Browse the corpus

With the acceleration of population aging, the number of older patients with lung cancer in China continues to rise. These patients often present with multiple chronic conditions and geriatric syndromes, which complicate perioperative management and significantly increase surgical risks []. Optimizing perioperative management strategies to effectively reduce postoperative complications and improve patients’ quality of life has become a critical issue requiring urgent attention in both geriatric medicine and thoracic surgery. Geriatric syndromes, such as frailty and malnutrition, are prevalent among older patients with lung cancer and are associated with increased risk of complications, prolonged hospital stays, delayed functional recovery, and poorer overall prognosis []. In addition, older patients frequently have comorbidities such as cardiovascular disease, further increasing the risk of perioperative mortality and complications [, ]. Postoperative complications, including infection, respiratory failure, cardiac dysfunction, and delirium, are more common in older patients. Therefore, early identification of complication risks and implementation of targeted interventions are crucial for improving postoperative recovery outcomes and shortening hospital stays []. This guideline provides specific recommendations on the screening and intervention for geriatric syndromes, management of comorbidities, and prevention and treatment of complications. Through standardized and comprehensive management approaches, it aims to improve both survival and quality of life, thereby providing more scientific and high‐quality medical care to older patients with lung cancer [].

This guideline was jointly developed by 94 multidisciplinary experts from 26 institutions, organized by West China Hospital of Sichuan University. The guideline was registered on the International Practice Guideline Registration for Transparency (PREPARE‐2025CN579), and its protocol has been published in the Chinese Journal of Evidence‐Based Medicine [].

Five working groups were established, including the Steering Committee, the Secretariat Group, the Evidence Evaluation Group, the Consensus Expert Group, and the External Review Expert Group (). The Steering Committee consisted of three experts in geriatrics, lung cancer, and evidence‐based medicine, responsible for defining working group roles and the scope of the guideline, reviewing conflicts of interest, validating clinical questions and evidence quality, organizing consensus meetings, overseeing the process, and approving final recommendations as well as their dissemination and updates. The Secretariat Group consisted of three researchers in geriatrics and guideline methodology, primarily responsible for guideline registration and protocol development, collecting clinical questions and outcome measures, organizing and documenting all process files, and coordinating related meetings. The Evidence Evaluation Group consisted of 42 multidisciplinary experts from geriatrics, thoracic surgery, pulmonology, anesthesiology, rehabilitation medicine, clinical nutrition, and the evidence‐based medicine center and is responsible for population, intervention, comparison, and outcome (PICO) deconstruction of clinical questions, literature search and screening, evidence quality assessment, Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence grading, drafting evidence summary tables, preliminary formulation of recommendations, and writing the first draft of the guideline. The Consensus Expert Group consisted of 41 multidisciplinary experts from geriatrics, pulmonology, anesthesiology, rehabilitation medicine, clinical nutrition, and the evidence‐based medicine center, responsible for the Delphi consultation on clinical questions and outcome measures, guiding evidence evaluation and grading, reaching consensus on recommendations, and overseeing the revision and improvement of the guideline. The External Review Expert Group consisted of eight peer experts who did not participate in the guideline development process and are responsible for reviewing the guideline recommendations as well as the clarity, feasibility, and endorsement of the guideline.

The target population of this guideline is perioperative elderly patients with lung cancer. This guideline is intended for professionals in geriatrics, thoracic surgery, general practice, oncology, anesthesiology, nutrition, and rehabilitation in China.

A systematic search was conducted for existing domestic and international guidelines, systematic reviews, and key original research in areas related to geriatric syndromes, comorbidity status, and complication management in older patients with lung cancer, based on the PICO. In combination with common issues encountered in clinical practice, 29 preliminary clinical questions were proposed. Using a modified Delphi method and scoring by 87 experts and 11 lung cancer patients, 28 clinical questions were ultimately selected.

We systematically searched Embase, PubMed, The Cochrane Library, and MEDLINE via OVID, as well as Chinese databases such as CNKI, WanFang Data, and China Biomedical Literature Database (CBM) from inception to August 25, 2025. Additional searches were performed in major guideline repositories, including the National Guideline Clearinghouse (NGC), the Scottish Intercollegiate Guideline Network (SIGN), and the Guidelines International Network (GIN). For each clinical question, two reviewers developed search strategies using controlled vocabulary and free‐text terms. The key search concepts and representative search terms are provided in Table . Eligible evidence included randomized controlled trials (RCTs), cohort studies, case–control studies, systematic reviews, and clinical practice guidelines involving patients aged ≥60 years undergoing lung cancer surgery. Outcomes of interest covered geriatric syndromes, comorbidities, perioperative complications, functional status, symptom burden, rehabilitation, safety, and healthcare utilization. Outcome domains and representative indicators are shown in Table . Study screening, data extraction, and cross‐checking were independently performed by two reviewers, with disagreements resolved by discussion or third‐party arbitration.

Methodological quality and risk of bias were assessed using validated appraisal tools according to evidence type and study design. Details are summarized in Table . The GRADE method was used to assess the certainty of evidence and develop recommendations []. The certainty of evidence for each outcome was rated by considering five downgrading domains—risk of bias, inconsistency, indirectness, imprecision, and publication bias—and three upgrading domains: large effect size, dose‐response relationship, and possible confounding factors. Good practice statements (GPSs) were used for clinically important recommendations that were not primarily based on direct empirical evidence [].

On the basis of the grading of evidence levels and the evidence‐to‐decision framework, careful consideration of factors, such as the balance of benefits and harms of interventions, the certainty of evidence, values and preferences, resource use and cost, equity, acceptability, and feasibility, was conducted. Two rounds of Delphi surveys were conducted from October to December 2025 through the “Fangdian: Medical Guideline and Consensus Development Platform” ( https://develop.guidelines‐registry.cn/my/guidelines ). Through this platform, the working group simultaneously uploaded supporting materials, including recommendations, recommendation rationales, evidence summaries, search strategies, evidence profile tables, and evidence grading tables. The first round of Delphi survey was conducted from October 31 to November 10, 2025, inviting 39 experts to reach consensus, all of whom provided feedback on the recommendations. For the 12 recommendations that failed to reach consensus (consensus rate <80%), a second round of Delphi survey was conducted from December 16 to December 24, 2025, inviting 41 experts to participate; all experts provided feedback. Five recommendations still failed to reach consensus (consensus rate <80%), so final recommendations were not established due to inconsistent expert opinions and insufficient evidence. After the initial draft of the guidelines was completed, eight experts who had not been involved in the earlier drafting process were invited to conduct an external review. After revising based on feedback, the guideline ultimately formed 28 clinical questions and 55 recommendations (Table ).

Routine frailty screening is recommended for patients aged ≥65 years undergoing lung cancer surgery (1A). The Geriatric 8 (G8) scale is suggested as the initial screening tool (2A). Patients with a positive G8 screening result (score ≤14) should undergo comprehensive geriatric assessment (CGA) (1B). On the basis of the assessment results, a stratified management approach is recommended: standard enhanced recovery after surgery (ERAS) protocols for non‐frail patients; a “prehabilitation + ERAS” model for prefrail patients; and individualized treatment through multidisciplinary consultation for frail patients (1A).

This recommendation is based on evidence from systematic reviews and meta‐analyses. Frailty is common among older patients with lung cancer and is consistently associated with adverse perioperative and long‐term outcomes, including postoperative complications, prolonged hospitalization, impaired functional recovery, and increased mortality [, , , , , , , , , , , , ]. The working group evaluated 42 studies and found that the prevalence of frailty among older patients with lung cancer was 41% (95% confidence interval [CI], 35–46). Frailty was also associated with poorer overall survival (hazard ratio [HR] = 3.01) and a higher risk of complications (odds ratio [OR] = 1.89) in lung cancer patients [, , ].

A systematic review of six studies by the working group [, , , , , ] showed that the G8 scale has high sensitivity for identifying frailty or vulnerability (90%, 95% CI, 87–92) and is easy to administer. A G8 score ≤14 was an independent predictor of mortality risk (HR = 3.21; 95% CI, 2.21–4.66), supporting its use for rapid preoperative identification of high‐risk patients. For patients with a positive G8 screening result (G8 score ≤14), CGA is recommended to inform treatment decisions [, , ]. CGA further refines risk stratification by predicting mortality, complications, and functional decline and may identify frailty not captured by conventional assessment in approximately 23% of patients [, , , , , , , , , ]. Regarding intervention strategies, the working group synthesized three meta‐analyses ( n = 5391), which indicated that ERAS tends to reduce postoperative pulmonary complications (PPCs) (risk ratio [RR] = 0.66; 95% CI, 0.59–0.75) and infection rates (RR = 0.52; 95% CI, 0.34–0.80) in lung cancer patients [, , ]. Additionally, preoperative pulmonary rehabilitation (PR) and multimodal prehabilitation incorporating exercise‐based, nutritional, and psychological interventions improve functional status and reduce PPCs [, , ]. Therefore, perioperative management should be implemented on the basis of frailty status [, , , ].

Timely identification of potential delirium is recommended for older patients with lung cancer during the perioperative period (1A). Assessment tools, such as confusion assessment method (CAM) or CAM–intensive care unit (ICU), may be used (1B), with an assessment frequency of at least once daily for a minimum of 3 days (2C). Preventive measures should be implemented for high‐risk older patients (Table ). Delirium prevention should primarily focus on multimodal non‐pharmacological interventions (1B). Routine use of antipsychotic medications for prophylaxis is not recommended (1B). Short‐term, low‐dose, and symptom‐directed use may be considered only when non‐pharmacological measures prove ineffective and significant agitation or safety risks are present (2C).

This recommendation is supported by high‐quality meta‐analyses. In a meta‐analysis of 12 studies [, , , , , , ], the working group found a pooled postoperative delirium incidence of 16% (95% CI, 12%–20%). A meta‐analysis identified prior delirium, frailty, cognitive impairment, functional decline, psychotropic medication use, and smoking as significant risk factors []. These risk factors may occur across the perioperative continuum []. Early recognition of delirium is critical for management [], and systematic review indicates that the CAM is the most used and effective screening tool for postoperative delirium in older patients across various clinical settings []. CAM–ICU is routinely recommended for ICU and mechanically ventilated patients. This guideline recommends delirium assessment at least once daily for a minimum duration of 3 days []. RCTs showed that haloperidol did not reduce delirium after thoracic surgery [], and meta‐analyses found no preventive benefit in older postoperative patients [, ].

Research indicates that comprehensive non‐pharmacological interventions can reduce delirium incidence by approximately 40% []. Effective strategies include precipitating factor control, sleep and pain management, orientation training, and early mobilization []. Notably, standardized postoperative analgesia significantly reduces delirium occurrence and severity []. Multidisciplinary non‐pharmacological interventions based on Hospital Elder Life Program model represent an effective management framework for reducing perioperative delirium risk [, ].

Nutrition risk screening 2002 and/or mini‐nutritional assessment (MNA)/mini‐nutritional assessment short form (MNA‐SF) are recommended for nutritional risk screening; the patient‐generated subjective global assessment (PG‐SGA) and/or Global Leadership Initiative on Malnutrition (GLIM) criteria are recommended for the diagnosis and severity grading of malnutrition (2C).

For patients at risk of dysphagia, swallowing function screening should be initiated as early as possible (2C). The eating assessment tool‐10 (EAT‐10) is recommended as the initial screening tool. For patients with positive screening results or at high risk, the volume–viscosity swallow test (V–VST) is recommended for bedside assessment. Additionally, the Kubota Water Swallow Test, standardized swallowing assessment (SSA), repetitive saliva swallowing test (RSST), or Gugging Swallowing Screen (GUSS) can be used as supplementary tools (GPS). For patients with suspected severe dysphagia or recurrent aspiration, consultation with rehabilitation medicine specialists or swallowing therapists is recommended, with consideration of fiber‐optic endoscopic evaluation of swallowing (FEES) or video fluoroscopic swallowing study (VFSS) (2D) to confirm the diagnosis and guide subsequent clinical interventions (2C).

Nutritional status in older lung cancer patients is an important determinant of postoperative recovery and long‐term prognosis. A meta‐analysis showed that a low prognostic nutritional index was associated with increased mortality in lung cancer patients []. Nutrition risk screening 2002 is broadly applicable in older and oncology populations, whereas MNA/MNA‐SF provides a geriatric‐focused assessment of nutritional risk. For diagnosis and grading, PG‐SGA is well validated in cancer populations, and the 2018 GLIM criteria demonstrate acceptable diagnostic performance [, ].

Dysphagia is frequent in older adults and contributes to malnutrition and aspiration pneumonia [, , ]. Because lung cancer‐specific standards are limited, pragmatic use of validated screening and bedside tools is recommended. EAT‐10 exhibits high reliability and validity, making it suitable for rapid initial screening. Meta‐analyses showed that the V–VST has high diagnostic sensitivity and good reliability, representing a preferred bedside assessment tool [, ]. VFSS or FEES should be considered when severe dysphagia or recurrent aspiration is suspected. Following diagnosis, the Functional Oral Intake Scale can be used to assess oral intake ability, and the Swallowing Quality of Life can be used to evaluate swallowing‐related quality of life. Integrating functional indicators with patient‐reported outcomes facilitates individualized intervention strategies to reduce complications and improve overall prognosis [, , ].

Nutritional interventions are recommended based on the principles of “early intervention, individualized management, and multidisciplinary collaboration.” Individualized nutritional goals should be established, with dynamic assessment and adjustment in conjunction with measures such as exercise rehabilitation (GPS). For older patients (≥75 years), those with multiple chronic conditions, or those with frailty, multidisciplinary nutritional management involving or led by the geriatrics department is recommended (1B).

A meta‐analysis of 6 RCTs conducted by the working group [, , , , , ] revealed that nutritional intervention significantly reduced the risk of postoperative complications (OR = 0.17; 95% CI, 0.10–0.28). Multiple studies confirmed that nutritional intervention can improve postoperative albumin [, , , , ], hemoglobin [, , ], prealbumin, and transferrin levels [, , , ], enhance cellular immune function [, ], shorten chest tube duration and hospital stay [, , , ], and improve pulmonary function indices and oxygenation status [, , ]. Although these findings support the overall effectiveness of perioperative nutritional management, existing studies exhibit significant heterogeneity in intervention forms, implementation timing, and duration, with evidence quality predominantly rated as moderate or low. Therefore, this guideline supports perioperative nutritional intervention as an integral component of comprehensive management but does not make restrictive recommendations regarding specific intervention modalities or periods.

Routine preoperative screening and assessment of sarcopenia are recommended (1A). Computed tomography (CT)‐based muscle mass evaluation methods are recommended, particularly using the lumbar 3 (L3) skeletal muscle index (L3MI = (L3 skeletal muscle cross‐sectional area)/(height 2 )) as the diagnostic criterion for sarcopenia, combined with muscle function indicators (such as grip strength, gait speed, or the five‐repetition sit‐to‐stand test) for comprehensive evaluation (2B). For patients diagnosed with sarcopenia, comprehensive management combining exercise intervention and nutritional support is recommended (1A). Preoperative rehabilitation should be incorporated into routine management pathways (1B).

Studies [, , ] have reported sarcopenia prevalence rates of 42.8%–45% in patients with lung cancer, whereas a systematic review of 30 studies by this guideline working group found a prevalence of 33.2% among older patients with lung cancer. Several studies indicated that sarcopenia is a significant predictor of poor outcomes in older patients with lung cancer, leading to significantly shortened overall survival [, , ], decreased 5‐year overall survival rates [], reduced disease‐free survival [], and significantly increased risk of perioperative complications [, ]. Although sarcopenia assessment should ideally include muscle mass, strength, and physical performance, CT‐based muscle measurement is the most feasible and widely supported approach in lung cancer because CT is routinely available for staging and has established prognostic value [, , , , , , , , ]. Combining CT, preferably L3 skeletal muscle index, with grip strength, gait speed, or the five‐repetition sit‐to‐stand test may further improve diagnostic accuracy. For intervention, the available evidence supports a multimodal strategy centered on exercise and nutritional support. Shen et al.’s meta‐analysis [] demonstrated that resistance training improves quality of life, grip strength, and gait speed and may be further enhanced by balance or aerobic training. A network meta‐analysis [] including 59 RCTs and meta‐analysis [] including 35 RCTs both confirmed that protein supplementation enhances muscle strength and mass. A meta‐analysis comparing different intervention strategies [] indicated that combined exercise and nutrition interventions are most effective in improving muscle mass. Two meta‐analyses [, ] indicated that preoperative exercise training in lung cancer patients can improve pulmonary function, shorten hospital stays, and reduce the risk of postoperative complications. Nevertheless, high‐quality perioperative evidence specific to older patients with lung cancer and sarcopenia remains insufficient.

Dynamic fall risk assessment is recommended (1A). The Hendrich II fall risk assessment model (HFRM) and Morse Fall Scale (MFS) are recommended as screening tools (1B).

A meta‐analysis of nine studies conducted by the working group demonstrated that history of falls was significantly associated with fall risk in older hospitalized patients and older patients with cancer (RR = 2.66; 95% CI, 1.91–3.71) [, , , , , , , , ]. The guideline recommends routinely assessing fall history within the previous 12 months to identify high‐risk individuals and guide perioperative comprehensive management [, , , , , , , , , , , ]. The working group synthesized data from 10 studies on fall risk screening tools [, , , , , , , , ]. Qualitative analysis consistently supported the combined use of the HFRM and MFS. Furthermore, the HFRM exhibits better sensitivity and specificity compared to the MFS [], making it more suitable for systematic assessment upon admission or after a fall [], whereas MFS features a concise structure appropriate for rapid initial screening. The guideline recommends combined application of both tools, with multifactorial, dynamic fall risk assessment conducted for patients identified as high risk at initial screening [].

CGA (1A) and exercise intervention (1A) are recommended. For patients with fall risk or rehabilitation needs, personalized rehabilitation plans should be developed (2C), and comprehensive rehabilitation management centered on multifactorial intervention should be implemented in the early postoperative period (2B).