Surgical strategy and prognostic factors in very elderly (≥ 75 Years) patients with stage I NSCLC: insights from a propensity score–matched analysis

The optimal surgical strategy for very elderly patients (≥ 75 years) with stage I non–small cell lung cancer (NSCLC) remains uncertain. We retrospectively analyzed 390 patients with pathologic stage I NSCLC (≤ 4 cm, N0) who underwent curative resection at two university-affiliated hospitals. Fifty-one patients were aged ≥ 75 years and 339 were < 75 years. Recurrence-free survival (RFS) was the primary endpoint, and overall survival (OS) was secondary. Propensity-score matching (PSM) balanced baseline factors, and multivariable Cox regression identified independent predictors of recurrence. Older patients had significantly worse outcomes than younger ones (5-year RFS 65% vs. 82%, p < 0.001; OS 69% vs. 92%, p < 0.001). After PSM, age ≥ 75 remained an independent predictor of recurrence (HR 2.40, p = 0.015) and overall survival (HR 4.40, p < 0.001). In the very elderly subgroup, lobectomy provided superior recurrence control compared with sublobar resection (5-year RFS 76.6% vs. 50.8%; HR 3.57, p = 0.046). Tumor size > 2 cm also predicted poorer RFS (HR 3.41, p = 0.026). High-risk pathological features (poor differentiation, lymphovascular invasion (LVI), spread through air spaces (STAS) were predictive in the overall cohort but less so in the very elderly. Adjuvant chemotherapy had no significant effect on RFS. In very elderly patients with stage I NSCLC, tumor size and surgical extent were the main predictors of recurrence. Lobectomy achieved superior recurrence-free survival, underscoring the importance of optimal oncologic clearance during initial surgery when adjuvant therapy is rarely feasible.