Practice pearls in the management of lung cancer in the elderly

Lung cancer is a disease that afflicts the elderly. It is a leading cause of cancer mortality worldwide. Treatment of lung cancer which was predominantly combination chemotherapy was initially thought to be too toxic for older patients with cancer due to their frail state. However a number of recent studies have shown that this is not necessarily true and many elderly can actually tolerate combination chemotherapy and derive just as much benefit from it as younger patients with lung cancer do. More recently it has been found that a significant proportion of lung cancer patients have tumors that harbor mutations that are targetable by molecularly targeted therapy (MTT). These targeted therapies have a much better tolerated side effect profile, hence have been used in elderly patient with lung cancer with great success. A new generation of drugs called immune checkpoint inhibitors have now come into the fray with exciting results in the second line treatment of lung cancer with a low side effect profile. A key element in deciding whether an elderly patient with lung cancer can tolerate treatment involves a detailed assessment using the comprehensive geriatric assessment (CGA). A number of CGA and clinical factors have also been found to be able to predict chemotherapy associated toxicity. This review of lung cancer in the elderly was part of a lecture on "Practice pearls in the management of lung cancer in the elderly" presented at the SIOG Annual Meeting in Prague in November 2015.

Adjuvant Chemotherapy After Lobectomy for T1-2N0 Non-Small Cell Lung Cancer: Are the Guidelines Supported?

BACKGROUND

Evidence guiding adjuvant chemotherapy (AC) use after lobectomy for stage I non-small cell lung cancer (NSCLC) is limited. This study evaluated the impact of AC use and tumor size on outcomes using a large, nationwide cancer database.

METHODS

The effect of AC on long-term survival among patients who underwent lobectomy for margin-negative pathologic T1-2N0M0 NSCLC in the National Cancer Data Base from 2003 to 2006 was estimated using the Kaplan-Meier method. The specific tumor size threshold at which AC began providing benefit was estimated with multivariable Cox proportional hazards modeling.

RESULTS

Overall 3,496 of 34,360 patients (10.2%) who met inclusion criteria were treated with AC, although AC use increased over time from 2003, when only 2.7% of patients with tumors less than 4 cm and 6.2% of patients with tumors of 4 cm or larger received AC. In unadjusted survival analysis, AC was associated with a significant 5-year survival benefit for patients with tumors less than 4 cm (74.3% vs 66.9%; P<.0001) and 4 cm or greater (64.8% vs 49.8%; P<.0001). In subanalyses of patients grouped by strata of 0.5-cm increments in tumor size, AC was associated with a survival advantage for tumor sizes ranging from 3.0 to 8.5 cm.

CONCLUSIONS

Use of AC among patients with stage I NSCLC has increased over time but remains uncommon. The results of this study support current treatment guidelines that recommend AC use after lobectomy for stage I NSCLC tumors larger than 4 cm. These results also suggest that AC use is associated with superior survival for patients with tumors ranging from 3.0 to 8.5 cm in diameter.

Management of Lung Cancer in the Elderly

Lung cancer is the leading cause of cancer-associated mortality in the USA. The median age at diagnosis of lung cancer is 70 years, and thus, about one-half of patients with lung cancer fall into the elderly subgroup. There is dearth of high level of evidence regarding the management of lung cancer in the elderly in the three broad stages of the disease including early-stage, locally advanced, and metastatic disease. A major reason for the lack of evidence is the underrepresentation of elderly in prospective randomized clinical trials. Due to the typical decline in physical and physiologic function associated with aging, most elderly do not meet the stringent eligibility criteria set forth in age-unselected clinical trials. In addition to performance status, ideally, comorbidity, cognitive, and psychological function, polypharmacy, social support, and patient preferences should be taken into account before applying prevailing treatment paradigms often derived in younger, healthier patients to the care of the elderly patient with lung cancer. The purpose of this chapter was to review the existing evidence of management of early-stage, locally advanced disease, and metastatic lung cancer in the elderly.

Biomarkers in early-stage non-small-cell lung cancer: current concepts and future directions

Advances in molecular biology and bioinformatics have resulted in the identification of a number of potential biomarkers that could be relevant in the management of patients with non-small-cell lung cancer (NSCLC). Although there is an increasing amount of literature related to these biomarkers, major issues need to be resolved including validity and reproducibility of results. Additionally, in order to interpret the existing literature accurately, a clear distinction must be made between the prognostic and predictive value of biomarkers. The practical applicability of biomarker discovery for patients with lung cancer includes the identification of patients with early-stage NSCLC who are most likely to benefit from adjuvant therapy. Information gleaned from biomarkers has the potential to help in evaluating the role of targeted therapies including immunotherapy in the neoadjuvant and adjuvant setting. The role of gene signatures and the use of newer platforms such as RNA, methylation, and protein signatures is being explored in patients with early-stage NSCLC. This review focuses on the applications of biomarker discovery in patients with early-stage NSCLC.

Cost-Effectiveness of Chemotherapy for Breast Cancer and Age Effect in Older Women

BACKGROUND

Previous economic evaluations compared specific chemotherapy agents using input parameters from clinical trials and resource utilization costs. Cost-effectiveness of treatment groups (drug classes) using community-level effectiveness and cost data, however, has not been assessed for elderly patients with breast cancer.

OBJECTIVE

To assess the cost-effectiveness of chemotherapy regimens by age and disease stage under "real-world" conditions for patients with breast cancer.

METHODS

The Surveillance Epidemiology and End Results-Medicare data were used to identify patients with breast cancer with American Joint Committee on Cancer stage I/II/IIIa, hormone receptor-negative (estrogen receptor-negative and progesterone receptor-negative) patients from 1992 to 2009. Patients were categorized into three adjuvant treatment groups: 1) no chemotherapy, 2) anthracycline, and 3) non-anthracycline-based chemotherapy. Median life-years and quality-adjusted life-years (QALYs) were measured using Kaplan-Meier analysis and were evaluated against average total health care costs (2013 US dollars).

RESULTS

A total of 4575 patients (propensity score-matched) were included for the primary analysis. The anthracycline group experienced 12.05 QALYs and mean total health care costs of $119,055, resulting in an incremental cost-effectiveness ratio of $7,688 per QALY gained as compared with the no chemotherapy group (QALYs 7.81; average health care cost $86,383). The non-anthracycline-based group was dominated by the anthracycline group with lower QALYs (9.56) and higher health care costs ($122,791). Base-case results were found to be consistent with the best-case and worst-case scenarios for utility assignments. Incremental cost-effectiveness ratios varied by age group (range $3,790-$90,405 per QALY gained).

CONCLUSIONS

Anthracycline-based chemotherapy was found cost-effective for elderly patients with early stage (stage I, II, IIIa) breast cancer considering the US threshold of $100,000 per QALY. Further research may be needed to characterize differential effects across age groups.

Radical Oncological Surgery and Adjuvan Therapy in Non- Small Cell Lung Cancer Patients over 70 years of Age

BACKGROUND

The incidence of lung cancer increases with age. Approximately 50% of non-small cell lung cancer (NSCLC) patients are over 70 years old. Because of the increasing elderly population, treatment approaches in this age group continue to be studied similar to groups of young people.

MATERIALS AND METHODS

In the current study, 26 patients who underwent radical surgery and adjuvan chemoradiation at Ataturk Chest Diseases and Chest Surgery Training and Research Hospital were evaluated retrospectively.

RESULTS

Of 21 patients (81%) were male and the average age was 74.4. Lobectomy was performed in 18 cases, pneumonectomy in 3, sleeve lobectomy in 3 and bilobectomy in 2. There was no perioperative or early period mortality. Overall survival was 24.5 months.

CONCLUSIONS

From our study, lung cancer surgery and adjuvant therapy can be performed safely with low morbidity in the elderly.

Post-operative radiation therapy

In completely resected non-small-cell lung cancer (NSCLC) patients with pathologically involved mediastinal lymph nodes (N2), administration of adjuvant platinum-based chemotherapy is now considered the standard of care, based on level 1 evidence. The role of post-operative radiotherapy (PORT) in this group of patients remains controversial. In the PORT meta-analysis published in 1998, the conclusions were that if adjuvant radiotherapy was detrimental to patients with early-stage completely resected NSCLC, the role of PORT in the treatment of tumours with N2 involvement was unclear and further research was warranted. Recent retrospective and non-randomized studies as well as subgroup analyses of recent randomized trials evaluating adjuvant chemotherapy, provide evidence of the possible benefit of PORT in patients with mediastinal nodal involvement. The question of PORT indication is also valid for those patients with proven N2 disease who undergo neo-adjuvant chemotherapy followed by surgery. The risk of local recurrence for N2 patients varies between 20% and 60%. Based on currently available data, PORT should be discussed for fit patients with completely resected NSCLC with N2 nodal involvement, within a multidisciplinary setting, preferably after completion of adjuvant chemotherapy or after surgery if patients have had neo-adjuvant chemotherapy. There is need for new randomized evidence to reassess PORT using modern three-dimensional conformal radiation technique, with attention to normal organ sparing, particularly lung and heart, to reduce the possible additional toxicity. Randomized evidence is needed. A new large international multi-institutional randomized trial Lung ART evaluating PORT in this patient population is now underway, as well as a Chinese study comparing postoperative sequential chemotherapy followed by radiotherapy versus adjuvant chemotherapy alone.

Adjuvant chemotherapy of completely resected early stage non-small cell lung cancer (NSCLC)

Surgery is regarded as the primary treatment modality for early stage non-small cell lung cancer (NSCLC), but even after complete resection, a substantial percentage of these patients eventually develop local recurrence or distant metastases. Therefore more effective treatment strategies to reduce lung cancer mortality and recurrence rate are needed. Only recently has the use of adjuvant chemotherapy become standard in early stage NSCLC, at least for stage II and resected IIIA NSCLC. Controversies remain about the benefit for stage I patients. Five-year survival improvements of 5% to 10% have been reported with cisplatin-based adjuvant chemotherapy from multiple large randomized phase III clinical trials and meta-analyses. Questions remain as to which patients benefit and which regimens are best. In this paper, important clinical research in the field of adjuvant chemotherapy of NSCLC is reviewed.

Pharmacotherapy for treatment of lung cancer in the elderly

INTRODUCTION

The chance for elderly patients with NSCLC to receive chemotherapy decreases significantly with age. In addition, older patients are often underrepresented in clinical trials. Consequently, due to the paucity of data, evidence-based decisions with regard to chemotherapy treatment strategies in the elderly are lacking.

AREAS COVERED

We performed a literature search to identify mainly randomized trials focusing on treatment of NSCLC in older patients with chemotherapy and targeted therapy, toxicity and quality of life. In conclusion, the efficacy of regular chemotherapy and targeted therapy seems quite similar in older patients compared to their younger counterparts, with increased toxicity, but acceptable. However, these data are mostly derived from subgroup analyses and highly selected fit patients, which may not represent the general older population.

EXPERT OPINION

Further research is necessary to investigate the role of a comprehensive geriatric assessment in older patients, before the start of a chemotherapeutic treatment. Proteomic tests can have potential in the future, if these tests turn out to be able to separate patients with advanced NSCLC into groups with better or worse outcomes. It can be of special interest for the elderly population, to prevent unnecessary side effects of a possible inferior treatment.

Treatment Approaches in 102 Elderly Patients With Non-Small Cell Lung Cancer

Background

The life expectancy and presence of co-morbidities cause reservations in treatment decisions for elderly patients with cancer. In this study, we retrospectively evaluated 102 patients who are considered as middle-old aged (aged 75 - 84) by gerontologists.

Methods

Medical records of patients were reviewed. One hundred and two patients with a diagnosis of non-small cell lung cancer (NSCLC) whose follow-up ended with death between March 2006 and May 2013 were examined.

Results

The median age at diagnosis was 77 (75 - 85) years. Thirty-three patients (67.6%) were over 80 years old. The number of patients with metastasis was 57 (55.8%). Forty-two (41.2%) patients had stage IIIA and IIIB disease. Fifteen of the metastatic patients (26.3%) were given chemotherapy, while 12 of the non-metastatic patients (26.6%) were given chemotherapy. Of the non-metastatic patients, 25 (55.6%) were treated with radiotherapy, and five (11.1%) were treated with chemotherapy. The median duration of follow-up was 4 (1-55) months. Progression-free survival (PFS) was 4 months in non-metastatic patients, and 3 months in metastatic patients. Overall survival (OS) was 4 months. OS rates for 1 and 2 years were 10% and 2%.

Conclusion

Chemotherapy and radiotherapy may be administered even to patients of this age group. The beneficial effect of chemotherapy in patients with metastasis on OS is an important finding of our study.

Non–small-cell lung cancer in elderly patients: a discussion of treatment options

Lung cancer is a disease of the elderly. In older patients, the management of a malignancy as complex and potentially as lethal as lung cancer is challenging. Despite the fact that a large proportion of patients with non–small-cell lung cancer are elderly, information remains scant on how best to treat these patients. The goal of this review is to discuss the published literature and to provide guidance on how to treat elderly patients within three broad stages: (1) metastatic cancer, (2) early-stage cancer after surgery, and (3) locally advanced inoperable cancer. Because decisions on how and when to prescribe systemic treatment can be particularly difficult, this review focuses heavily on chemotherapy-related treatment decisions with some discussion of emerging data on the use of the comprehensive geriatric assessment.

Management of non-small cell lung cancer in the elderly

Most developed countries accepted the chronological age of 70 years as the definition of "elderly" and there is a general consensus in clinical practice to consider this age as the threshold in risk assessment. This has a strong impact in the choice of treatment of these lung cancer patients. Indeed, more than 50% of these patients are over 70 and nearly 30% are over 75 years old. Because of the increasing number of elderly patients that are generally fitter than in the past, the treatment options should rather be based on individual fitness, taking into account risks and benefits of the diagnostic and therapeutic procedures. This means considering biological rather than chronological age to make decisions. For these reasons, we developed a simplified short comprehensive geriatric assessment (sCGA), including a standardised evaluation of activity of daily living, depression, cognitive status, comorbidities and geriatric syndromes. This allowed us the classification of these patients into 3 categories: frail, vulnerable and fit. Through the emblematic case of a fit elderly man affected by NSLCC, we present the multidisciplinary assessment and discussions to identify the best treatment options for this patient.

Non-small-cell lung cancer in the elderly with an emphasis on chemotherapy in the adjuvant and metastatic disease settings

SUMMARY 

Most lung cancer patients in the USA are older than 65 years of age, and yet oncologists continue to struggle with how best to treat these older patients. This article reviews the medical management of non-small-cell lung cancer in older patients with a focus on decision-making with respect to chemotherapy in the adjuvant setting and metastatic disease settings. In these two settings, chemotherapy as a single-modality intervention can provide a major positive impact. Nonetheless, a relative dearth of evidence in these settings underscores the need to summarize the available data in an effort to make patient counseling easier for healthcare providers and to make decision-making easier for patients and their families.

Benefit of adjuvant chemotherapy after resection of stage II (T1-2N1M0) non-small cell lung cancer in elderly patients

BACKGROUND

We evaluated the use and efficacy of adjuvant chemotherapy after resection of T1-2N1M0 non-small cell lung cancer (NSCLC) in elderly patients.

METHODS

Factors associated with the use of adjuvant chemotherapy in patients older than 65 years of age who underwent surgical resection of T1-2N1M0 NSCLC without induction chemotherapy or radiation in the Surveillance, Epidemiology, and End Results-Medicare database from 1992 to 2006 were assessed using a multivariable logistic regression model that included treatment, patient, tumor, and census tract characteristics. Overall survival (OS) was analyzed using the Kaplan-Meier approach and inverse probability weight-adjusted Cox proportional hazard models.

RESULTS

Overall, 2,781 patients who underwent surgical resection as the initial treatment for T1-2N1M0 NSCLC and survived at least 31 days after surgery were identified, with adjuvant chemotherapy given to 784 patients (28.2 %). Factors that predicted adjuvant chemotherapy use were younger age and higher T status. The 5-year OS was significantly better for patients who received adjuvant chemotherapy compared with patients not given adjuvant chemotherapy: 35.8 % (95 % confidence interval [CI] 31.9-39.6) vs. 28.0 % (95 % CI 25.9-30.0) (p = 0.008). In the inverse probability weight-adjusted Cox proportional hazard regression model, adjuvant chemotherapy use predicted significantly improved survival (hazard ratio 0.84; 95 % CI 0.76-0.92; p = 0.0002).

CONCLUSIONS

Adjuvant chemotherapy after resection of T1-2N1M0 NSCLC is associated with significantly improved survival in patients older than 65 years. These data can be used to provide elderly patients with realistic expectations of the potential benefits when considering adjuvant chemotherapy in this setting.

A review of the management of elderly patients with non-small-cell lung cancer

Most patients with non-small-cell lung cancer (NSCLC) are elderly but evidence to guide appropriate treatment decisions for this age group is generally scant. Careful evaluation of the elderly should be undertaken to ensure that treatment appropriate for the stage of the tumour is guided by patient characteristics and not by age. The Comprehensive Geriatric Assessment (CGA) remains the preferred option, but briefer tools may be appropriate to select patients for further evaluation. The predicted outcome should be used to guide management decisions together with a reappraisal of polypharmacy. Patient expectations should also be taken into account. Management recommendations are generally similar to those of general guidelines for the NSCLC population, although the risks of surgery and toxicity of chemotherapy and radiotherapy are often increased in the elderly compared with younger patients; therefore, patients should be closely scrutinised and subjected to a CGA to ensure suitability of the planned treatment. If surgery is indicated, then lobectomy is generally the preferred option, although limited resection may be more feasible for some. Radiotherapy with curative intent is an alternative, with stereotactic body radiotherapy the most likely preferred modality. Adjuvant chemotherapy is also an appropriate approach, whereas adjuvant radiotherapy is generally not recommended. Concurrent chemoradiotherapy should be considered for elderly patients with inoperable locally advanced disease and chemotherapy for advanced/metastatic disease. Efforts should also be made to increase participation of elderly patients with NSCLC in clinical trials, thereby enhancing evidence-based treatment decisions for this majority group. This will require overcoming barriers relating to trial design and to physician and patient awareness and attitudes.

[Advance of postoperative adjuvant therapy in non-small cell lung cancer]

Lung cancer including non-small cell lung cancer (NSCLC) and SCLC is the most commonly diagnosed cancer and leading cause of cancer-related death worldwide. This review focuses on progress of the effect, indications, regimens and the related biological markers of postoperative adjuvant chemotherapy in NSCLC.

Reviews of individual patient data (IPD) are useful for geriatrics: an overview of available IPD reviews

OBJECTIVES

To determine how many individual patient data (IPD) reviews that included older people were available in MEDLINE and whether the effectiveness of treatments differed between older and younger individuals.

DESIGN

Overview of IPD reviews.

SETTING

A MEDLINE search was conducted for IPD reviews of randomized controlled trials published before July 2012.

PARTICIPANTS

IPD reviews that presented a regression model that included age as a factor or a subgroup analysis of individuals aged 70 and older or in which all participants were aged 70 and older.

MEASUREMENTS

Whether the IPD reviews reported similar conclusions for the younger and older populations was evaluated.

RESULTS

Twenty-six IPD reviews with a subgroup of older individuals and eight reviews with only older individuals were included (median N = 3,351). The most important reason for choosing an IPD review was the ability to perform a subgroup analysis in the older population. Fourteen IPD reviews suggested that older people should receive different treatments from younger people because of differences in effectiveness, six of which indicated that the investigated treatment(s) should be avoided in older adults.

CONCLUSION

IPD review is a valuable approach for generating evidence in older adults. Treatment effects frequently differed between older and younger individuals. Still, IPD results should be applied to older adults cautiously, because they are often excluded from primary trials. The collaborative sharing of raw data should be promoted to improve evidence-based decisions for this group.

2nd ESMO Consensus Conference on Lung Cancer: early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on early-stage disease.

The Lake Wobegon effect: are all cancer patients above average?

CONTEXT

When elderly patients face a terminal illness such as lung cancer, most are unaware that what we term in this article "the Lake Wobegon effect" taints the treatment advice imparted to them by their oncologists. In framing treatment plans, cancer specialists tend to intimate that elderly patients are like the children living in Garrison Keillor's mythical Lake Wobegon: above average and thus likely to exceed expectations. In this article, we use the story of our mother's death from lung cancer to investigate the consequences of elderly people's inability to reconcile the grave reality of their illness with the overly optimistic predictions of their physicians.

METHODS

In this narrative analysis, we examine the routine treatment of elderly, terminally ill cancer patients through alternating lenses: the lens of a historian of medicine who also teaches ethics to medical students and the lens of an actuary who is able to assess physicians' claims for the outcome of medical treatments.

FINDINGS

We recognize that a desire to instill hope in patients shapes physicians' messages. We argue, however, that the automatic optimism conveyed to elderly, dying patients by cancer specialists prompts those patients to choose treatment that is ineffective and debilitating. Rather than primarily prolong life, treatments most notably diminish patients' quality of life, weaken the ability of patients and their families to prepare for their deaths, and contribute significantly to the unsustainable costs of the U.S. health care system.

CONCLUSIONS

The case described in this article suggests how physicians can better help elderly, terminally ill patients make medical decisions that are less damaging to them and less costly to the health care system.

Epigenetic inactivation of microRNA-34b/c predicts poor disease-free survival in early-stage lung adenocarcinoma

PURPOSE

The microRNA-34b/c (miR-34b/c) is considered a tumor suppressor in different tumor types and a transcriptional target of TP53. The main objectives of this study were to investigate the clinical implications of miR-34b/c methylation in patients with early-stage lung adenocarcinoma and to determine the functional role of miR-34b/c re-expression in lung adenocarcinoma cell lines.

EXPERIMENTAL DESIGN

Aberrant methylation and expression of miR-34b/c were assessed in 15 lung adenocarcinoma cell lines and a cohort of 140 early-stage lung adenocarcinoma. Lung adenocarcinoma cell lines were transfected with miR-34b/c and the effects upon cell proliferation, migration, invasion, and apoptosis were investigated.

RESULTS

Aberrant methylation of miR-34b/c was detected in 6 (40%) of 15 lung adenocarcinoma cell lines and 64 of 140 (46%) primary lung adenocarcinoma. Expression of miR-34b/c was significantly reduced in all methylated cell lines and primary tumors, especially with TP53 mutations. Patients with increased miR-34b/c methylation had significantly shorter disease-free and overall survival as compared to patients with unmethylated or low level of miR-34b/c methylation. Ectopic expression of miR-34b/c in lung adenocarcinoma cell lines decreased cell proliferation, migration, and invasion.

CONCLUSIONS

Epigenetic inactivation of miR-34b/c by DNA methylation has independent prognostic value in patients with early-stage lung adenocarcinoma. Reexpression of miR-34b/c leads to a less aggressive phenotype in lung adenocarcinoma cell lines.

Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.

METHODS

The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians.

RESULTS

Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (&lt; 3 cm) peripheral NSCLC that are clinical stage I.

Computed tomography RECIST assessment of histopathologic response and prediction of survival in patients with resectable non-small-cell lung cancer after neoadjuvant chemotherapy

INTRODUCTION

This study's objectives were to determine whether tumor response measured by computed tomography (CT) and evaluated using Response Evaluation Criteria in Solid Tumors (RECIST) correlated with overall survival (OS) in patients with non-small-cell lung cancer (NSCLC) after neoadjuvant chemotherapy and surgical resection.

METHODS

We measured primary tumor size on CT before and after neoadjuvant chemotherapy in 160 NSCLC patients who underwent surgical resection. The relationship between CT-measured response (RECIST) and histopathologic response (≤ 10% viable tumor) and OS were assessed by Kaplan-Meier survival, univariable, and multivariable Cox proportional hazards regression.

RESULTS

There was a statistically significant association between CT-measured response (RECIST) and OS (p = 0.03). However, histopathologic response was a stronger predictor of OS (p = 0.002), with a more pronounced separation of the survival curves when compared with CT-measured response. In multivariable Cox regression analysis, only pathologic stage and histopathologic response were significant predictors of OS. A 41% overall discordance rate was noted between CT RECIST response and histopathologic response. CT RECIST classified as nonresponders a subset of patients with histopathologic response (8 out of 30 points, 27%) who demonstrated prolonged survival after neoadjuvant chemotherapy.

CONCLUSION

We were unable to show that CT RECIST is a reliable predictor of OS in patients with NSCLC undergoing surgical resection after neoadjuvant chemotherapy. The failure of CT RECIST to predict long-term outcome may be because of the inability of CT imaging to consistently identify patients with histopathologic response. CT RECIST may have only a limited role as an efficacy endpoint after neoadjuvant chemotherapy in patients with resectable NSCLC.

Determinants of survival in advanced non--small-cell lung cancer in the era of targeted therapies

BACKGROUND

Molecular profiling of non-small-cell lung cancer (NSCLC) samples has a profound impact on choice of therapy. However, it is less clear whether EGFR and KRAS mutations are prognostic outside of a trial-based treatment paradigm.

METHODS

We performed a retrospective chart review of 513 patients with NSCLC undergoing EGFR and KRAS mutational analysis at the Hospital of the University of Pennsylvania between May 2008 and November 2011. Survival analysis was based on the 376 patients who received systemic treatment, and their survival was determined from the date of initiation of systemic therapy.

RESULTS

The median overall survival (OS) was 30.8 months (95% confidence interval [CI], 24.7-36.9). Neither EGFR mutational status (P = .09) nor KRAS mutational status (0.69) was associated with OS. Female sex (P < .001), never smoker status (P = .01), better performance status (PS) (P < .001), lower Charlson Comorbidity Index (P < .001), and lower age-weighted index (P < .001) were associated with prolonged survival. The presence of bone metastases (P = .001) and liver metastases (P = .004) was also associated with a shortened survival. In a multivariable regression that adjusted for stage, we demonstrated that male gender (P = .002), worse Eastern Cooperative Oncology Group PS (P = .01), metastases to bone (P = .03), and higher age-weighted comorbidity index (P = .001) were independent prognostic factors for shorter survival. EGFR mutation status was not prognostic (P = .85).

CONCLUSION

In our series, EGFR and KRAS do not function as prognostic determinants for NSCLC.

Adjuvant treatment in resected non-small cell lung cancer: current and future issues

The cornerstone of treatment for early-stage non-small cell lung cancer (NSCLC) has been surgical resection. In the last five years two phase III trials have provided evidence of adjuvant platinum-based chemotherapy for completely resected stage II-IIIA patients. We review the evidence supporting adjuvant therapy in early-stage NSCLC; we discuss new issues surrounding adjuvant therapy such as treatment in the elderly-unfit population, treatment toxicity and its influence on outcomes, the importance of histology and gender in adjuvant treatment; and we discuss the future landscape of early-stage NSCLC research, namely, therapeutic strategies exploiting pharmacogenomic and gene-expression profiling, in an attempt to customize the treatment.

Adjuvant chemotherapy after pulmonary resection for lung cancer

Adjuvant chemotherapy using a cisplatin-based regimen is currently recommended for patients with stage II and III non-small cell lung cancer (NSCLC) after complete tumor resection and may be considered for patients with stage IB NSCLC. Although adjuvant chemotherapy after complete resection of localized NSCLC is associated with an absolute survival advantage of approximately 5% at 5 years, there is still a relatively high risk of relapse even for early-stage NSCLC. Efforts are ongoing to identify new treatments in the adjuvant setting and to select patients for individualized treatment based on biomarkers.

Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy

Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.

Factors associated with referral to medical oncology and subsequent use of adjuvant chemotherapy for non-small-cell lung cancer: a population-based study

BACKGROUND

Adjuvant chemotherapy (act) for non-small-cell lung cancer (nsclc) is associated with improved survival in the general population, but may be underutilized. We explored the factors associated with referral to medical oncology and subsequent use of act among all patients with resected nsclc in Ontario, Canada.

METHODS

The Ontario Cancer Registry was used to identify all incident cases of nsclc diagnosed in Ontario during 2004-2006. We linked electronic records of treatment and of physician billing to identify surgery, act, and medical oncology consultation. A multivariate logistic regression model was used to evaluate factors associated with referral to medical oncology and subsequent use of act.

RESULTS

Among 3354 cases of nsclc resected in Ontario during 2004-2006, 1830 (55%) were seen postoperatively by medical oncology, and 1032 (31%) were treated with act. Patients more than 70 years of age were less likely than younger patients to have a consultation [odds ratio (or): 0.4; p < 0.001]. A higher proportion of cases with stage ii or iii nsclc than with stage i disease were referred (ors: 2.7, 2.0 respectively; p < 0.005). We observed substantial geographic variation in the proportion of surgical cases referred (range: 32%-88%) that was not explained by differences in case mix. Among cases referred to medical oncology, older patients (age 60-69 years, or: 0.4; age 70+ years, or: 0.1; p < 0.001) with greater comorbidity (Charlson comorbidity index: 3+; or: 0.5; p < 0.05) and a longer postoperative stay (median length of stay: 7+ days; or: 0.7; p = 0.001) were less likely to receive act. Use of act was greater in patients with stage ii or iii than with stage i disease (ors: 3.0, 2.7 respectively; p < 0.001); use also varied with geographic location (range: 46%-63%).

CONCLUSIONS

The initial decision to refer to medical oncology is associated with age and stage of disease, and those factors have an even greater effect on the decision to offer act. Comorbidity and postoperative length of stay were not associated with initial referral, but were associated with use of act in patients seen by medical oncology.

Evaluation and management of elderly patients with lung cancer

Most patients diagnosed with lung cancer are older than 65 years. Advancing age is associated with increased medical and psychosocial issues that increase the complexity of care. This article provides a summary and update of work-up and management of elderly patients with lung cancer. Patient-related prognostic factors with attention to assessment of comorbidity in lung cancer patients are reviewed. Recent literature regarding toxicity and advances in locoregional and systemic therapies are reviewed, with recommendations for management.

Cisplatin-based combination chemotherapy in septuagenarians with metastatic urothelial cancer

PURPOSE

Cisplatin-based chemotherapy is standard first-line treatment for metastatic urothelial carcinoma. However, cisplatin is frequently avoided in elderly patients due to concerns regarding toxicities. We analyzed the efficacy, and tolerability, of cisplatin-based chemotherapy in elderly patients.

METHODS

Individual patient data were pooled from 8 phase II and III trials evaluating cisplatin-based first-line chemotherapy in patients with metastatic urothelial carcinoma. Adverse events, treatment delivery, response proportions, and survival outcomes were compared between patients aged<70 vs. ≥ 70 years.

RESULTS

Of the 543 patients included, 162 patients (30%) were ≥ 70 years old. The majority (93%) of elderly patients were aged 70 to 79 years. There was no significant difference in the proportions of patients experiencing Grade 3 to 4 renal failure, febrile neutropenia, or treatment-related death between younger and older patient cohorts. The median survival of the patients ≥ 70 years was 12.1 months compared to 12.8 months for patients<70 years (P = 0.91). There was no significant difference in survival between age groups when controlling for baseline performance status or the presence of visceral metastases or both.

CONCLUSIONS

Fit septuagenarians, with adequate renal function, tolerate cisplatin-based chemotherapy similarly to their younger counterparts and achieve comparable clinical outcomes.

Prospective analysis of quality of life in elderly patients treated with adjuvant chemotherapy for non-small-cell lung cancer

BACKGROUND

Given the more comorbidities with a decline in physiologic reserve, it can be challenging to make appropriate treatment decisions in the elderly.

PATIENTS AND METHODS

Here, we prospectively evaluated and compared the health-related quality of life (HRQOL) of patients aged ≥ 65 with aged <65 who were treated with a postoperative chemotherapy for completely resected stage Ib, II or IIIa non-small-cell lung cancer (NSCLC). Either four cycles of paclitaxel (Taxol)-carboplatin (PC) or vinorelbine-cisplatin (NP) was used. The HRQOL was assessed with EORTC QLQ-C30 and EORTC QLQ-LC13.

RESULTS

Between October 2008 and October 2011, a total of 139 patients (aged <65, n = 73; ≥ 65, n = 66) were enrolled, and 127 (91.4%) completed the questionnaire. Overall, the quality of life (QOL) in elderly patients did not significantly deteriorate with adjuvant chemotherapy and the time trend of QOL in elderly patients was similar to that of younger patients. Although the elderly suffered from increased treatment-related adverse events involving sore mouth, peripheral neuropathy and alopecia compared with the baseline, the same time trends were also observed in younger group. The mean dose intensities (MDIs) for PC and NP regimen were not significantly different between the two age groups.

CONCLUSIONS

Postoperative chemotherapy did not substantially reduce HRQOL in elderly NSCLC patients, and HRQOL during and after adjuvant chemotherapy did not significantly differ by age.

Adjuvant chemotherapy in older adults with non-small cell lung cancer

Platinum-based adjuvant chemotherapy is the standard of care for patients with early-stage non-small cell lung cancer (NSCLC) treated with surgery. There is a paucity of data regarding the appropriate use of adjuvant chemotherapy in the treatment of older adults. In the absence of prospective randomized controlled trials specific to this population, the available evidence is limited to post hoc analyses of prospective studies in age-unselected populations and retrospective reviews of population databases. The available evidence for treatment of older adults with adjuvant therapy using cisplatin- and carboplatin-based therapy is reviewed. Strategies for future research, as well as the role of geriatric assessment in risk stratification, will be addressed.

Adjuvant chemotherapy and age-related biases in non-small cell lung cancer

BACKGROUND

Five-year survival for early-stage lung cancer despite complete surgical resection is approximately 50%. Adjuvant chemotherapy has been shown to improve survival in some patients. Older cancer patients do not always receive standard therapy. The purpose of this study was to determine if there were age-related biases concerning the use of adjuvant chemotherapy after lobectomy for elderly patients with non-small cell lung cancer (NSCLC).

METHODS

A prospective lung cancer outcomes database was queried for all patients undergoing lobectomy for NSCLC pathologic stage IB and higher between April 2006 and October 2010. Patients who received neoadjuvant treatment or who died within 30 days of operation were excluded. Ninety-nine patients met the inclusion criteria. Patients were divided into 2 groups based on age (<70 or ≥70 years). The use of adjuvant chemotherapy was compared between groups.

RESULTS

Sixty-nine patients (70%) were younger than 70 years and 30 (30%) were 70 years or older. There was a significant difference in the use of adjuvant chemotherapy between the 2 groups, with 46 (66.7%) of the younger patients and 7 (25%) of the elderly patients receiving adjuvant treatment (p<0.01). The difference persisted when analyzed by stage, with older patients less likely to receive chemotherapy among all patients with stage IB disease, stage II or more advanced disease, and stage IB lesions greater than or equal to 4 cm plus stage II or more advanced disease. In multivariate analysis of preoperative and postoperative factors, age remained the only independent predictor of chemotherapy use.

CONCLUSIONS

Patients undergoing lobectomy who were 70 years of age or older received adjuvant chemotherapy less often than did younger patients.

Survival analysis of patients with stage I non-small-cell lung cancer using clinical and DNA repair pathway expression variables

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality. Understanding patient attributes that enhance survival and predict recurrence is necessary to individualize treatment options.

METHODS

Patients (N = 162) were dichotomized into favorable (n = 101) and unfavorable (n = 61) groups based on survival characteristics. Ku86 and poly(ADP-ribose) polymerase (PARP) expression measures were incorporated into the analyses. LR, Kaplan-Meier analysis, and Cox regression were used to investigate intervariable relationships and survival. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were used to assess associations.

RESULTS

Sex (OR, 0.32; CI-0.14, 0.76), squamous cell carcinoma (SCC) (OR, 0.41; CI-0.17, 0.98), and recurrence (OR, 0.04; CI-0.01, 0.20) confer an unfavorable outcome with area under the receiver operating characteristic curve (Az) = 0.788. Patients with increased tumor grade (OR = 1.84; CI-1.06, 3.19) or increased Ku86 intensity (OR, 2.03; CI-1.08, 3.82) were more likely to be male individuals, and older patients (OR, 1.70; CI-(1.14, 2.52) were more likely to have SCC. Patients older than the median age (HR, 1.86; CI-1.11, 3.12), patients with SCC (HR, 1.78; CI-1.05, 3.01), patients with recurrence (HR, 4.16; CI-2.37, 7.31), and male patients (HR, 2.03; CI-1.20, 3.43) have a higher hazard. None of the DNA repair measures were associated with significant HRs.

CONCLUSION

Clinical and pathologic factors that enhance and limit survival for patients with stage I NSCLC were quantified. The DNA repair measures showed little association. These findings are important given that certain clinical and pathologic features are related to better long-term survival outcome than others.

Feasibility of adjuvant chemotherapy with S-1 consisting of a 4-week administration and a two-week rest period in patients with completely resected non-small cell lung cancer

The efficacy of adjuvant chemotherapy with S-1 in patients with completely resected non-small cell lung cancer (NSCLC) has yet to be clarified, and the appropriate schedule for the adjuvant chemotherapy with S-1 remains unknown. A phase II study was conducted to evaluate the feasibility and efficacy of adjuvant chemotherapy with S-1. Patients enrolled in this study were 20-75 years old, had pathological stage IB-IIIA NSCLC, and had received complete resection of NSCLC. S-1 (80 mg/m²) was administered orally to the patients for four weeks followed by a two-week rest period (conventional schedule), for a maximum of eight cycles. The primary endpoint was relative dose intensity (RDI), while the secondary endpoints were safety and 1 year of disease-free survival (1y-DFS). Between May 2007 and October 2009, 28 patients were enrolled. The RDI was 63.1% (95% CI, 48.6-77.7). No grade 3 or worse hematological toxicity was observed. Grade 3 non-hematological toxicities were observed in four patients. No grade 4 or worse hematological toxicity was detected. The probability of 1y-DFS was 85.7% (95% CI, 72.8-98.6). In the subgroup analysis, the median RDI of patients over 65 years old was lower compared to the other patients (44.8 vs. 100%; P=0.013; Mann-Whitney U test). Creatinine clearance (CCr) was lower in the older group, with more grade 2 or 3 non-hematological toxicities in the elderly patients. These results suggest that the conventional schedule of adjuvant chemotherapy with S-1 is not likely to be feasible in older patients with completely resected NSCLC.

Adjuvant chemotherapy and targeted therapy in elderly non-small-cell lung cancer patients

Adjuvant chemotherapy and targeted therapies comprise two salient practice-changing improvements in the treatment of non-small-cell lung cancer. Despite the fact that these improvements have been largely data-driven, the following questions arise: what is the role of adjuvant chemotherapy in elderly patients with non-small-cell lung cancer? What is the role of targeted agents, such as erlotinib and bevacizumab, in older non-small-cell lung cancer patients? These questions are relevant because the current median age of lung cancer patients at diagnosis in the USA is 69 years, and the number of older patients developing this malignancy is increasing. This review provides guidance on how best to approach the use of adjuvant chemotherapy and targeted therapies in older patients with this disease.