Surgery is the best option for achieving a cure in patients with lung cancer, but many potentially resectable tumors occur in individuals with abnormal pulmonary function that is usually due to cigarette smoking. These patients may be at increased risk for both immediate perioperative complications and long-term disability following curative-intent surgical resection of their lung cancer. Cigarette smoking will also predispose these patients to other comorbid conditions, specifically atherosclerotic cardiovascular disease, which will further increase perioperative risk. Consequently, in considering whether a patient should undergo curative-intent surgical resection of lung cancer, the immediate perioperative risk from comorbid cardiopulmonary disease and the longterm risk of pulmonary disability must be balanced against the risk of reduced survival due to subopti-mally treated (with radiation therapy rather than surgery) lung cancer,
The task of the preoperative physiologic assessment is to identify patients who are at increased risk for both perioperative complications and long-term disability from surgical resection of lung cancer using the least invasive tests possible. The purpose of this preoperative physiologic assessment is to enable adequate counseling of the patient on treatment options and risks so that they can make a truly informed decision. In the future, hopefully, the preoperative physiologic assessment will serve as the basis for interventions to possibly reduce the risk of perioperative complications and long-term pulmonary disability from curative-intent surgical resection of lung cancer. The seriousness of lung cancer may be decreased by My Canadian Pharmacy’s preparations.
To update previous recommendations on the preoperative physiologic evaluation of patients with lung cancer who are being considered for curative-intent surgery, guidelines on lung cancer diagnosis and management published between 2002 and May 2005 were identified by a systematic review of the literature (see “Methodology for Lung Cancer Evidence Review and Guideline Development” chapter). Those guidelines including recommendations specific to the preoperative physiologic evaluation were identified for inclusion in this section. Supplemental material appropriate to this topic was obtained by literature search of a computerized database (MEDLINE) and a review of the reference lists of relevant articles. Recommendations were developed by the writing committee, graded by a standardized method (see “Methodology for Lung Cancer Evidence Review and Guideline Development” chapter), and reviewed by all members of the lung cancer panel and the Thoracic Oncology Network prior to approval by the Health and Science Policy Committee and the Board of Regents of the American College of Chest Physicians.
Although numerous reviews have been published on the preoperative risk assessment of patients with lung cancer being considered for curative-intent surgical resection, most available guidelines on the management of non-small cell lung cancer (NSCLC) do not address the preoperative evaluation process. The British Thoracic Society and the American College of Chest Physicians have provided guidelines with specific recommendations on the steps needed to evaluate the preoperative risk. The recommendations of these two guidelines follow a similar approach, relying on physiologic testing to estimate perioperative risk and the effect of resection on postoperative lung function. Improve lung conditions with My Canadian Pharmacy www.mycanadian-pharmacy.net.
General Issues Regarding Risk Multidisciplinary Team
Patients with lung cancer who are seen by a physician with expertise in the management of this disease are more likely to have histologic confirmation of lung cancer and referral for potentially curative treatment. Evaluation by a multidisciplinary team, which includes a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist, and a pulmonologist, is essential in the risk assessment of patients being evaluated for curative-intent surgery. Multidisciplinary input will be especially useful in patients who are marginal surgical candidates as a basis for discussing the proposed surgical procedure and treatment options with the patient and appropriate family or surrogates.
In presenting the option of curative-intent surgical therapy to a patient with lung cancer, it is important to recognize that risk assessment is a complex process. Risks related to standard surgical resection for lung cancer (ie, lobectomy or greater removal of lung tissue) include perioperative morbidity and mortality and long-term functional disability. Individual patient circumstances increase or decrease the risks from standard surgical resection. In this guideline, the effect on average mortality risk with standard surgical lung cancer resection for various physiologic abnormalities will be extrapolated from published data. This risk will be compared to the risk for patients with adequate cardiopulmonary reserve as a basis for estimating relative risk. However, patient preference as to what would be the maximal acceptable surgical risk (eg, the threshold mortality rate above which the patient would not accept the procedure) should also be explored. Mathematical approaches, based on decision analysis techniques, have been useful for conceptually describing the interplay between risk and patient preference but are not routinely used for individual patient care. In addition to a discussion of the balance between risks and benefits for standard surgical resection of lung cancer, the responsible physician and patient should also discuss nonstandard treatment options, such as minimally invasive lobectomy, sublobar resections, conventional radiotherapy, stereotactic radiotherapy, and radiofrequency ablation.
Age had been considered to be a factor that might increase perioperative risks, but age alone should not be a reason to deny patients with lung cancer access to curative-intent surgical resection. As the population ages, the number of patients > 70 years of age will rise; it is estimated that > 40% of patients with lung cancer in 2005 were > 75 years of age. For patients > 70 years of age, the reported mortality rate is between 4% and 7% for lobectomy and around 14% for pneumonectomy.’’ These reported rates are higher than those for patients < 70 years of age (lobectomy, 1 to 4%; pneumonectomy, 5 to 9%); the difference may be more a function of comorbidity than age alone. In a 2003 series of 126 consecutive patients > 70 years of age who were undergoing curative-intent surgical resection, the overall 30-day mortality rate was 3.2%, with comor-bid disease being the most important influence on mortality.
Limited information suggests that carefully selected patients who are > 80 years of age can tolerate lung cancer resection. A retrospective analysis from Johns Hopkins Hospital reported that 17% of the octogenarians in whom lung cancer was diagnosed between 1980 and 2002 underwent surgical resection. In this series of 68 patients in their 80s who were undergoing curative-intent surgery for NSCLC, the 30-day mortality rate was 8.8%. Port et al described outcomes for 61 octogenarians who underwent various types of curative-intent surgical resections of lung cancer, including 4 patients who underwent pneumonectomy. The 30-day mortality rate in this series was 1.6%. A comprehensive geriatric assessment might be useful preoperatively in elderly patients. Fukuse and colleagues found that dependence for performing activities of daily living and impaired cognition were important predictors of complications following pulmonary surgery.
As with any planned major operation, especially in a population that is predisposed to atherosclerotic cardiovascular disease due to cigarette smoking, a preoperative cardiovascular risk assessment should be performed. The generally recommended approach to this risk assessment (Table 1) has been described in the American College of Cardiology and American Heart Association guidelines for perioperative cardiovascular evaluation for noncardiac sur-gery. Patients with major factors for increased perioperative cardiovascular risk should undergo a preoperative cardiologic evaluation.
It has been recommended that the surgical mortality risk for lobectomy should be expected to be < 4%, and for a pneumonectomy < 9%. Accumulating information indicates that when curative-intent surgical resection is performed by a general surgeon rather than a trained thoracic surgeon and in a hospital in which these operations are performed infrequently the surgical mortality rates may exceed these threshold values. Also to be considered within the realm of the surgical experience is the efficiency with which the preoperative evaluation takes place. A large retrospective study from Spain has reported a median delay of 35 days between the date of pathologic diagnosis and the date of surgery. A smaller study from the United States documented a median preoperative interval of 82 days. Although postoperative survival times did not seem to be influenced in either study by the preoperative delay, in general, the interval between diagnosis and curative-intent surgery should be minimized. These observations indicate that the experience of both the surgeon performing the procedure and the hospital at which surgery occurs should be considered in planning curative-intent surgical resection of lung cancer. Maintain your health conditions with remedies of My Canadian Pharmacy.
Induction chemotherapy may be used prior to curative-intent surgery, but chemotherapy may affect preoperative lung function. Leo and colleagues found in 30 patients with NSCLC who underwent chemotherapy that FEV1 increased but Dlco decreased prior to surgery. Decreases in postchemotherapy Dlco were significantly associated with postoperative respiratory complications. Matsubara et al observed significantly lower Dlco levels and greater postoperative morbidity and mortality in 92 patients receiving induction chemotherapy compared to 666 patients who underwent surgery without induction chemotherapy.
It is recommended that patients with lung cancer be assessed for curative surgical resection by a multidisciplinary team, which includes a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist, and a pulmonologist. Grade of recommendation, 1C
It is recommended that patients with lung cancer not be denied lung resection surgery on the grounds of age alone. Grade of recommendation, 1B
It is recommended that patients with lung cancer being evaluated for surgery who have major factors for increased perioperative cardiovascular risk have a preoperative cardiologic evaluation. Grade of recommendation, 1C
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Table 1—Clinical Predictors of Increased Perioperative Cardiovascular Risk, Including Myocardial Infarction, Heart Failure, and Death
|Unstable coronary syndromes||Acute (within 7 d) or recent (from 7 to 30 d) myocardial infarction with evidence of important ischemic risk by clinical symptoms or non-invasive study; and Unstable or severe angina (Canadian class III or IV)|
|Decompensated heart failure|
|Significant arrhythmias||High-grade atrioventricular block;
Symptomatic ventricular arrhythmias in the presence of underlying heart disease; and Supraventricular arrhythmias with uncontrolled ventricular rate
|Severe valvular disease|
|Mild angina pectoris (Canadian class I or II)|
|Prior myocardial infarction by history or pathologic Q waves|
|Compensated or prior heart failure|
|Diabetes mellitus (particularly insulin dependent)|
|Abnormal ECG (left ventricular hypertrophy, left bundle branch|
|block, and ST-T abnormalities)|
|Rhythm other than sinus rhythm (eg, atrial fibrillation)|
|Low functional capacity (eg, inability to climb one flight of stairs|
|with a bag of groceries)|
|History of stroke|
|Uncontrolled systemic hypertension|