SIOG 11th Annual MeetingNovember 4 2011

Selection of Appropriate Surgery

November 4, 2011

Selection of Appropriate Surgery for Early Lung Cancer

Michael Jaklitsch, MDDivision of Thoracic Surgeryg y

Francine Jacobson, MDDivision of Thoracic RadiologyDivision of Thoracic Radiology

H dHarvardMedical School

Disclosures

• Data Figures and Tables cited on slides• Images of elderly individuals obtained fromImages of elderly individuals obtained from

Google.com/images• Dr Jacobson has Toshiba Corporation• Dr. Jacobson has Toshiba Corporation

Grant to study lung nodule detection from novel CT imagesnovel CT images

Natural History of Lung CancerDetectable by Test

Signs and Symptoms

Disease Onset DeathOnset Death

Cli i lP li i l ClinicalLung cancer in elderly is suited to screening

T b ff

Pre clinical

Treatment can be very effective

SEER Database Shows Increase in Stage I SEER Database Shows Increase in Stage I cancer with age: N = 14 555cancer with age: N = 14 555cancer with age: N = 14,555cancer with age: N = 14,555

< 65 yrs< 65 yrs(n=5057)(n=5057)

65 65 -- 74 yrs74 yrs(n=6073)(n=6073)

7575 yrsyrs(n=3425)(n=3425)

PP(n=5057)(n=5057)

5555

(n=6073)(n=6073)

5757

(n=3425)(n=3425)

5454Males, %Males, % 0.00620.0062

7979 8383 8787Stage I, %Stage I, % <0.0001<0.0001

26265858

35355050

35354646

Histology, %Histology, %SquamousSquamousAdenoCaAdenoCa

<0.0001<0.00015858 5050 4646AdenoCaAdenoCa

Squamous cell cancers have higher rates of local disease, l d l l

Mery. Chest 2005

lower recurrence rates, and longer survival times.

Rate of surgically resectable disease increases with age (N=22,874) observed in 1987.

< 54 years 55 – 64 years 65 – 74 years > 75 years

15.3% 19.2% 21.9% 25.4%

O’Rourke. JAMA 1987

Curative surgeryCurative surgery100%

Curative surgeryCurative surgery

60%

80% 92% 86%

70%

40%

60%

0%

20%

< 65 65 - 74 > 75

Curative surgeryCurative surgery Age (yrs)Age (yrs)

No curative surgeryNo curative surgery p<0.0001p<0.0001

Mery. Chest 2005

Age Is A Risk Factor For DeathAge Is A Risk Factor For DeathAge Is A Risk Factor For Death After Thoracotomy

Age Is A Risk Factor For Death After Thoracotomy

Lung Cancer Study Group (LCSG) l i i i i(LCSG) multi-institution prospective data on open lobectomy or less N=2200:y

27 / 368 (7.3 %) > 70 years

3 / 27 (11 %) > 80 years

Ginsberg, et al, JTCVS, 1983

Minimally – InvasiveMinimally Invasive Surgical Revolution

• Laparoscopy 1980s

• Thoracoscopy and VATS early 1990s

• Optics, cameras, instruments, new surgical paradigmsparadigms

• Less pain, less pulmonary insult quick return homeinsult, quick return home

860 patients, 896 thoracoscopic procedures from 7/1/1991 to 6/15/1994370 procedures on elderly patients

Chest 1996; 110;751-758*Google founded 1998

Comparison of Operative Mortality

LCSG:LCSG:Open Thoracotomy - Lobectomy or less

27 / 368 (7.3%) 70 years3 / 27 (11%) 80 years( ) y

Brigham VATS:Brigham VATS:Lobectomy or segmentectomy 0 / 32L i 1 / 156Lesser resections 1 / 156

Modern Thoracotomy OperativeModern Thoracotomy Operative Mortality: SEER data

Age < 65 years 65 – 74 years > 75 years

Operative mortality

0.5% 0.6% 1.2% (P=0 001)mortality (P=0.001)

• N = 14 555N 14,555• Curative resections from 1992-1997

M Ch t 2005Mery. Chest 2005

VATS for stage I lung cancer eliminated postop deaths in the elderlyeliminated postop deaths in the elderly

Authors # pts Mean age Technique Morb (%) Death %)(pub Year)(pub. Year)_____________________________________________________________________ Shennib 30 71 yrs Wedge 23 3(1993) Excision_____________________________________________________________________________________________ McKenna 9 81 yrs Major 22 0 (1994)_____________________________________________________________________________________________ Roviaro 13 70 yrs Wedge 8 0(1995)( )_____________________________________________________________________________________________ Yim 22 78 yrs Minor/Major 9 0(1996)_____________________________________________________________________________________________ Jaklitsch 296* 65-90 yrs Minor/Major 9 0Jaklitsch 296 65 90 yrs Minor/Major 9 0(1996)_____________________________________________________________________________________________ Asamura 8 81 yrs Lobectomy 28 0(1997)

*Benign lesions included

Are Elderly Patients Too Frail forAre Elderly Patients Too Frail for Chest Surgery?

• Single institution studies of carefully l d ld l i l k fselected very elderly patients lack of

measures of frailty.

• Referral for surgery of elderly patients decreases with increasing agedecreases with increasing age.

BWH Thoracic Surgery

Operative Risk of Death AfterOperative Risk of Death After Thoracotomy

• Physiologic insult of thoractomyPhysiologic insult of thoractomy

L f l i (l b )• Loss of lung tissue (lobectomy)

BWH Thoracic Surgery

Early Interesting Observations inEarly Interesting Observations in Regards to the Frail Elderly

• Overall mortality < 1%

• 2% mortality if FEV-1 < 1 liter

• 10% mortality if Karnofsky scale < 8(unable to carry on normal activity)

Jaklitsch.. Chest 1996 (110):751-8

Risk of Operative Mortality inRisk of Operative Mortality in Elderly is Primarily Respiratory Risk

• Kyphosis

• Decreased excursion of lower ribs

• Increased dependence on diaphragmsdiaphragms

• Aspiration

Potential Options

• Always acknowledge “Do nothing” is an option• A diagnosis should be made

St i h ld b l t d t id th• 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)Lesser surgery (wedge resection)– No surgery but local ablation – Radiation therapy

Second Operative Risk Factor for Elderly Patients is Amount of Lung Parenchyma Removed

• Lobectomy:• Lobectomy:May remove too much lung in elderlyHigher morbidityVery low recurrence rate (6%)

• Thoracoscopic Wedge:Less than 1% mortality rate, even in elderlyLess morbidityMay have a 17% local recurrence rate

Type of curative surgeryType of curative surgery100% 8% 12% 17%

Type of curative surgeryType of curative surgery

60%

80% 81% 81% 78%

40%

60%

0%

20%

< 65 65 - 74 > 75LobectomiesLobectomiesPneumonectomiesPneumonectomies

Age (yrs)Age (yrs)PneumonectomiesPneumonectomies p<0.0001p<0.0001Limited resectionsLimited resections

Overall mortalityOverall mortality65 65 -- 74 yrs74 yrs

1

.8

LobectomiesLobectomies

Limited rsctLimited rsct.4

.6

Limited rsctLimited rsct

.2

.4

0

0 10 20 30 40 50 60 70 80

Survival (mos)Survival (mos) p = 0.0009p = 0.0009

Mery…Jaklitsch, Chest 2005; 128:237

Overall mortalityOverall mortality 7575 yrsyrs

1

.8

LobectomiesLobectomies4

.6

LobectomiesLobectomies

Limited rsctLimited rsct.2

.4

0

0 10 20 30 40 50 60 70 80Survival (mos)Survival (mos) p = NSp = NS

0 10 20 30 40 50 60 70 80

Mery…Jaklitsch, Chest 2005; 128:237

LCSG data shows no difference for first 4 years postoperatively

Lobectomy versus Wedge ResectionLobectomy versus Wedge Resection

Elderly Stage I NSCLCElderly Stage I NSCLCSurgical Resections at BWH

• 1134 SPNs wedged at BWH (1989-98)g ( )

• 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

Is Mortality the Important Endpoint?

• Traditional surgical endpoints are morbidity and mortalitymorbidity and mortality

• What is “true risk” of operative procedures?

Unclear if important to patient pop lation• Unclear if important to patient population

Patient asked to express the risk of death they are

illi twilling to take to avoid thethe intermediate health state and achieve normal health

BWH Thoracic SurgeryCykert S, Kissling G, Hansen CJ. Patient preferences regarding possible outcomes of lung resection. Chest. 2000;117(6):1551‐1559.

CanCORS Rigorous observational study designed to

identify clinically important differences in lung y y p gand colorectal cancer treatment and outcomes

Ayanian JZ, Chrischilles EA, Fletcher RH, et al.. J. Clin. Oncol. 2004;22(15):2992-2996.

Results

BWH Thoracic SurgeryFigure 1. Flowchart of study participants

Billmeier, in press

Death or N rsing Home AdmissionDeath or Nursing Home Admission

• 34 (3%) admitted to nursing home in 1st year after surgeryg y

• 124 (12%) died in 1st year

• 146 (15%) with composite outcome of death or nursing home admissionnursing home admission

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.

Traditional Outcome Measures AreTraditional Outcome Measures Are Not Really Helpful

• Morbidity, mortality• Disease-free Survival• Recurrence

W N d N M fWe Need New Measures of:• Loss of independence• Time to return homeTime to return home• Functional impairment• Nursing home riskg

Also We Need Better Selection Tools:Also, We Need Better Selection Tools:Functional Age, Not Constitutional Age

• Preserved function– Anatomic resection

• Impaired (frail)• Impaired (frail)• VATS anatomic or

– Locally ablative• Seriously impaired

– Locally ablative• Invalid• Invalid• Locally ablative or

– Locally palliative

Goal: Match Surgical Resection risks and benefitsto the Patient Constitution

Current Selection Paradigms Measure Cardiac/Pulm Functiong

Can we tell Strong from Frail?

• The borderline frail are skilled at hiding their frailty from: their doctors, their y ,children, themselves, and their children who are doctors!

• Global loss of organ reserve may not be detectable by current measurementsdetectable by current measurements.

• Falls as predictor of NHP.H i 2008

BWH Thoracic Surgery

Hurria, 2008

Brief Geriatric Assessment

• Functional Status (ADLs, IADLS)• Comorbidityy• Cognition• Ps chological Stat s• Psychological Status• Social Functioning and Support• Nutritional Status• BODE index - BMI, spirometry, , p y,

Dyspnea, 6 MWT

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 theIf the patient cannot answer the questionnaires, that has predictive value.

P i l f f “R ”• Potential for measure of “Recovery.”

BWH Thoracic Surgery

How Old is Too Old?

• No chronologic age limit

F i l li i ll• Functional limit at all ages

• New technology allows tailoring treatmentNew 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