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Eur J Cardiothorac Surg 2005;28:182
© 2005 Elsevier Science NL
Letter to the Editor |
Unit of Thoracic Surgery, "Umberto I°" Regional Hospital, Ancona, Italy
Received 25 February 2005; accepted 4 April 2005.
* Address: Via S. Margherita 23, Ancona 60129, Italy. Tel.: +39 071 5964439; fax: +39 071 5964433. (Email: alexit_2000{at}yahoo.com).
Key Words: Elderly • Lung resection • Gender • Mortality
I read with interest the article of Rostad et al. [1]. The authors collected all elderly patients resected for lung cancer in Norway from 1993 to 2000, and reported a 30-day mortality rate of 9%. Moreover, they found a higher mortality rate after pneumonectomy (20%) and in men undergoing bilobectomy and pneumonectomy compared to women (25 vs. 7.5%).
At our Institution, 402 patients older than 70 years of age were operated on for lung cancer from 1994 to 2004 (39 sub-lobar resections, 280 lobectomy, 38 bilobectomy, 45 pneumonectomy). Thirty-day or in-hospital mortality rate was 6.2% (25 cases). We also observed a higher mortality rate after pneumonectomy compared to other procedures (22% in pneumonectomy vs. 4.4% in lobectomy or bilobectomy, vs. 2.5% in sub-lobar resections, respectively; P<0.0001).
Similarly to Rostad et al. [1], we found a higher cumulative mortality rate in men compared to women (7.4 vs. 0, respectively, Fisher's exact test P=0.02).
Rostad et al. explained this finding primarily for a higher proportion of pneumonectomies among the male patients with respect to females. This was also the case in our series whereby only 4 women had pneumonectomy compared to 41 men. However, elderly men patients had also a higher incidence of co-morbidities, which may have contributed to increase the risk of postoperative early mortality in this gender category. In particular, compared to women, the men had lower FEV1 (83 vs. 99%, P<0.0001), lower FEV1/FVC ratio (0.67 vs. 0.74, P<0.0001), lower carbon monoxide lung diffusion capacity (72 vs. 79%, P=0.06), lower arterial oxygen tension (78.7 vs. 83.7, P=0.003), a more pronounced smoking history (pack-years index: 48 vs. 10, P<0.0001), a higher proportion of concomitant peripheral vascular (12 vs. 3%, P=0.005), cerebrovascular (7.4 vs.1.6%, P=0.09) and cardiac ischaemic diseases (14.7 vs. 4.7%, P=0.04). Of the 25 deaths observed in our series, 12 were pulmonary in origin, 5 due to cardiac complications, 3 caused by stroke and 5 occurred as a consequence of bronchopleural fistula.
Although the authors should be commended for achieving the difficult objective to collect and carefully analyse a sizable nation-wide multi-institutional sample of elderly patients, their findings emphasise, in my opinion, the need to develop risk-adjusting models or balancing scores to analyse the outcomes for clinical purposes or quality-of-care monitoring.
The difference in raw mortality rates between genders, such as the one reported in the paper of Rostad et al. [1], should be interpreted with caution, since it may vary according to different selection criteria and populations. Unadjusted outcome measures may be deceiving and lead to inappropriate clinical and administrative conclusions.
References
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  H. Rostad, T.-E. Strand, and J. Norstein Reply to Brunelli Eur. J. Cardiothorac. Surg., July 1, 2005; 28(1): 182 - 183. [Full Text] [PDF]
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