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



      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.


      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.


      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.


      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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        • Donington J.
        • Ferguson M.
        • Mazzone P.
        • Handy Jr., J.
        • Schuchert M.
        • Fernando h
        • et al.
        American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer.
        Chest. 2012; 142: 1620-1635
        • Bakaeen F.G.
        • Svensson L.G.
        • Mitchell J.D.
        • Keshavjee S.
        • Patterson G.A.
        • Weisel R.D.
        The American Association for Thoracic Surgery/Society of Thoracic Surgeons position statement on developing clinical practice documents.
        J Thorac Cardiovasc Surg. 2017; 153: 999-1005
        • Brunelli A.
        • Kim A.W.
        • Berger K.I.
        • Addrizzo-Harris D.J.
        Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2013; 143: e166S-e190S
        • Ferguson M.K.
        • Gaissert H.A.
        • Grab J.D.
        • Sheng S.
        Pulmonary complications after lung resection in the absence of chronic obstructive pulmonary disease: the predictive role of diffusing capacity.
        J Thorac Cardiovasc Surg. 2009; 138: 1297-1302
        • Ferguson M.K.
        • Vigneswaran W.T.
        Diffusing capacity predicts morbidity after lung resection in patients without obstructive lung disease.
        Ann Thorac Surg. 2008; 85 (discussion: 1164-5): 1158-1164
        • Takeda S.
        • Funakoshi Y.
        • Kadota Y.
        • Koma M.
        • Maeda H.
        • Kawamura S.
        • et al.
        Fall in diffusing capacity associated with induction therapy for lung cancer: a predictor of postoperative complication?.
        Ann Thorac Surg. 2006; 82: 232-236
        • Cerfolio R.J.
        • Talati A.
        • Bryant A.S.
        Changes in pulmonary function tests after neoadjuvant therapy predict postoperative complications.
        Ann Thorac Surg. 2009; 88 (discussion: 935-6): 930-935
        • Leo F.
        • Solli P.
        • Spaggiari L.
        • Veronesi G.
        • de Braud F.
        • Leon M.E.
        • et al.
        Respiratory function changes after chemotherapy: an additional risk for postoperative respiratory complications?.
        Ann Thorac Surg. 2004; 77 (discussion: 265): 260-265
        • Brunelli A.
        • Charloux A.
        • Bolliger C.T.
        • Rocco G.
        • Sculier J.P.
        • Varela G.
        • et al.
        ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy).
        Eur Respir J. 2009; 34: 17-41
        • Ueda K.
        • Murakami J.
        • Tanaka T.
        • Hayashi M.
        • Okabe K.
        • Hamano K.
        Preoperative risk assessment with computed tomography in patients undergoing lung cancer surgery.
        J Thorac Dis. 2018; 10: 4101-4108
        • Kaplan T.
        • Atac G.K.
        • Gunal N.
        • Kocer B.
        • Alhan A.
        • Cubuk S.
        • et al.
        Quantative computerized tomography assessment of lung density as a predictor of postoperative pulmonary morbidity in patients with lung cancer.
        J Thorac Dis. 2015; 7: 1391-1397
        • Edwards J.G.
        • Duthie D.J.
        • Waller D.A.
        Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema.
        Thorax. 2001; 56: 791-795
        • Lafata K.J.
        • Zhou Z.
        • Liu J.G.
        • Hong J.
        • Kelsey C.R.
        • Yin F.F.
        An exploratory radiomics approach to quantifying pulmonary function in CT images.
        Sci Rep. 2019; 9: 11509
        • Brunelli A.
        Risk assessment for pulmonary resection.
        Semin Thorac Cardiovasc Surg. 2010; 22: 2-13
        • Marjanski T.
        • Wnuk D.
        • Bosakowski D.
        • Szmuda T.
        • Sawicka W.
        • Rzyman W.
        Patients who do not reach a distance of 500 m during the 6-min walk test have an increased risk of postoperative complications and prolonged hospital stay after lobectomy.
        Eur J Cardiothorac Surg. 2015; 47: e213-e219
        • Nakagawa T.
        • Tomioka Y.
        • Toyazaki T.
        • Gotoh M.
        Association between values of preoperative 6-min walk test and surgical outcomes in lung cancer patients with decreased predicted postoperative pulmonary function.
        Gen Thorac Cardiovasc Surg. 2018; 66: 220-224
        • Nikolić I.
        • Majerić-Kogler V.
        • Plavec D.
        • Maloca I.
        • Slobodnjak Z.
        Stairs climbing test with pulse oximetry as predictor of early postoperative complications in functionally impaired patients with lung cancer and elective lung surgery: prospective trial of consecutive series of patients.
        Croat Med J. 2008; 49: 50-57
        • Brunelli A.
        • Refai M.
        • Xiume F.
        • Salati M.
        • Sciarra V.
        • Socci L.
        • et al.
        Performance at symptom-limited stair-climbing test is associated with increased cardiopulmonary complications, mortality, and costs after major lung resection.
        Ann Thorac Surg. 2008; 86 (discussion: 247-8): 240-247
        • Rodrigues F.
        • Grafino M.
        • Faria I.
        • Pontes da Mata J.
        • Papoila A.L.
        • Félix F.
        Surgical risk evaluation of lung cancer in COPD patients - a cohort observational study.
        Rev Port Pneumol (2006). 2016; 22: 266-272
        • Sova M.
        • Genzor S.
        • Ghazal Asswad A.
        • Kolek V.
        Chronotropic incompetence could negatively influence post-operative risk assessment in patients before lung cancer surgery.
        J Thorac Dis. 2020; 12: 2595-2601
        • Makey I.
        • Berger R.L.
        • Cabral H.J.
        • Celli B.
        • Folch E.
        • Whyte R.I.
        Maximal oxygen uptake–risk predictor of NSCLC resection in patients with comorbid emphysema: lessons from NETT.
        Semin Thorac Cardiovasc Surg. 2015; 27: 225-231
        • Brunelli A.
        • Belardinelli R.
        • Pompili C.
        • Xiume F.
        • Refai M.
        • Salati M.
        • et al.
        Minute ventilation-to-carbon dioxide output (VE/VCO2) slope is the strongest predictor of respiratory complications and death after pulmonary resection.
        Ann Thorac Surg. 2012; 93: 1802-1806
        • Fleisher L.A.
        • Fleischmann K.E.
        • Auerbach A.D.
        • Barnason S.A.
        • Beckman J.A.
        • Bozkurt B.
        • et al.
        2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association task force on practice guidelines.
        J Am Coll Cardiol. 2014; 64: e77-e137
        • Brunelli A.
        • Varela G.
        • Salati M.
        • Jimenez M.F.
        • Pompili C.
        • Novoa N.
        • et al.
        Recalibration of the revised cardiac risk index in lung resection candidates.
        Ann Thorac Surg. 2010; 90: 199-203
        • Thomas D.C.
        • Blasberg J.D.
        • Arnold B.N.
        • Rosen J.E.
        • Salazar M.C.
        • Detterbeck F.C.
        • et al.
        Validating the thoracic revised cardiac risk index following lung resection.
        Ann Thorac Surg. 2017; 104: 389-394
        • Ferguson M.K.
        • Saha-Chaudhuri P.
        • Mitchell J.D.
        • Varela G.
        • Brunelli A.
        Prediction of major cardiovascular events after lung resection using a modified scoring system.
        Ann Thorac Surg. 2014; 97: 1135-1140
        • Fleisher L.A.
        • Beckman J.A.
        • Brown K.A.
        • Calkins H.
        • Chaikof E.
        • Fleischmann K.E.
        • et al.
        ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (writing committee to revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.
        Circulation. 2007; 116: e418-e499
        • Sekine Y.
        • Yamada Y.
        • Chiyo M.
        • Iwata T.
        • Nakajima T.
        • Yasufuku K.
        • et al.
        Association of chronic obstructive pulmonary disease and tumor recurrence in patients with stage IA lung cancer after complete resection.
        Ann Thorac Surg. 2007; 84: 946-950
        • Hu X.L.
        • Xu S.T.
        • Wang X.C.
        • Luo J.L.
        • Hou D.N.
        • Zhang X.M.
        • et al.
        Development and validation of nomogram estimating post-surgery hospital stay of lung cancer patients: relevance for predictive, preventive, and personalized healthcare strategies.
        EPMA J. 2019; 10: 173-183
        • Wei S.
        • Chen F.
        • Liu R.
        • Fu D.
        • Wang Y.
        • Zhang B.
        • et al.
        Outcomes of lobectomy on pulmonary function for early stage non-small cell lung cancer (NSCLC) patients with chronic obstructive pulmonary disease (COPD).
        Thorac Cancer. 2020; 11: 1784-1789
        • Henderson M.
        • McGarry R.
        • Yiannoutsos C.
        • Fakiris A.
        • Hoopes D.
        • Williams M.
        • et al.
        Baseline pulmonary function as a predictor for survival and decline in pulmonary function over time in patients undergoing stereotactic body radiotherapy for the treatment of stage I non-small-cell lung cancer.
        Int J Radiat Oncol Biol Phys. 2008; 72: 404-409
        • Sato T.
        • Kondo H.
        • Watanabe A.
        • Nakajima J.
        • Niwa H.
        • Horio H.
        • et al.
        A simple risk scoring system for predicting acute exacerbation of interstitial pneumonia after pulmonary resection in lung cancer patients.
        Gen Thorac Cardiovasc Surg. 2015; 63: 164-172
        • Kaw R.
        • Pasupuleti V.
        • Deshpande A.
        • Hamieh T.
        • Walker E.
        • Minai O.A.
        Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery.
        Respir Med. 2011; 105: 619-624
        • Ramakrishna G.
        • Sprung J.
        • Ravi B.S.
        • Chandrasekaran K.
        • McGoon M.D.
        Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality.
        J Am Coll Cardiol. 2005; 45: 1691-1699
        • Wei B.
        • D’Amico T.
        • Samad Z.
        • Hasan R.
        • Berry M.F.
        The impact of pulmonary hypertension on morbidity and mortality following major lung resection.
        Eur J Cardiothorac Surg. 2014; 45: 1028-1033
        • Shen Y.
        • Wan C.
        • Tian P.
        • Wu Y.
        • Li X.
        • Yang T.
        • et al.
        CT-base pulmonary artery measurement in the detection of pulmonary hypertension: a meta-analysis and systematic review.
        Medicine (Baltimore). 2014; 93: e256
        • Asakura K.
        • Mitsuboshi S.
        • Tsuji M.
        • Sakamaki H.
        • Otake S.
        • Matsuda S.
        • et al.
        Pulmonary arterial enlargement predicts cardiopulmonary complications after pulmonary resection for lung cancer: a retrospective cohort study.
        J Cardiothorac Surg. 2015; 10: 113
        • Kneuertz P.J.
        • Yudovich M.S.
        • Amadi C.C.
        • Bashian E.
        • D’Souza D.M.
        • Abdel-Rasoul M.
        • et al.
        Pulmonary artery size on computed tomography is associated with major morbidity after pulmonary lobectomy.
        J Thorac Cardiovasc Surg. February 5, 2021; ([Epub ahead of print])
        • Clark J.M.
        • Kozower B.D.
        • Kosinski A.S.
        • Chang A.
        • Broderick S.R.
        • David E.A.
        • et al.
        Variability in smoking status for lobectomy among Society of Thoracic Surgeons database participants.
        Ann Thorac Surg. 2021; 111: 1842-1848
        • Yoshida Y.
        • Kage H.
        • Murakawa T.
        • Sato Y.
        • Ota S.
        • Fukayama M.
        • et al.
        Worse prognosis for stage IA lung cancer patients with smoking history and more severe chronic obstructive pulmonary disease.
        Ann Thorac Cardiovasc Surg. 2015; 21: 194-200
        • Husain Z.A.
        • Kim A.W.
        • Yu J.B.
        • Decker R.H.
        • Corso C.D.
        Defining the high-risk population for mortality after resection of early stage NSCLC.
        Clin Lung Cancer. 2015; 16: e183-e187
        • Kawaguchi Y.
        • Hanaoka J.
        • Ohshio Y.
        • Igarashi T.
        • Kataoka Y.
        • Okamoto K.
        • et al.
        A risk score to predict postoperative complications after lobectomy in elderly lung cancer patients.
        Gen Thorac Cardiovasc Surg. 2018; 66: 537-542
        • Mery C.M.
        • Pappas A.N.
        • Bueno R.
        • Colson Y.L.
        • Linden P.
        • Sugarbaker D.J.
        • et al.
        Similar long-term survival of elderly patients with non-small cell lung cancer treated with lobectomy or wedge resection within the Surveillance, Epidemiology, and End Results database.
        Chest. 2005; 128: 237-245
        • Sandri A.
        • Papagiannopoulos K.
        • Milton R.
        • Chaudhuri N.
        • Kefaloyannis E.
        • Pompili C.
        • et al.
        High-risk patients and postoperative complications following video-assisted thoracic surgery lobectomy: a case-matched comparison with lower-risk counterparts.
        Interact Cardiovasc Thorac Surg. 2015; 21: 761-765
        • Puri V.
        • Crabtree T.D.
        • Bell J.M.
        • Kreisel D.
        • Krupnick A.S.
        • Broderick S.
        • et al.
        National cooperative group trials of “high-risk” patients with lung cancer: are they truly “high-risk”?.
        Ann Thorac Surg. 2014; 97 (discussion: 1683-5): 1678-1683
        • Zhang R.
        • Ferguson M.K.
        Video-assisted versus open lobectomy in patients with compromised lung function: a literature review and meta-analysis.
        PLoS One. 2015; 10: e0124512
        • Okami J.
        • Higashiyama M.
        • Asamura H.
        • Goya T.
        • Koshiishi Y.
        • Sohara Y.
        • et al.
        Pulmonary resection in patients aged 80 years or over with clinical stage I non-small cell lung cancer: prognostic factors for overall survival and risk factors for postoperative complications.
        J Thorac Oncol. 2009; 4: 1247-1253
        • Kosacka M.
        • Jankowska R.
        The epidemiology of lung cancer [in Polish].
        Pneumonol Alergol Pol. 2007; 75: 76-80
        • Birim O.
        • Kappetein A.P.
        • Bogers A.J.
        Charlson comorbidity index as a predictor of long-term outcome after surgery for nonsmall cell lung cancer.
        Eur J Cardiothorac Surg. 2005; 28: 759-762
        • Lüchtenborg M.
        • Jakobsen E.
        • Krasnik M.
        • Linklater K.M.
        • Mellemgaard A.
        • Møller H.
        The effect of comorbidity on stage-specific survival in resected non-small cell lung cancer patients.
        Eur J Cancer. 2012; 48: 3386-3395
        • Lembicz M.
        • Gabryel P.
        • Brajer-Luftmann B.
        • Dyszkiewicz W.
        • Batura-Gabryel H.
        Comorbidities with non-small cell lung cancer: is there an interdisciplinary consensus needed to qualify patients for surgical treatment?.
        Ann Thorac Med. 2018; 13: 101-107
        • Kaneda H.
        • Nakano T.
        • Murakawa T.
        The predictive value of preoperative risk assessments and frailty for surgical complications in lung cancer patients.
        Surg Today. 2021; 51: 86-93
        • Wan M.A.
        • Clark J.M.
        • Nuno M.
        • Cooke D.T.
        • Brown L.M.
        Can the risk analysis index for frailty predict morbidity and mortality in patients undergoing high-risk surgery?.
        Ann Surg. November 17, 2020; ([Epub ahead of print])
        • Hirpara D.H.
        • Kidane B.
        • Rogalla P.
        • Cypel M.
        • de Perrot M.
        • Keshavjee S.
        • et al.
        Frailty assessment prior to thoracic surgery for lung or esophageal cancer: a feasibility study.
        Support Care Cancer. 2019; 27: 1535-1540
        • Dewan K.C.
        • Navale S.M.
        • Hirji S.A.
        • Koroukian S.M.
        • Dewan K.S.
        • Svensson L.G.
        • et al.
        The role of frailty in failure to rescue after cardiovascular surgery.
        Ann Thorac Surg. 2021; 111: 472-478
        • Shoji F.
        • Haratake N.
        • Akamine T.
        • Takamori S.
        • Katsura M.
        • Takada K.
        • et al.
        The preoperative controlling nutritional status score predicts survival after curative surgery in patients with pathological stage I non-small cell lung cancer.
        Anticancer Res. 2017; 37: 741-747
        • Busch E.
        • Verazin G.
        • Antkowiak J.G.
        • Driscoll D.
        • Takita H.
        Pulmonary complications in patients undergoing thoracotomy for lung carcinoma.
        Chest. 1994; 105: 760-766
        • Fiorelli A.
        • Vicidomini G.
        • Mazzella A.
        • Messina G.
        • Milione R.
        • Di Crescenzo V.G.
        • et al.
        The influence of body mass index and weight loss on outcome of elderly patients undergoing lung cancer resection.
        Thorac Cardiovasc Surg. 2014; 62: 578-587
        • Zhang X.
        • Liu Y.
        • Shao H.
        • Zheng X.
        Obesity paradox in lung cancer prognosis: evolving biological insights and clinical implications.
        J Thorac Oncol. 2017; 12: 1478-1488
        • Tulinsky L.
        • Mittak M.
        • Tomaskova H.
        • Ostruszka P.
        • Penka I.
        • Ihnat P.
        Obesity paradox in patients undergoing lung lobectomy - myth or reality?.
        BMC Surg. 2018; 18: 61
        • Paul S.
        • Andrews W.
        • Osakwe N.C.
        • Port J.L.
        • Lee P.C.
        • Stiles B.M.
        • et al.
        Perioperative outcomes after lung resection in obese patients.
        Thorac Cardiovasc Surg. 2015; 63: 544-550
        • Li S.
        • Wang Z.
        • Huang J.
        • Fan J.
        • Du H.
        • Liu L.
        • et al.
        Systematic review of prognostic roles of body mass index for patients undergoing lung cancer surgery: does the ‘obesity paradox’ really exist?.
        Eur J Cardiothorac Surg. 2017; 51: 817-828
        • Kawaguchi Y.
        • Hanaoka J.
        • Ohshio Y.
        • Okamoto K.
        • Kaku R.
        • Hayashi K.
        • et al.
        Sarcopenia predicts poor postoperative outcome in elderly patients with lung cancer.
        Gen Thorac Cardiovasc Surg. 2019; 67: 949-954
        • Kim E.Y.
        • Lee H.Y.
        • Kim K.W.
        • Lee J.I.
        • Kim Y.S.
        • Choi W.J.
        • et al.
        Preoperative computed tomography-determined sarcopenia and postoperative outcome after surgery for non-small cell lung cancer.
        Scand J Surg. 2018; 107: 244-251
        • Miller J.A.
        • Harris K.
        • Roche C.
        • Dhillon S.
        • Battoo A.
        • Demmy T.
        • et al.
        Sarcopenia is a predictor of outcomes after lobectomy.
        J Thorac Dis. 2018; 10: 432-440
        • Miura A.
        • Yamamoto H.
        • Sato H.
        • Tomioka Y.
        • Shiotani T.
        • Suzawa K.
        • et al.
        The prognostic impact of sarcopenia on elderly patients undergoing pulmonary resection for non-small cell lung cancer.
        Surg Today. 2021; 51: 1203-1211
        • Shinohara S.
        • Otsuki R.
        • Kobayashi K.
        • Sugaya M.
        • Matsuo M.
        • Nakagawa M.
        Impact of sarcopenia on surgical outcomes in non-small cell lung cancer.
        Ann Surg Oncol. 2020; 27: 2427-2435
        • Nishimura J.M.
        • Ansari A.Z.
        • D'Souza D.M.
        • Moffatt-Bruce S.D.
        • Merritt R.E.
        • Kneuertz P.J.
        Computed tomography-assessed skeletal muscle mass as a predictor of outcomes in lung cancer surgery.
        Ann Thorac Surg. 2019; 108: 1555-1564
        • Fukuse T.
        • Satoda N.
        • Hijiya K.
        • Fujinaga T.
        Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients.
        Chest. 2005; 127: 886-891
        • Fernando H.C.
        • Landreneau R.J.
        • Mandrekar S.J.
        • Nichols F.C.
        • DiPetrillo T.A.
        • Meyers B.F.
        • et al.
        Analysis of longitudinal quality-of-life data in high-risk operable patients with lung cancer: results from the ACOSOG Z4032 (Alliance) multicenter randomized trial.
        J Thorac Cardiovasc Surg. 2015; 149 (discussion: 725-6): 718-725
        • Samson P.
        • Robinson C.G.
        • Bradley J.
        • Lee A.
        • Broderick S.
        • Kreisel D.
        • et al.
        The national surgical quality improvement program risk calculator does not adequately stratify risk for patients with clinical stage I non-small cell lung cancer.
        J Thorac Cardiovasc Surg. 2016; 151: 697-705.e1
        • Saji H.
        • Ueno T.
        • Nakamura H.
        • Okumura N.
        • Tsuchida M.
        • Sonobe M.
        • et al.
        A proposal for a comprehensive risk scoring system for predicting postoperative complications in octogenarian patients with medically operable lung cancer: JACS1303.
        Eur J Cardiothorac Surg. 2018; 53: 835-841
        • Ferguson M.K.
        • Huisingh-Scheetz M.
        • Thompson K.
        • Wroblewski K.
        • Farnan J.
        • Acevedo J.
        The influence of physician and patient gender on risk assessment for lung cancer resection.
        Ann Thorac Surg. 2017; 104: 284-289
        • Sullivan D.R.
        • Eden K.B.
        • Dieckmann N.F.
        • Golden S.E.
        • Vranas K.C.
        • Nugent S.M.
        • et al.
        Understanding patients' values and preferences regarding early stage lung cancer treatment decision making.
        Lung Cancer. 2019; 131: 47-57
        • Samson P.
        • Waters E.A.
        • Meyers B.
        • Politi M.C.
        Shared decision making and effective risk communication in the high-risk patient with operable stage I non-small cell lung cancer.
        Ann Thorac Surg. 2016; 101: 2049-2052
        • Choong C.K.
        • Meyers B.F.
        • Battafarano R.J.
        • Guthrie T.J.
        • Davis G.E.
        • Patterson G.A.
        • et al.
        Lung cancer resection combined with lung volume reduction in patients with severe emphysema.
        J Thorac Cardiovasc Surg. 2004; 127: 1323-1331
        • Poonyagariyagorn H.
        • Mazzone P.J.
        Lung cancer: preoperative pulmonary evaluation of the lung resection candidate.
        Semin Respir Crit Care Med. 2008; 29: 271-284
        • Templeton R.
        • Greenhalgh D.
        Preoperative rehabilitation for thoracic surgery.
        Curr Opin Anaesthesiol. 2019; 32: 23-28
        • Brocki B.C.
        • Andreasen J.J.
        • Langer D.
        • Souza D.S.
        • Westerdahl E.
        Postoperative inspiratory muscle training in addition to breathing exercises and early mobilization improves oxygenation in high-risk patients after lung cancer surgery: a randomized controlled trial.
        Eur J Cardiothorac Surg. 2016; 49: 1483-1491
        • Carli F.
        • Ferreira V.
        Prehabilitation: a new area of integration between geriatricians, anesthesiologists, and exercise therapists.
        Aging Clin Exp Res. 2018; 30: 241-244
        • Wilson H.
        • Gammon D.
        • Routledge T.
        • Harrison-Phipps K.
        Clinical and quality of life outcomes following anatomical lung resection for lung cancer in high-risk patients.
        Ann Thorac Med. 2017; 12: 83-87