Age Should Not Limit Aggressive Mesothelioma Surgery

Age should not be a deterrent to aggressive, potentially curative surgery for malignant pleural mesothelioma.

Renowned thoracic surgeon Dr. Wickii Vigneswaran in Chicago believes too many patients with mesothelioma today are being misguided into bypassing major surgery because of their age.

Vigneswaran, a surgeon for more than 25 years, wants to dispel the lingering myth that many patients are too old to benefit from a therapeutic option that could improve their quality of life and extend survival.

"There has always been this tendency to say 'He's a little too old for surgery.' But the decision [to have surgery] today should not be age-based," Vigneswaran told Asbestos.com. "If you are fit enough, regardless of age, you can benefit. The risks are no different than with a younger person."

Vigneswaran speaks from his own surgical experience. He and his colleagues at the University of Chicago Medical Center recently published a study in the Annals of Thoracic Surgery that followed more than 100 consecutive patients who underwent pleurectomy/decortication (P/D) surgery for mesothelioma.

After reviewing these cases, Vigneswaran's team concluded that when it comes to P/D surgery, advanced age doesn't necessarily translate to higher mortality rates or shorter long-term survival.

Comparing Patient Outcomes by Age

The study followed 117 people who underwent P/D surgery at the University of Chicago Medical Center from 2008 to 2013. Researchers compared the results of patients 70 and older with those of younger patients. Vigneswaran performed surgery on all patients involved.

"The findings of the study were very interesting. We've been able to show for the first time that older patients do just as well as younger ones," he said. "It's a different ball game today. You should not use age as a cutoff. If you're getting around and [being] functional, your age shouldn't matter. Surgery can improve your quality of life at any age."

Only four patients died, two from each age group. Three patients in the older group experienced major complications, compared to seven patients in the younger group.

Vigneswaran's team also predicted the patients' long-term survival. One year out from surgery, the researchers expected 64 percent of older patients would still be alive. They predicted only 55 percent of younger patients would survive one year.

Projected long-term survival outcomes after three years were similar between groups, but researchers determined the younger patients would perform slightly better. After five years, however, the team predicted 20 percent of younger patients would survive, compared to 13 percent of older patients.

Older patients came into surgery with more hypertension and more coronary artery disease, but those factors played no role in postsurgery recovery. The average hospital stay after the procedure was six days for both groups.

Older Patients Sometimes Fare Better

Pleurectomy/decortication surgery removes the entire pleural membrane surrounding the lung, the lining around the heart, much of the diaphragm and any visible tumor growth in the chest cavity. Only an extrapleural pneumonectomy (EPP), which removes an entire lung, is more aggressive.

"This is a big operation — six to seven hours — but with advances in surgery and postoperative care at a specialty center like ours, we can do it safely," Vigneswaran said. "And in some cases, the older patients can do better."

In the study, median survival was slightly higher among older patients, who survived 15.6 months compared to 14 months in the younger group.

"By definition, people used to say over [age] 60 was elderly. But not anymore. A 60-year-old will look like he's in his 40s now. I see people in their 80s, and even 90s, and they still look pretty active," he said. "Age is only a number."

Several factors contribute to the decision on whether a patient is a good candidate for surgery. Among those factors is the extent of cancer, the extent of lymph node involvement and overall performance status after a battery of tests.

Age Doesn't Make a Difference

The issue of age is particularly relevant to mesothelioma because it most often strikes early in retirement after years of occupational exposure to asbestos. An estimated 80 percent of people in the U.S. who have died from mesothelioma in the last 15 years were older than 65.

"I'm convinced more than ever that age just doesn't make a difference, but it raises the importance of finding a specialty center that does a lot of these operations," Vigneswaran said. "I've heard of too many places where there is a reluctance [to perform surgery] because of age. It's important for people to know this can be done safely at all ages."