Impact of Age on Long-Term Outcomes of Surgery for Malignant Pleural Mesothelioma

Our plain-English summary of Impact of Age on Long-Term Outcomes of Surgery for Malignant Pleural Mesothelioma, by C.J. Yang, B.W. Yan, R.R. Meyerhoff, et al (Clinical Lung Cancer, 2016).

The study

• Authors: C.J. Yang, B.W. Yan, R.R. Meyerhoff, S.M. Saud, B.C. Gulack, P.J. Speicher, M.G. Hartwig, T.A. D'Amico, D.H. Harpole, M.F. Berry
• Journal: Clinical Lung Cancer
• Published: 2016;17(5):419-426
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Although malignant pleural mesothelioma (MPM) is generally a disease associated with more advanced age, the association of age, treatment, and outcomes has not been well-characterized. We evaluated the impact of age on outcomes in patients with MPM to provide data for use in the treatment selection process for elderly patients with potentially resectable disease.

Patients And Methods: Overall survival (OS) of patients younger than 70 and 70 years or older with Stage I to III MPM who underwent cancer-directed surgery or nonoperative management in the Surveillance, Epidemiology, and End Results database (2004-2010) was evaluated using multivariable Cox proportional hazard models and propensity score-matched analysis.

Results: Cancer-directed surgery was used in 284 of 879 (32%) patients who met inclusion criteria, and was associated with improved OS in multivariable analysis (hazard ratio, 0.71; P = .001). Cancer-directed surgery was used much less commonly in patients 70 years and older compared with patients younger than 70 years (22% [109/497] vs. 46% [175/382]; P < .001), but patients 70 years and older had improved 1-year (59.4% vs. 37.9%) and 3-year (15.4% vs. 8.0%) OS compared with nonoperative management. The benefit of surgery in patients 70 years and older was observed even after propensity score-matched analysis was used to control for selection bias.

Conclusion: Surgical treatment is associated with improved survival compared with nonoperative management for both patients younger than 70 years and patients aged 70 years or older.

Copyright © 2016 Elsevier Inc. All rights reserved.

In plain English

Using the U.S. Surveillance, Epidemiology, and End Results (SEER) cancer registry, the authors studied 879 adults diagnosed from 2004 to 2010 with stage I to III malignant pleural mesothelioma of epithelioid or biphasic type. They compared survival after cancer-directed surgery with survival under nonoperative management, separately for patients younger than 70 and those 70 or older. Surgery was used in 46% (175/382) of the younger patients and 22% (109/497) of the older patients. After adjusting for other characteristics, surgery was associated with better overall survival (hazard ratio 0.71; 95% CI 0.58 to 0.86). Among patients 70 or older, 1-year survival was 59.4% with surgery versus 37.9% without, and 3-year survival was 15.4% versus 8.0%. The association held in both age groups after propensity matching. Among patients 80 or older, surgery was not associated with improved survival (hazard ratio 0.96; 95% CI 0.57 to 1.61). The registry lacked information on chemotherapy and on the type of operation. The authors concluded that advanced age alone should not be an absolute contraindication to surgery, though the benefits may not extend to patients older than 80.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective, population-based analysis of the U.S. SEER cancer registry, using multivariable Cox proportional hazards models and propensity score-matched analysis
• Who was studied: 879 adults (18 or older) in the U.S. SEER database diagnosed from 2004 to 2010 with pathologically proven stage I to III malignant pleural mesothelioma of epithelioid or biphasic (nonsarcomatoid) histology. 382 were younger than 70 and 497 were 70 or older.
• Exposure: Not an asbestos exposure study. It compared cancer-directed surgery (SEER surgery codes 30, 40, 50 and 60: partial removal, total removal, debulking, radical surgery) with nonoperative management, by age group.
• Main results:
  • Surgery was used in 22% (109/497) of patients 70 and older, compared with 46% (175/382) of patients younger than 70 (P < .001)
  • In the whole cohort, after adjustment, cancer-directed surgery was associated with improved survival (hazard ratio 0.71; 95% CI, 0.58-0.86; P = .001)
  • In the whole cohort, after adjustment, age (HR 1.03; 95% CI 1.02-1.03) and biphasic histology (HR 1.51; 95% CI 1.22-1.86) were associated with worse survival
  • In patients 70 years and older, surgery compared with nonoperative management was associated with 1-year survival of 59.4% vs. 37.9% and 3-year survival of 15.4% vs. 8.0%
  • In unadjusted analysis, surgery was associated with significantly better overall survival than nonoperative management both in patients younger than 70 and in patients 70 and older
  • After propensity matching (89 vs. 89 patients younger than 70; 81 vs. 81 patients 70 and older), surgery remained associated with significantly better overall survival in both age groups
  • Among surgery patients only, age under 70 was associated with better survival than age 70 and over (P = .03)
  • 30-day mortality was 11.7% in patients who did not have surgery versus 4.3% in patients who had surgery (P = .001)
  • In patients 80 years or older, surgery was not associated with improved survival (HR 0.96; 95% CI 0.57-1.61; P = .87)
• The authors' conclusion: The authors concluded that surgery is associated with improved long-term outcomes even among the elderly, and that appropriately selected elderly patients may benefit. They said advanced age alone should not be used as an absolute contraindication to surgery, although the potential advantages may not translate to patients older than 80.
• Limitations the authors state:
  • SEER lacked information on patient comorbidities, socioeconomic status, chemotherapy regimens, details of the operation, and details of clinical and pathologic staging
  • The type of surgery was not specified, so some operations may have been palliative, which may underestimate the effect of curative-intent surgery. A sensitivity analysis restricted to likely curative-intent surgery gave consistent results.
  • Staging was pathologic for surgery patients but clinical for nonoperative patients, so the stage was recorded differently in the two groups
  • The authors stated that the results cannot show a definitive benefit of surgery for all elderly patients

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Overall Survival, Epidemiology, Hazard Ratio, Selection Bias.

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