Lung cancer resection in high-risk patients: a narrative review

"Background and Objective: The National Lung Cancer Audit (NLCA) 2022 report showed that for England in 2019, the curative treatment rates of non-small cell lung cancer (NSCLC) patients with stage I/II disease and good performance status were 81%, this metric fell to 73% in 2020 with resection rates falling from 20% to 15%. The impact of COVID-19 could well have influenced this and indeed lung cancer patients diagnosed in 2020 were more likely to have a worse performance status, diagnosed as emergency presentations and less likely to have a pathological diagnosis. Assessing risk in the current era and defining which patients are high-risk needs formal exploration and definition if we are to improve resection rates in a safe and equitable manner. Methods: We conducted a narrative literature review to explore the paradigm of risk in thoracic surgery and in particular address the concept of what is considered to be ""high risk""for surgery. We searched MEDLINE, EMBASE and Cochrane Library databases using the OVID interface. We reviewed articles between January 1, 2000, and December 31, 2021 and restricted this to full text papers only in the English language. Conference s were not considered. Key Content and Findings: A delineation must be made between the assessment of risk for an individual patient (usually peri-operative complication and death) and the assessment of risk for an entire cohort, i.e., determining safety, efficacy, and feasibility of an intervention for a particular group. Both components are necessary when communicating risk. There is no fixed model of the high-risk patient, but instead an individualised risk profile which should serve to employ pre-operative optimisation strategies, pulmonary rehabilitation, smoking cessation programmes, exercise rehabilitation and post-operative rehabilitation. Conclusions: By understanding risk and benchmarking patients appropriately and in a uniform way, one can be more objective and scientific in assessing suitability for resection. This is but one pillar of a multifaceted approach to help inform patients and healthcare providers in a constructive way and increase surgical rates in an appropriate and safe way. © Shanghai Chest. All rights reserved."