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Thoracic: Lung Cancer: 2021 AATS Expert Consensus Document: Definition and Assessment of High Risk in Patients Considered for Lobectomy for Stage I Non–Small Cell Lung Cancer| Volume 162, ISSUE 6, P1605-1618.e6, December 01, 2021

Definition and assessment of high risk in patients considered for lobectomy for stage I non–small cell lung cancer: The American Association for Thoracic Surgery expert panel consensus document

      Abstract

      Objective

      Lobectomy is a standard treatment for stage I non–small cell lung cancer, but a significant proportion of patients are considered at high risk for complications, including mortality, after lobectomy and might not be candidates. Identifying who is at risk is important and in evolution. The objective of The American Association for Thoracic Surgery Clinical Practice Standards Committee expert panel was to review important considerations and factors in assessing who is at high risk among patients considered for lobectomy.

      Methods

      The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an expert panel that developed an expert consensus document after systematic review of the literature. The expert panel generated a priori a list of important risk factors in the determination of high risk for lobectomy. A survey was administered, and the expert panel was asked to grade the relative importance of each risk factor. Recommendations were developed using discussion and a modified Delphi method.

      Results

      The expert panel survey identified the most important factors in the determination of high risk, which included the need for supplemental oxygen because of severe underlying lung disease, low diffusion capacity, the presence of frailty, and the overall assessment of daily activity and functional status. The panel determined that factors, such as age (as a sole factor), were less important in risk assessment.

      Conclusions

      Defining who is at high risk for lobectomy for stage I non–small cell lung cancer is challenging, but remains critical. There was impressive strong consensus on identification of important factors and their hierarchical ranking of perceived risk. The panel identified several key factors that can be incorporated in risk assessment. The factors are evolving and as the population ages, factors such as neurocognitive function and frailty become more important. A minimally invasive approach becomes even more critical in this older population to mitigate risk. The determination of risk is a clinical decision and judgement, which should also take into consideration patient perspectives, values, preferences, and quality of life.

      Key Words

      Abbreviations and Acronyms:

      AATS (The American Association for Thoracic Surgery), ACCP (American College of Chest Physicians), ADL (activities of daily living), BMI (body mass index), CGA (comprehensive geriatric assessment), CONUT (Controlling Nutritional Status), COPD (chronic obstructive pulmonary disease), CPET (cardiopulmonary exercise testing), CPSC (Clinical Practice Standards Committee), DLCO (diffusion capacity of the lung for carbon monoxide), ESLD (end-stage liver disease), ESTS (European Society of Thoracic Surgeons), FEV1 (forced expiratory volume in 1 second), FTR (failure to rescue), FVC (forced vital capacity), HRCT (high-resolution chest computed tomography), MMSE (Mini-Mental State Examination), NETT (National Emphysema Treatment Trial), NSCLC (non–small cell lung cancer), PH (pulmonary hypertension), ppo (predicted postoperative), QOL (quality of life), SABR (stereotactic ablative radiotherapy), SBRT (stereotactic body radiation therapy), SpO2 (oxygen saturation measured using pulse oximetry), SRS (stereotactic radiosurgery), ThRCRI (Thoracic Revised Cardiac Risk Index), VATS (video-assisted thoracoscopic surgery), VE/VCO2 (ventilation-to-carbon dioxide output), VO2 max (maximum volume of oxygen consumed)
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