 2018 with an indication to ACT according to current guidelines. A propensity score-matched analysis was performed to avoid cofounding biases.

RESULTS

Thirty of 140 patients (21%) received ACT. Most patients (n = 24, 80%) received carboplatin in combination with vinorelbine, while 5 patients (17%) received cisplatin plus vinorelbine and one patient (3%) carboplatin plus gemcitabine. The occurrence of adverse events led to treatment discontinuation in 8 (27%) cases, while 19 (63%) patients completed 4 chemotherapy cycles. Common reported adverse events with ACT were anemia (n = 20, 67%), neutropenia (n = 18, 60%), thrombocytopenia (n = 9, 30%), renal impairment (n = 4, 13%) and transaminase elevation (n = 4, 13%). No toxic deaths occurred. The median follow-up was 67 months (IQR: 53-87). ACT was associated with a significant benefit in both relapse-free survival (median 36 vs. 18.5 months, p = 0.049) and overall survival (median not reached [NR] vs. 33.5 months, p = 0.023) in a propensity score-matched analysis which controlled for cofounders.

CONCLUSION

ACT confers a survival benefit after curative resection of stage II-III NSCLC in selected patients aged 75 years or older with a manageable toxicity profile.

The role of immunotherapy in treating lung cancer: current status and future perspective

Lung cancers have the worst incident and mortality rates. Cancers such as advanced non-small-cell lung carcinomas are inoperable and often the only treatment available is chemo-radiotherapy. There has been little improvement in long-term survival recently, prompting research into novel treatments. Immune checkpoint inhibitors (ICIs) are a form of immunotherapy used in lung cancer. The efficacy of ICIs is dependent on: the part of the pathway affected; the presence of prognostic biomarkers; the method of efficacy assessment; the stage of the disease and other drugs involved. Monoclonal antibodies, Toll-like receptor agonists and cancer vaccines have shown modest effects on survival. Refinement of treatment regimens and prognostic biomarkers will help improve the survival of patients in the future.

Adjuvant Chemotherapy for T4 Non-Small Cell Lung Cancer with Additional Ipsilateral Lung Nodules

BACKGROUND

Adjuvant chemotherapy is indicated for patients with resectable stage II and IIIa non-small cell lung cancer. With the revised definition of T4 tumors with nodules in a different ipsilateral lobe, the survival advantage imparted by adjuvant chemotherapy has yet to be defined. We evaluated the role of adjuvant chemotherapy in patients with T4 disease characterized by additional tumor nodules in a different ipsilateral lobe treated with surgical resection.

METHODS

We identified patients with T4 disease and additional tumor nodules in a different ipsilateral lobe treated with surgical resection alone or with adjuvant chemotherapy in the National Cancer Database between 2010 and 2016. The primary outcome was 3-year overall survival (OS).

RESULTS

A total of 920 patients with T4 tumors and additional tumor nodules in a different ipsilateral lobe were identified. We excluded patients with lymph node metastases, tumors 4 cm or greater, and local invasion. Of the remaining 373 patients, 152 received surgery and adjuvant multiagent chemotherapy whereas 221 received surgery alone. When adjusted for patient, tumor, and treatment factors, the use of adjuvant chemotherapy was associated with improved 3-year OS compared with surgery alone (hazard ratio = 0.572; 95% confidence interval, 0.348-0.940; P = .03).

CONCLUSIONS

Adjuvant chemotherapy in patients with T4 non-small cell lung cancer with additional tumor nodules in a different ipsilateral lobe is associated with improved 3-year OS. Accurate identification of T4 disease is important to define patients in whom adjuvant chemotherapy should be considered. Further prospective study is needed to delineate further the use of adjuvant chemotherapy for this patient population.

Use of adjuvant chemotherapy for nonsmall cell lung cancer: Is advanced age a prognostic factor?

PURPOSE

In patients with nonsmall cell lung cancer (NSCLC), the effect of age on adjuvant chemotherapy (CT) after primary surgical treatment is controversial. The aim of this study was to investigate the effect of age and other clinical variables on survival in NSCLC patients who received adjuvant CT.

MATERIALS AND METHODS

NSCLC patients who underwent primary resection and received adjuvant CT between January 2012 and January 2016 were included in the study. The patients were divided into two age groups: (1) patients >65 years old (older patient group) and (2) patients ≤ 65 years old (young patient group). The effects of clinical variables such as age, histology, pT stage, pN stage, pTNM stage, adjuvant thoracic radiotherapy, and recurrence status on survival were assessed using the log-rank test and multivariable Cox regression analysis.

RESULTS

A total of 91 NSCLC patients who received adjuvant CT after complete resection were included in the study. The median age of the patients was 60 (36-73) years. Eighty-six percent of the patients were male. 49.4% had squamous NSCLC and 50.6% had nonsquamous NSCLC. 59% had stage I and II disease and 41% had stage III disease. The mean overall survival was 61.9 months [95% confidence interval (CI) 51.28-72.69] in the young patient group and 73.1 months (95% CI 60.24-85.94) in the older patient group . The mean disease-free survival was 47.0 months (95% CI 37.81-56.23) in the young patient group and 51.1 months (95% CI 40.68-57.17) in the older patient group (P = 0.119 and P = 0.407, respectively). Pathological stage III [heart rate (HR): 2.615, P = 0.014] and presence of recurrence (HR: 2.496, P = 0.019) were found to be independent risk factors. However, age did not show statistical significance (HR: 0.428, 95% CI 0.128-1.427, P = 0.167).

CONCLUSION

In NSCLC patients who underwent complete resection and received adjuvant CT, advanced age had no prognostic effect on survival.

Lepidic, Papillary Components and EGFR Mutations are Frequent in Patients With Lung Adenocarcinoma Who are Over 75 Years Old

Treatment for lung adenocarcinoma frequently diverges from standard treatment in older patients. Clinical, pathologic, and molecular characteristics of lung cancer in patients over 75 years old have not been fully described. The aim of our work was to describe the rate of EGFR, KRAS, BRAF, and HER2 mutations, and ALK rearrangement and pathologic characteristics in patients with lung adenocarcinoma over 75, compared with patients below 75 years old. This is a retrospective study from 2 cohorts: a histopathologic cohort of all consecutively resected lung adenocarcinoma in our institution for patients over 75 (n=54, from 2006 to 2017) compared with patients below 75 years old (n=148, from 2014 to 2017) and a molecular cohort of all stage IIIb or IV lung adenocarcinoma from 2009 to 2017 (n=1611). Papillary and lepidic components were more frequently found in patients over 75 years old (P=0.046 and 0.0078, respectively). The rate of current smokers was lower in older patients (P<0.0001). EGFR mutations were more frequent in patients over 75 than in younger patients: 17% versus 8.1% (P<0.0001). The mutually exclusive KRAS mutation was more frequent in patients below 75 years old than in older patients: 25.8% versus 12.8% (P<0.0001). There was no difference for the proportion of the 2 most frequent EGFR mutations (exon 19 deletion and L858R mutation) (P=0.85) or KRAS-mutated codon (P=0.22) between tumors in younger or older patients. There was no statistically significant difference for the presence of BRAF, HER2 mutations, and ALK rearrangement (P=0.44, 0.71, and 1, respectively). Our work highlights the fact that EGFR mutations are more frequent in patients over 75 years old in our population. We can hypothesize that this difference might be mainly caused by the less frequent occurrence of tobacco-smoking-related lung cancers in the elderly and the presence of a lepidic or papillary component in this age group.