Preoperative Evaluation and Risk Assessment for Elderly Thoracic Surgery Patients

The US population is aging. With an increase in life expectancy to 77.8 years and an aging baby boomer population, the number of people in the United States aged more than 65 years is expected to double by 2040. Currently, 12.5% of the US population is over the age of 65 years, and this percentage is projected to increase to 20% by the year 2050. 1–3 Older patients increasingly present for consideration of thoracic surgery, and determining the best management for this group of patients will be a more frequent challenge in the future. Although elderly patients present with a spectrum of thoracic disease, both benign and malignant, patients with cancer comprise the largest and most studied subset of this population. Lung cancer is a disease of the elderly. The median age of diagnosis in the United States is 71 years, and over 65% of patients are diagnosed after age 65 years. National Cancer Institute statistics indicate that lung cancer remains the second most common cancer after breast cancer in women and prostate cancer in men. It is the leading cause of cancer mortality as shown in Figs. 1 and 2. 4,5 In 2008 anestimated 215,020 Americanswill bediagnosed and 161,840 people will die of lung cancer. Over 100,000 lung cancer deaths will be in patients aged more than 65 years. 6 Surgical resection for non–small cell lung cancer (NSCLC) offers the best chance for cure if the disease is detected in the early stages. Unfortunately, only 15% to 25% of patients have locally staged disease at diagnosis. O’Rourke and colleagues used a database of 22,874 patients to demonstrate that the percentage of patients with surgically resectable disease at diagnosis increases with age. The percentage of lung cancer patients with local disease increased from 15.3% of those aged 54 years or younger to 19.2% of those aged 55 to 64 years to 21.9% of those aged 65 to 74 years to 25.4% of those aged 75 years or older. 7 Data published from the Surveillance, Epidemiology, and End Results (SEER) database in 2005 analyzing a cohort of 14,555 patients with early stage NSCLC showed that the frequency of stage I disease increased from 79% in patients aged less than 65 years to 87% in patients aged 75 years or greater. 8 Although the elderly are at increased risk of developing lung cancer, a higher proportion present with potentially curable disease. Additionally, multiple studies have shown that, in elderly patients, tumor histology is more likely to be squamous cell carcinoma. 9–11 Mery and colleagues’s 8 analysis of the SEER database showed that the frequency of squamous cell carcinoma increased from 27% in patients less than 65 years old to 38% in patients 75 years and older, with parallel decreases in the frequency of adenocarcinoma from 61% to 50% in corresponding age groups, as depicted in Fig. 3. Squamous cell carcinomas are associated with a higher incidence