When Carlton Hughes, a longtime smoker, was diagnosed with lung cancer in June 2002, his doctor said he needed six weeks of breathing therapy before he could undergo cancer surgery. Mr. Hughes also suffered from emphysema, and his doctor wanted to bolster his lung capacity before operating.

But Mr. Hughes, 70 years old at the time, was reluctant to wait for the operation, and went to see Stephen Yang in Baltimore. 
Dr. Yang, the chief of thoracic surgery at Johns Hopkins Medical Institutions, had developed a reputation for aggressively treating older patients whom other doctors sometimes shied away from. He declared Mr. Hughes ready for surgery and operated a few days later. Mr. Hughes, who lives near Harrisburg, Pa., has been free of cancer ever since.

Within Johns Hopkins, such cases have earned Dr. Yang the sobriquet "surgeon to the seniors." The 46-year-old Dr. Yang is convinced that older patients -- those in their 70s and 80s -- sometimes don't get the kind of aggressive treatment they need to be cured. "The older cancer patient is underserved," he says. "Helping them is my passion."

Dr. Yang is one of a growing number of surgeons looking for ways to safely perform -- rather than avoid -- surgery on older adults. During the past two decades, the percentage of operations involving patients over 65 has increased significantly, and it is likely to continue to rise sharply as the population ages. The number of older Americans is expected to increase 13% by 2010 and 53% by 2020, making seniors the fastest-growing age group in the country, according to the Census Bureau. And given increased life expectancies, many surgeries that wouldn't have been performed 20 years ago now make sense.

Increasingly, "most of the diseases we are operating on are diseases of age -- such as cancer, heart disease, and bone and joint disease," says Ronnie Rosenthal, associate professor of surgery at Yale University School of Medicine and chief of surgery at VA Connecticut Health Care System in West Haven, Conn.  Often, she says, older patients do as well in surgery as younger ones -- if they are free of complications such as kidney disease. But mortality rates rise, she says, if they develop a complication such as a postoperative infection.

In addition, Dr. Rosenthal says, older patients are especially sensitive to narcotics prescribed for pain relief after surgery. If they are given too much, they can become disoriented and delirious; that can lead to other problems, such as dangerous falls. If they aren't given enough, they can become overly sleepy without actually falling asleep. That increases the risk that they may vomit and aspirate the secretions into their lungs, which can cause pneumonia.

'Huge Topic'
Sorting out these issues has made geriatric surgery "a huge topic" in medicine, says Dana Anderson, vice chairman of the surgery department at Johns Hopkins. While geriatric surgery currently isn't considered a "bona fide subspecialty," as pediatric surgery is, it eventually might end up that way, he says.

During his 12 years at Johns Hopkins, Dr. Yang has performed surgery on about 200 people who were older than 80. The oldest was 86. Many of his patients have lung or esophageal cancer.

"I get a lot of referrals from outside surgeons saying that their patients are too old for an operation," Dr. Yang says. But, in fact, he says, it's hard to generalize about patients based on their age. "I see 65-year-olds that look like 80-year-olds and 80-year-olds that look like 60-year-olds," he says. One week, he saw a 78-year-old, an 81-year-old and an 83-year-old, all with esophageal cancer. They all had surgery and fared well.

The outcomes among older people are getting better all the time, he says, due to the development of newer, less-invasive surgical practices, better anesthesia and improved physical therapy and pain management.

Lucille Schneyer, an 87-year-old resident of Owings Mill, Md., was diagnosed with lung cancer three years ago. "Usually, the diagnosis in my kind of case is very bad," she says. But Dr. Yang removed part of her lung, and she has been in good health ever since.

'Eyeball Test'
In trying to assess whether an older patient will benefit from surgery, Dr. Yang looks hard at the person's lung and heart function, while trying to gauge whether he can completely remove the cancer. Then he gives patients the "eyeball test." If "they come in in a wheelchair, I say, 'I don't think so.' Too fragile. But if they come in bouncing around, I think, 'You are a young 80.' "

Patients' attitudes vary. "Some older patients say, 'Why should I go through this? I have had a good life,' " he says. "Others say, 'Treat me like I'm 60.' "
Increasingly, children are demanding the newest, most aggressive treatments for their parents. "Kids fight for their parents," Dr. Yang says. "They're on the Internet, and are very well informed." He says that if his 82-year-old father or 79-year-old mother got sick, he would push doctors to be aggressive. Statistics show, after all, that an 80-year-old could easily live an additional eight years, and many will live even longer than that.

When Saul Friedman, a longtime political reporter and now a columnist for Melville, N.Y.-based Newsday, was diagnosed at age 76 with esophageal cancer last year, he sought out Dr. Yang for help but was afraid that the doctor wouldn't take him as a patient. Because of a previous stroke, Mr. Friedman's right side was partially paralyzed.

To show that he's a fighter, Mr. Friedman walked down the long corridor leading to Dr. Yang's office. "It was a long, painful walk for someone like me," says the Edgewater, Md., resident. "But I was trying to impress him that I was worthy of surgery."

Dr. Yang accepted Mr. Friedman as a patient and ordered three months of chemotherapy and radiation. Then, in June 2005, Dr. Yang removed most of Mr. Friedman's esophagus, using a minimally invasive technique. "If you look at my scar, it's minimal," says Mr. Friedman. "I can eat well -- it worked. I am, as far as I can tell, cured of a cancer that kills thousands of people a year."

Tolerating Pain
In many cases, Dr. Yang says, older patients tolerate pain better than younger ones -- partly because they tend to have less muscle mass, but also because "emotionally, they have dealt with a lot of trauma" throughout their lives. On the other hand, certain drugs and anesthesia have to be handled with special care.
Dr. Yang's patients are grateful that he pushed to cure them, not just make them comfortable.

"I consider him a friend," says Mr. Hughes, who before his retirement owned a steel-fabrication company and a construction-equipment company in Harrisburg. "I have had him to my house." Mr. Hughes also has made financial contributions to Dr. Yang to allow him to expand his research on geriatric surgery.

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