Lobectomy outweighs sublobar resection for elderly early-stage NSCLC patients

By Lucy Piper, Senior medwireNews Reporter

Lobectomy may the best option for elderly patients with early-stage non-small-cell lung cancer (NSCLC) who are able to undergo surgery, say researchers from the US.

Despite it being a more extensive procedure than sublobar resection, the team found that lobectomy was associated with a significantly lower rate of mortality after 3 years of follow-up, at 25.0% versus 35.3%. The rate was also significantly lower than that for stereotactic ablative radiotherapy (SABR), at 45.1%.

Due to a growth in the ageing population and increased computed tomographic screening, the incidence of early-stage NSCLC among the elderly is expected to rise dramatically, note researcher Benjamin Smith (The University of Texas MD Anderson Cancer Center, Houston) and colleagues.

It is therefore important to compare the most commonly used definitive therapies for early-stage NSCLC in the elderly and understand which is best for a population that is likely to have extensive comorbidities and need surgical risk balanced with therapeutic efficacy, they say.

The team analysed observational data from the Surveillance, Epidemiology, and End Results database for 9093 patients with early-stage, node-negative NSCLC who were aged a median of 75 years.

The patients underwent definitive treatment of lobectomy (n=7215), sublobar resection (n=1496) or SABR (n=382) between 2003 and 2009.

The results showed that at 90 days, the unadjusted rate of mortality was higher following lobectomy than sublobar resection and significantly higher than that following SABR, at 4.0% versus 3.7% and 1.3%, respectively.

But by 3 years, the unadjusted mortality rate was lowest for lobectomy. And after adjusting for patient and tumour characteristics as well economic and other co-variables, worse overall survival in the NSCLC patients was significantly predicted by sublobar resection, with an adjusted hazard ratio (HR) of 1.32 versus lobectomy.

“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 (Banner MD Anderson Cancer Center, Arizona, USA) 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.

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 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.”

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