Octogenarians treated for thoracic and lung cancers: Impact of comprehensive geriatric assessment

Optimization of treatment strategies for elderly patients with advanced non-small cell lung cancer

Lung cancer stands as a malignant neoplasm bearing the highest burden of morbidity and mortality within the elderly population on a global scale. Among the lung cancer subtypes, non-small cell lung cancer (NSCLC) prevails as the most prevalent. As age advances, elderly patients often present with an increased prevalence of comorbidities, diminished organ reserve function, and alterations in drug pharmacokinetics, including absorption, distribution, metabolism, and clearance. These factors collectively contribute to a reduction in their capacity to tolerate therapeutic interventions. Regrettably, there exists a paucity of research data and evidence regarding the management of elderly patients afflicted by advanced lung cancer. This article endeavors to compile and elucidate strategies for the enhancement of treatment approaches, with the aim of aiding clinical decision-making. Prior to the selection of clinical treatment modalities for elderly patients with advanced NSCLC, a comprehensive assessment should be conducted, taking into account various facets, including tumor characteristics, patient age, physiological status, and the presence of comorbidities. The treatment strategy should be implemented in a tiered fashion, thereby affording the opportunity for the tailoring of individualized therapeutic approaches for elderly patients afflicted by advanced NSCLC. The demographic of elderly patients confronting advanced NSCLC presents a complex landscape marked by intricate underlying conditions, necessitating the imperative optimization of treatment strategies.

The Role of Immunotherapy in the First-Line Treatment of Elderly Advanced Non-Small Cell Lung Cancer

Immune checkpoint inhibitors have changed the history of NSCLC treatment by becoming, alone or in combination with platinum-based chemotherapy, a mainstay of first-line therapy for advanced NSCLC. This increasingly dictates the identification of predictive biomarkers of response that can guide patient selection, in order to rationalize and personalize therapies, particularly in elderly patients. Immunotherapy in these patients raises questions of efficacy and tolerability related to aging, which is accompanied by a progressive decline in various body functions. Physical, biological and psychological changes contribute to individual validity status and, preferably, 'fit' patients are generally enrolled in clinical trials. In elderly patients, especially frail and complex patients with more than one chronic disease, data are poor and specific prospective studies are needed. This review reports the main available results on the use of immune checkpoint inhibitors in older patients with advanced NSCLC, in terms of efficacy and toxicity, and aims to highlight the need to better predict which patients might benefit from immunotherapy agents by probing knowledge and integrating information on immune system changes and age-related physiopathological modifications.

Association of Preoperative Rehabilitation With Postoperative Length of Hospital Stay for Elderly Lung Cancer Patients

This study aimed to evaluate the effect of preoperative rehabilitation on postoperative hospital stay in elderly lung cancer patients following lung resection. This was a retrospective observational study using the Japanese Diagnosis Procedure Combination database. Data of patients diagnosed between April 2016 and March 2020 were collected. Patients were identified using the International Statistical Classification of Disease and Related Health Problems Version 10-10 codes, C34.0-C34.3 and C34.8. Multilevel linear regression analysis was performed to evaluate the effect of preoperative rehabilitation on the length of hospital stay. A total of 9,393 patients were included in the study. Univariate analysis showed that preoperative rehabilitation was significantly associated with postoperative length of hospital stay (coefficient: -1.61; 95% confidence interval: -2.42, -0.81; P <0.001). In addition, multivariate analysis showed preoperative rehabilitation to be associated with a significant decrease in postoperative length of hospital stay (coefficient=-1.38; 95% confidence interval: -2.19, -0.58; P =0.001). Preoperative rehabilitation may shorten length of hospital stay in elderly patients with lung cancer.

Older Patients with Lung Cancer: a Summary of Seminal Contributions to Optimal Patient Care

PURPOSE OF REVIEW

This review aspires to summarize the landmark advancements in the management of the non-small cell lung cancer (NSCLC), both historically and contemporarily with special focus in older adults.

RECENT FINDINGS

The past two decades have witnessed remarkable improvements in the diagnosis and management of lung cancer. Screening recommendations now facilitate earlier diagnosis in high-risk individuals, PET/CT scans have improved radiologic accuracy in identifying sites of disease, and surgical management with minimally invasive techniques has rendered surgery safer in those with limited physiologic reserve. Radiation enhancements, especially radiosurgery, have extended the reach and safety of radiation among high-risk populations. Finally, the revolution in precision medicine with identification of numerous actionable mutations, the advent of immunotherapy, and enhanced supportive care have revolutionized the outcomes in patients with advanced lung cancer. Older adults who represent a majority of patients battling lung cancer have not benefitted to the same extent as their younger counterparts. This special population is only expected to grow in coming days. Hence, addressing major gaps in the management of older adults with NSCLC and optimizing the care are much needed.

Identifying octogenarians with non-small cell lung cancer who could benefit from surgery: A population-based predictive model

Background

As the population ages, there will be an increasing number of octogenarian patients with non-small cell lung cancer (NSCLC). In carefully selected elderly patients, surgery can improve long-term survival. To identify candidates who would benefit from surgery, we performed this study and built a predictive model.

Materials and methods

Data from NSCLC patients over 80 years old were obtained from the Surveillance, Epidemiology and End Results database. A 1:1 propensity score matching was performed to balance the clinicopathological features between the surgery and non-surgery groups. Kaplan-Meier analyses and log-rank tests were used to assess the significance of surgery to outcome, and Cox proportional-hazards regression and competing risk model were conducted to determine the independent prognostic factors for these patients. A nomogram was built using multivariable logistic analyses to predict candidates for surgery based on preoperative factors.

Results

The final study population of 31,462 patients were divided into surgery and non-surgery groups. The median cancer-specific survival time respectively was 53 vs. 13 months. The patients’ age, sex, race, Tumor, Node, Metastasis score, stage, chemotherapy use, tumor histology and nuclear grade were independent prognostic factors. Apart from race and chemotherapy, other variates were included in the predictive model to distinguish the optimal surgical octogenarian candidates with NSCLC. Internal and external validation confirmed the efficacy of this model.

Conclusion

Surgery improved the survival time of octogenarian NSCLC patients. A novel nomogram was built to help clinicians make the decision to perform surgery on elderly patients with NSCLC.

A Geriatric Assessment Intervention to Reduce Treatment Toxicity Among Older Adults With Advanced Lung Cancer: A Subgroup Analysis From a Cluster Randomized Controlled Trial

Introduction

More older adults die from lung cancer worldwide than breast, prostate, and colorectal cancers combined. Current lung cancer treatments may prolong life, but can also cause considerable treatment-related toxicity.

Objective

This study is a secondary analysis of a cluster-randomized clinical trial which evaluated whether providing a geriatric assessment (GA) summary and GA-guided management recommendations can improve grade 3-5 toxicity among older adults with advanced lung cancer.

Methods

We analyzed participants aged ≥70 years(y) with stage III & IV (advanced) lung cancer and ≥1 GA domain impairment starting a new cancer treatment with high-risk of toxicity within the National Cancer Institute's Community Oncology Research Program. Community practices were randomized to the intervention arm (oncologists received GA summary & recommendations) versus usual care (UC: no summary or recommendations given). The primary outcome was grade 3-5 toxicity through 3 months post-treatment initiation. Secondary outcomes included 6-month (mo) and 1-year overall survival (OS), treatment modifications, and unplanned hospitalizations. Outcomes were analyzed using generalized linear mixed and Cox proportional hazards models with practice site as a random effect. Trial Registration: NCT02054741.

Results & Conclusion

Among 180 participants with advanced lung cancer, the mean age was 76.3y (SD 5.1), 39.4% were female and 82.2% had stage IV disease. The proportion of patients who experienced grade 3-5 toxicity was significantly lower in the intervention arm vs UC (53.1% vs 71.6%, P=0.01). More participants in the intervention arm received lower intensity treatment at cycle 1 (56.3% vs 35.3%; P<0.01). Even with a cycle 1 dose reduction, OS at 6mo and 1 year was not significantly different (adjusted hazard ratio [HR] intervention vs. UC: 6mo HR=0.90, 95% CI: 0.52-1.57, P=0.72; 1 year HR=0.89, 95% CI: 0.58-1.36, P=0.57). Frequent toxicity checks, providing education and counseling materials, and initiating direct communication with the patient's primary care physician were among the most common GA-guided management recommendations. Providing a GA summary and management recommendations can significantly improve tolerability of cancer treatment among older adults with advanced lung cancer.

Measuring Walking Speed Failed to Predict Early Death and Toxicity in Elderly Patients with Metastatic Non-Small-Cell Lung Cancer (NSCLC) Selected for Undergoing First-Line Systemic Treatment: An Observational Exploratory Study

Walking speed (WS) has emerged as a potential predictor of mortality in elderly cancer patients, yet data involving non-small-cell lung cancer (NSCLC) patients are scarce. Our prospective exploratory study sought to determine whether WS would predict early death or toxicity in patients with advanced NSCLC receiving first-line systemic intravenous treatment. Overall, 145 patients of ≥70 years were diagnosed with NSCLC over 19 months, 91 of whom displayed locally-advanced or metastatic cancer. As first-line treatment, 21 (23%) patients received best supportive care, 13 (14%) targeted therapy, and 57 (63%) chemotherapy or immunotherapy. Among the latter, 38 consented to participate in the study (median age: 75 years). Median cumulative illness rating scale for geriatrics (CIRS-G) was 10 (IQR: 8−12), and median WS 1.09 (IQR: 0.9−1.31) m/s. Older age (p = 0.03) and comorbidities (p = 0.02) were associated with Grade 3−4 treatment-related adverse events or death within 6 months of accrual. Overall survival was 14.3 (IQR: 6.1-NR) months for patients with WS < 1 m/s versus 17.3 (IQR: 9.2−26.5) for those with WS ≥ 1 m/s (p = 0.78). This exploratory study revealed WS to be numerically, yet not significantly, associated with early mortality in older metastatic NSCLC patients. Following these hypothesis-generating results, a larger prospective, multicenter study appears to be required to further investigate this outcome.