Selection of Appropriate Surgery for Early Lung Cancer

Transcription

1 SIOG 11 th Annual Meeting November 4, 2011 Selection of Appropriate Surgery for Early Lung Cancer Michael Jaklitsch, MD Division of Thoracic Surgery Francine Jacobson, MD Division of Thoracic Radiology Harvard Medical School

2 Disclosures Data Figures and Tables cited on slides Images of elderly individuals obtained from Google.com/images Dr. Jacobson has Toshiba Corporation Grant to study lung nodule detection from novel CT images

3 Natural History of Lung Cancer Detectable by Test Signs and Symptoms Disease Onset Death Pre clinical i l Clinicali l Lung cancer in elderly is suited to screening Treatment can be very effective

4 SEER Database Shows Increase in Stage I cancer with age: N = 14,555 < 65 yrs (n=5057) yrs (n=6073) 75 yrs (n=3425) P Males, % Stage I, % < Histology, % Squamous AdenoCa < Squamous cell cancers have higher rates of local disease, lower recurrence rates, and longer survival times. Mery. Chest 2005

5 Rate of surgically resectable disease increases with age (N=22,874) observed in < 54 years years years > 75 years 15.3% 19.2% 21.9% 25.4% O Rourke. JAMA 1987

6 Curative surgery 100% 80% 92% 86% 60% 70% 40% 20% 0% Curative surgery No curative surgery < > 75 Age (yrs) p< Mery. Chest 2005

7 Age Is A Risk Factor For Death After Thoracotomy Lung Cancer Study Group (LCSG) multi-institution i i i prospective data on open lobectomy or less N=2200: 27 / 368 (7.3 %) > 70 years 3 / 27 (11 %) > 80 years Ginsberg, et al, JTCVS, 1983

8 Minimally Invasive Surgical Revolution Laparoscopy 1980s Thoracoscopy and VATS early 1990s Optics, cameras, instruments, new surgical paradigms Less pain, less pulmonary insult, quick return home

9 860 patients, 896 thoracoscopic procedures from 7/1/1991 to 6/15/ procedures on elderly patients *Google founded 1998 Chest 1996; 110;

10 LCSG: Comparison of Operative Mortality Open Thoracotomy - Lobectomy or less 27 / 368 (7.3%) 70 years 3 / 27 (11%) 80 years Brigham VATS: Lobectomy or segmentectomy 0 / 32 Lesser resections 1 / 156

11 Modern Thoracotomy Operative Mortality: SEER data Age < 65 years years > 75 years Operative mortality 0.5% 0.6% 1.2% (P=0.001) 001) N = 14,555 Curative resections from Mery. Chest 2005

12 VATS for stage I lung cancer eliminated postop deaths in the elderly Authors # pts Mean age Technique Morb (%) Death %) (pub. Year) Shennib yrs Wedge 23 3 (1993) Excision McKenna 9 81 yrs Major 22 0 (1994) Roviaro yrs Wedge 8 0 (1995) Yim yrs Minor/Major 9 0 (1996) Jaklitsch 296* yrs Minor/Major 9 0 (1996) Asamura 8 81 yrs Lobectomy 28 0 (1997) *Benign lesions included

13 Are Elderly Patients Too Frail for Chest Surgery? Single institution studies of carefully selected very elderly l patients lack of measures of frailty. Referral for surgery of elderly patients decreases with increasing age. BWH Thoracic Surgery

14 Operative Risk of Death After Thoracotomy Physiologic insult of thoractomy Loss of flung tissue (lobectomy) BWH Thoracic Surgery

15 Early Interesting Observations in Regards to the Frail Elderly Jaklitsch.. Chest 1996 (110):751-8 Overall mortality < 1% 2% mortality if FEV-1 < 1 liter 10% mortality if Karnofsky scale < 8 (unable to carry on normal activity)

16 Risk of Operative Mortality in Elderly is Primarily Respiratory Risk Kyphosis Decreased excursion of lower ribs Increased dependence on diaphragms Aspiration

17 Potential Options Always acknowledge Do nothing is an option A diagnosis should be made Staging should be completed to guide therapy Intervention must be based on strength or frailty Cancer treatment options: Surgery (lobectomy, segmentectomy) Lesser surgery (wedge resection) No surgery but local ablation Radiation therapy

18 Second Operative Risk Factor for Elderly Patients is Amount of Lung Parenchyma Removed Lobectomy: May remove too much lung in elderly Higher morbidity Very low recurrence rate (6%) Thoracoscopic Wedge: Less than 1% mortality rate, even in elderly Less morbidity May have a 17% local recurrence rate

19 Type of curative surgery 100% 8% 12% 17% 80% 81% 81% 78% 60% 40% 20% 0% Lobectomies Pneumonectomies Limited resections < > 75 Age (yrs) p<0.0001

20 Overall mortality yrs Lobectomies Limited rsct Survival (mos) p = Mery Jaklitsch, Chest 2005; 128:237

21 1 Overall mortality 75 yrs Lobectomies Limited rsct Survival (mos) p = NS Mery Jaklitsch, Chest 2005; 128:237

22 LCSG data shows no difference for first 4 years postoperatively Lobectomy versus Wedge Resection

23 Elderly Stage I NSCLC Surgical Resections at BWH 1134 SPNs wedged at BWH ( ) 563 were proven NSCLC 98 were 75 yrs (elderly), 465 were <75 yrs Surgeon s choice to proceed with anatomic lung resection or treat with wedge alone Jaklitsch, Proc ASCO 1999:18;471a

24 Is Mortality the Important Endpoint? Traditional surgical endpoints are morbidity and mortality What is true risk of operative procedures? Unclear if important to patient population

25 BWH Thoracic Surgery Patient asked to express the risk of death they are willing to take to avoid the intermediate health state and achieve normal health Cykert S, Kissling G, Hansen CJ. Patient preferences regarding possible outcomes of lung resection. Chest. 2000;117(6):

26 CanCORS Rigorous observational study designed to identify clinically important differences in lung and colorectal cancer treatment and outcomes Ayanian JZ, Chrischilles EA, Fletcher RH, et al.. J. Clin. Oncol. 2004;22(15):

27 Results BWH Thoracic Surgery Figure 1. Flowchart of study participants Billmeier, in press

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29 DeathorN Nursing rsinghomeadmission 34 (3%) admitted to nursing home in 1 st year after surgery 124 (12%) died in 1 st year 146 (15%) with composite outcome of death or nursing home admission

30 Thus, American surgeons are able to tailor surgery to those less than 75 years of age, but are not properly selecting patients over age 75.

31 Traditional Outcome Measures Are Morbidity, mortality Disease-free Survival Recurrence Not Really Helpful We Need dnew Measures of: Loss of independence Time to return home Functional impairment Nursing home risk

32 Also, We Need Better Selection Tools: Functional Age, Not Constitutional Age Preserved function Anatomic resection Impaired (frail) VATS anatomic or Locally ablative Seriously impaired Locally ablative Invalid Locally ablative or Locally palliative Goal: Match Surgical Resection risks and benefits to the Patient Constitution

33 Current Selection Paradigms Measure Cardiac/Pulm Function

34 Can we tell Strong from Frail? The borderline frail are skilled at hiding their frailty from: their doctors, their children, themselves, and their children who are doctors! Global loss of organ reserve may not be detectable by current measurements. Falls as predictor of NHP. BWH Thoracic Surgery Hurria, 2008

35 Brief Geriatric Assessment Functional Status (ADLs, IADLS) Comorbidity Cognition Psychological Status Social Functioning and Support Nutritional Status BODE index - BMI, spirometry, Dyspnea, 6 MWT

36 Simplicity, Accuracy These tests can be combined into a 30 minute questionnaire that takes 10 minutes of the surgeons time. If the patient cannot answer the questionnaires, that has predictive value. Potential lfor measure of f R Recovery. BWH Thoracic Surgery

37 How Old is Too Old? Nochronologic age limit Functional llimit i at all ages New technology allows tailoring treatment to functional status W till l k th d t th t ld l We still lack the data that our elderly patients most commonly request