Surgery Versus Radiation for Stage 1A NSCLC in Nonagenarians: 20 Years of Data, Decisions, and Outcomes

BACKGROUND AND PURPOSE: The optimal treatment strategy for non-small-cell lung cancer (NSCLC) in patients aged > 90 years is unclear. This study evaluates overall survival and treatment-specific outcomes in nonagenarians with stage 1A NSCLC. METHODS: We retrospectively analyzed 2785 nonagenarians with stage 1A NSCLC from 2004 to 2024 using the National Cancer Database. Propensity score matching was performed using stage, tumor site, tumor characteristics, demographics, facility type and Charlson-Deyo comorbidity score. Overall survival was compared using Kaplan-Meier analysis. RESULTS: Of 2785 patients, 707 (25%) received no treatment, 269 (13%) underwent surgery, and 1717 (83%) received radiation only. Patients undergoing surgery had the highest overall survival rate: 86.9% vs 82.8% vs 61.8% at 1 year (p < 0.05) and 38.3% vs 23.2% vs 12.0% at 5 years for surgery, radiation, and no treatment, respectively (p < 0.05). After propensity score matching, surgery remained associated with improved overall survival, with 3-year survival of 64.6% vs 44.0% (p < 0.05) and 5-year survival of 37.8% vs 20.7% for surgery and radiation, respectively (p < 0.05). Within the surgery group, 30- and 90-day mortality rates were 6% and 9%, respectively, the unplanned readmission rate was 6%, and the median hospital stay was 4 days. These rates were consistent across different Charlson-Deyo comorbidity score groups, and survival outcomes in the surgery cohort were not influenced by the facility type (p = 0.20). CONCLUSION: Surgical resection was associated with improved observed overall survival compared with radiation therapy among carefully selected patients, suggesting that chronological age alone should not preclude consideration of surgical evaluation.