The curative treatment by radiation therapy alone of Stage I non-small cell lung cancer in a geriatric population

Surgery or radiotherapy for stage I lung cancer? An intention-to-treat analysis

INTRODUCTION

Surgery is the standard of care for early-stage lung cancer, with stereotactic ablative body radiotherapy (SABR) a lower morbidity alternative for patients with limited physiological reserve. Comparisons of outcomes between these treatment options are limited by competing comorbidities and differences in pre-treatment pathological information. This study aims to address these issues by assessing both overall and cancer-specific survival for presumed stage I lung cancer on an intention-to-treat basis.

METHODS

This retrospective intention-to-treat analysis identified all patients treated for presumed stage I lung cancer within a single large UK centre. Overall survival, cancer-specific survival, and combined cancer and treatment-related survival were assessed with adjustment for confounding variables using Cox proportional hazards and Fine-Gray competing risks analyses.

RESULTS

468 patients (including 316 surgery and 99 SABR) were included in the study population. Compared with surgery, SABR was associated with inferior overall survival on multivariable Cox modelling (SABR HR 1.84 (95% CI 1.32-2.57)), but there was no difference in cancer-specific survival (SABR HR 1.47 (95% CI 0.80-2.69)) or combined cancer and treatment-related survival (SABR HR 1.27 (95% CI 0.74-2.17)). Combined cancer and treatment-related death was no different between SABR and surgery on Fine-Gray competing risks multivariable modelling (subdistribution hazard 1.03 (95% CI 0.59-1.81)). Non-cancer-related death was significantly higher in SABR than surgery (subdistribution hazard 2.16 (95% CI 1.41-3.32)).

CONCLUSION

In this analysis, no difference in cancer-specific survival was observed between SABR and surgery. Further work is needed to define predictors of outcome and help inform treatment decisions.

Curative resection for lung cancer in octogenarians is justified

BACKGROUND

Due to an increased life expectancy in a healthy aging population and a progressive incidence of lung cancer, curative pulmonary resections can be performed even in octogenarians. The present study aims to investigate whether surgery is justified in patients reaching the age of 80 years and older who undergo resection for non-small cell lung cancer (NSCLC).

METHODS

In this retrospective multi-centre analysis, the morbidity, mortality and long-term survival of 88 patients (24 females) aged ≥80 who underwent complete resection for lung cancer between 2000 and 2013 were analysed. Only fit patients with few comorbidities, low cardiopulmonary risk, good quality of life and a life expectancy of at least 5 years were included.

RESULTS

Curative resections from three thoracic surgery centres included 61 lobectomies, 9 bilobectomies, 6 pneumonectomies and 12 segmentectomies or wide wedge resections with additional systematic mediastinal lymphadenectomy in all cases. Final histology revealed squamous cell carcinoma [33], adenocarcinoma [41], large cell carcinoma [5] or other histological types [9]. Lung cancer stage distribution was 0 [1], I [53], II [17] and IIIA [14]. The overall 90-day mortality was 1.1%. The median hospitalisation and chest drainage times were 10 days (range, 5-27 days) and 5 days (range, 0-17 days), respectively. Thirty-six patients were complication-free (41%). In particular, pulmonary complications occurred in 25 patients (28%). In addition, 23 patients (26%) developed cardiovascular complications requiring medical intervention, while 24 patients (27%) had cerebrovascular complications, urinary tract infection and others. The median survival time was 51 months (range, 1-110 months), and the 5-year overall survival reached 45% without significance between tumour stages.

CONCLUSIONS

Curative lung resections in selected octogenarians can be safely performed up to pneumonectomy for all tumour stages with a perioperative mortality, morbidity, and 5-year survival rate comparable to younger cohorts.

The SABRTooth feasibility trial protocol: a study to determine the feasibility and acceptability of conducting a phase III randomised controlled trial comparing stereotactic ablative radiotherapy (SABR) with surgery in patients with peripheral stage I non-small cell lung cancer (NSCLC) considered to be at higher risk of complications from surgical resection

Background

Stage I non-small cell lung cancer (NSCLC) is potentially curable, and surgery is considered to be the standard of care for patients with good performance status and minimal co-morbidity. However, a significant proportion of patients with stage I NSCLC have a poorer performance status and significant medical co-morbidity that make them at higher risk of morbidity and mortality from surgery.

Stereotactic ablative radiotherapy (SABR), which uses modern radiotherapeutic techniques to deliver large doses of radiation, has shown superiority over conventional radiotherapy in terms of local control and toxicity and is a standard of care for patients with stage I NSCLC who are at too high risk for surgery. However, it is not known whether surgery or SABR is the most effective in patients with stage I NSCLC who are suitable for surgery but are less fit and at higher risk surgical complications. Previous randomised studies have failed to recruit in this setting, and therefore, a feasibility study is required to see whether a full randomised control trial would be possible.

Methods/design

SABRTooth is a UK-based, multi-centre, open-label, two-group individually (1:1) randomised controlled feasibility study in patients with peripheral stage I NSCLC considered to be at higher risk from surgical resection. The study will assess the feasibility of conducting a definitive large-scale phase III trial. The primary objective is to assess recruitment rates to provide evidence that, when scaled up, recruitment to a large phase III trial would be possible; the target recruitment being 54 patients in total, over a 21-month period. There are multiple secondary and exploratory objectives designed to explore the optimum recruitment and data collection strategies to help optimise the design of a future phase III trial.

Discussion

To know whether SABR is a better, equivalent or inferior alternative to surgery for higher risk patients is a key question in lung cancer. Other studies comparing SABR to surgery have closed early due to poor recruitment, and therefore, the SABRTooth feasibility study has been designed around the UK National Health Service (NHS) cancer pathway incorporating many design features in order to maximise recruitment for a future definitive phase III trial.

Trial registration

controlled-trials.com ISRCTN13029788

Stereotactic ablative body radiation therapy for tumors in the lung in octogenarians: a retrospective single institution study

Background

Treatment of cancer in the lung in octogenarians is limited by their health and functional status. Stereotactic ablative radiotherapy is an established noninvasive treatment option for medically inoperable patients, with a toxicity profile that may be more tolerable in elderly patients.

Methods

Patients more than 80 years old treated with stereotactic ablative radiotherapy for malignant tumors in the lung between January 2007 and August 2012 at a single institution were identified and retrospectively analyzed for toxicity and survival.

Results

Thirty patients were identified with a total of 32 lesions treated. Patients ranged in age from 80.8 to 90.7 years old (median 84.9) at the time of treatment. Twenty patients had ECOG performance status 0–1, and 10 had performance status 2–3. Stage distribution at treatment was: stage I (20 patients), stage III (1), stage IV (1), and 8 recurrent tumors. Patients were treated to a median total dose of 54 Gy in 3 fractions (range 20–60 Gy in 1 to 5 fractions). Median follow up was 13 months (range 2–60 months). Fifteen patients were still living at last review. There was one failure in field and one failure in the same lobe that was treated. One patient died with progressive regional disease, and four died of progressive metastatic disease. Three patients had late grade 3 pulmonary dyspnea with no grade 4 or 5 toxicities. One patient had late grade 2 pneumonitis, and 3 patients had late grade 1 pneumonitis. Three patients had grade 1 chest wall pain.

Conclusions

Octogenarians tolerated ablative treatment with minimal toxicity. Stereotactic ablative body radiotherapy is an option to consider in treatment of elderly patients.

International patterns of radiotherapy practice for non-small cell lung cancer

Radiotherapy is an important treatment modality for non-small cell lung cancer (NSCLC). There are models of radiotherapy utilization that estimate the proportion of patients with NSCLC who have an evidence-based indication for radiotherapy. These estimates range from 46%-68% for radiotherapy utilization at diagnosis and 64%-75% overall. However, actual radiotherapy utilization throughout much of the world is lower than this, ranging from 28%-53%, with the largest differences between actual and estimated radiotherapy utilization seen in stage III NSCLC. Some of this discrepancy is attributable to the assumptions in the models that are based on broad factors such as stage and performance status. Characteristics of the population with underlying lung cancer that often has comorbidities or compromised respiratory function also influence the ability to deliver radiotherapy safely. Sociodemographic factors such as race and income have been found to affect access to radiotherapy in certain jurisdictions. The type of clinician or medical setting the patient presents to initially can also influence radiotherapy use in NSCLC. Potential solutions to improve appropriate radiotherapy utilization for NSCLC include restructuring models of care to ensure that all patients with lung cancer are managed within a multidisciplinary team including a radiation oncologist.

Evaluation and treatment of high-risk patients with early-stage lung cancer

Standard therapy for early-stage non-small cell lung cancer is lobectomy for patients who are able to tolerate such surgery. However, the risk of postoperative morbidity is not trivial, with a 30% to 40% incidence of postoperative complications and a 1% to 5% incidence of operative mortality. Some patients, though technically resectable, refuse surgery or are considered medically inoperable because of insufficient respiratory reserve, cardiovascular disease, or general frailty. This group is considered either "high risk" or "medically inoperable."

Inoperable early stage non-small cell lung cancer: comorbidity, patterns of care and survival

PURPOSE

To evaluate comorbidities, patterns of care and outcomes for patients with inoperable stage I and II non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients diagnosed with stage I or II NSCLC in British Columbia between 1996 and 2005 who did not undergo primary surgery and were referred for oncology assessment were identified in a retrospective analysis. Baseline comorbidity and pulmonary function data for patients treated with curative radiotherapy (CurRT; biologically effective dose [BED]>58 Gy(10)) were abstracted by chart review. Kaplan-Meier and Cox regression were used to determine factors associated with overall survival (OS) and cause-specific survival (CSS) based on treatment group [no radiotherapy (NoRT), palliative radiotherapy (PallRT), or CurRT].

RESULTS

Of 1043 patients identified, approximately 1/3 received CurRT, and these patients had better performance status and lower stage disease than the other groups. There was a high prevalence of comorbid conditions in the CurRT group; 90% of CurRT patients had an age-adjusted Charlson comorbidity index (CCI) score ≥5. CurRT patients had a median survival 1-year longer than patients treated with PallRT or NoRT (p < 0.0001). In CurRT patients, CCI was predictive of OS (HR 1.1 per point CCI increase; p = 0.044), but not CSS. Patients receiving PallRT with a BED > 50 Gy(10) had significantly longer OS than those receiving PallRT of ≤50 Gy(10) (p < 0.0001).

CONCLUSIONS

Treatment of medically inoperable early stage NSCLC patients with CurRT is associated with a significantly longer survival, and for these patients CCI is a significant predictor of OS. For patients treated with PallRT, higher doses of palliative thoracic RT is associated with improved OS.

Do multidisciplinary meetings follow guideline-based care?

PURPOSE

Multidisciplinary meetings (MDMs) are increasingly being mandated as essential to oncology practice. However, there is a paucity of data on their effectiveness. The aim of this study was to assess whether MDM recommendations were concordant with guidelines in the treatment of lung cancer.

PATIENTS AND METHODS

The Lung Cancer Multidisciplinary Meeting in South West Sydney, Australia, prospectively collects data on all patients whose cases have been presented. New patients with lung cancer who presented between December 1, 2005, and December 31, 2007, were reviewed. Patients were assigned to treatment on the basis of evidence-based guidelines according to pathology, stage, and Eastern Cooperative Oncology Group (ECOG) performance status. MDM recommendations were compared with guideline treatment, and reasons for discrepancy were noted.

RESULTS

There were 335 patients with a median age of 69 years. Of these, 82% had non-small-cell lung cancer (NSCLC), 14% had small-cell lung cancer, and 4% had no pathologic diagnosis. Eighty-four percent had locally advanced or metastatic disease. Concordance of MDM recommendations with guideline treatment existed in 29 (58%) of 50 cases for surgery, 201 (88%) of 228 cases for radiotherapy, and 200 (77%) of 260 cases for chemotherapy. Overall concordance with guideline treatment was 71% (239 of 335 cases). On multivariate analysis, age greater than 70 years, ECOG performance status of 2 or higher, and stage III NSCLC were associated with the MDM not recommending guideline treatment. The primary reasons for this were physician decision (39%), comorbidity (25%), and technical factors (22%).

CONCLUSION

MDM recommendations were largely concordant with guidelines. Physician discretion in not recommending guideline treatment was most often exercised in older patients and those with borderline performance status. Individual factors that may preclude guideline treatment cannot be accounted for by guidelines.

Are we treating enough elderly patients with early stage non-small cell lung cancer?

Despite the fact that non-small-cell lung cancer (NSCLC) is very common in the older population, these patients are frequently underrepresented in clinical trials evaluating new anti-cancer agents, and thus it is difficult to reach evidence-based recommendations for this special population. The purpose of the present paper is to present the currently available evidence regarding treatment of early-stages of NSCLC in older patients. Although, age is still considered as a negative factor influencing treatment decisions and curative cancer-directed surgery is often omitted in the older population several studies support that surgical resection is feasible in the older patient and that age per se is not a contraindication for various surgical procedures. Pneumonectomy is associated with a higher mortality in the older population and this issue should be taken into account when deciding whether a patient is suitable for pneumonectomy. Older patients should be considered for adjuvant chemotherapy after surgical resection although little information is available regarding the real benefit and tolerability of these regimens for patients over 75 years of age. Given the lack of demonstrated benefit for the use of adjuvant RT it is also not recommended in older population.

Impact of Introducing Stereotactic Lung Radiotherapy for Elderly Patients With Stage I Non–Small-Cell Lung Cancer: A Population-Based Time-Trend Analysis

Purpose

Stereotactic body radiotherapy (SBRT) for stage I non–small-cell lung cancer (NSCLC) is associated with high local control rates. The impact of introducing SBRT in patients 75 years of age or older was studied using a population-based cancer registry.

Methods

The Amsterdam Cancer Registry was assessed in three eras: 1999 to 2001 (period A, pre-SBRT); 2002 to 2004 (period B, some availability of SBRT), and 2005 to 2007 (period C, full access to SBRT). χ2, Kaplan-Meier, and Cox regression were used to compare treatment patterns and overall survival (OS) in three treatment groups: surgery, radiotherapy (RT), or neither.

Results

A total of 875 elderly patients were diagnosed with stage I NSCLC in the study period. Median follow-up was 54 months. Primary treatment was surgery in 299 patients (34%), RT in 299 patients (34%), and neither in 277 patients (32%). RT use increased between periods A and C (26% v 42%, P < .01), corresponding to a decrease in untreated patients. The percentage of RT patients undergoing SBRT in periods B and C was 23% and 55%, respectively. Median survival for all patients increased from 16 months in period A to 21 months in period C (log-rank P < .01; hazard ratio [HR] = 0.65; 95% CI, 0.54 to 0.80). The improvement in OS was confined to RT patients (HR = 0.70; 95% CI, 0.49 to 0.99), whereas no significant survival improvements were seen in the other groups.

Conclusion

SBRT introduction was associated with a 16% absolute increase in RT use, a decline in the proportion of untreated elderly patients, and an improvement in OS.

Stage I non-small cell lung cancer (NSCLC) in patients aged 75 years and older: does age determine survival after radical treatment?

INTRODUCTION

Curative treatment of stage I non-small cell lung cancer (NSCLC) in elderly patients represents a therapeutic challenge. Data examining outcomes for the elderly after radical radiotherapy (RT) or surgery in the same geographic population are limited.

METHODS

Using prospective databases from British Columbia, patients with stage I NSCLC treated curatively with either surgery or RT between 2000 and 2006 were identified. Kaplan-Meier, Cox regression, and competing risk analyses were used to assess overall survival (OS) and disease-specific survival in the elderly, and the relationship between age and survival outcomes.

RESULTS

Of a total of 558 patients with stage I disease, 310 (56%) received surgery and 248 (44%) received RT. Elderly patients (age > or =75 years) were less likely to undergo resection than their younger counterparts (43% versus 72%, p < 0.0001). Actuarial OS after surgery for elderly patients was 87% at 2 years and 69% at 5 years. On multivariate analysis, OS after surgery was dependent on tumor stage (p = 0.034) and performance status (p = 0.03), but not age (p = 0.87). After RT, actuarial OS for elderly patients was 53% at 2 years and 23% at 5 years. On multivariate analysis, age did not predict for OS after RT (p = 0.43), whereas tumor stage (p = 0.033), sex (p = 0.044), and dose (p = 0.01) were significant predictors.

CONCLUSIONS

Survival after radical treatment for stage I NSCLC is dependent on factors such as tumor stage, performance status, sex, and RT dose, but not age. Elderly patients who are sufficiently fit should not be considered ineligible for radical treatment based on age alone.

Lung cancer in octogenarians

BACKGROUND

Lung cancer has progressively become a disease of older people, with the median age at diagnosis now exceeding 70 years. Octogenarians represent a rapidly growing proportion of patients diagnosed with lung cancer and can present distinct challenges. Nevertheless, current literature that has set the evidence-based standards of care in this disease does not include significant numbers of patients older than 80 years.

METHODS

We have compiled and reviewed the available literature on the specific management and treatment of lung cancer in patients older than 80 years.

RESULTS

Retrospective series suggest that surgery is safe and effective in treating early-stage non-small cell lung cancer in selected patients older than 80 years. There is minimal data to support the use of adjuvant chemotherapy in this group. In addition, no data exist on the use of combined chemotherapy and radiotherapy for locally advanced disease. In advanced or metastatic disease, similar to younger elderly populations, single-agent chemotherapy is feasible and seems to offer benefit in terms of symptoms and outcomes. Small cell lung cancer in this population is not well characterized, but small studies suggest symptom improvement and prolongation of survival with the use of chemotherapy.

CONCLUSION

Based on retrospective series, octogenarians with lung cancer can derive benefit from many of the treatment modalities used for younger patients including surgery for early-stage disease and single-agent chemotherapy for advanced disease. More elderly specific trials are needed to better refine treatment decisions and improve the care of lung cancer in this group.

Thoracic irradiation in the elderly

This article has reviewed radiation treatment of thoracic malignancies in elderly patients. In general the literature suggests that thoracic irradiation is equally efficacious in elderly patients as in younger patients and is associated with increased but acceptable toxicity. Technical advances are allowing a further reduction in morbidity with preliminary results suggestive of stable outcomes. Prospective data from elderly specific trials are needed to determine the optimal treatment of lung cancer and to compare innovative radiation technology with standard therapies.

EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIOG) experts' opinion for the treatment of non-small-cell lung cancer in an elderly population

Non-small-cell lung cancer (NSCLC) represents a common health issue in the elderly population. Nevertheless, the paucity of large, well-conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The present paper reviews the currently available evidence regarding treatment of all stages of NSCLC in elderly patients. Surgery remains the standard for early-stage disease, though pneumonectomy is associated with higher incidence of postoperative mortality in elderly patients. Given the lack of demonstrated benefit for the use of adjuvant radiotherapy, it is also not recommended in elderly patients. Elderly patients seem to derive the same benefit from adjuvant chemotherapy as younger patients do, with no significant increase in toxicity. For locally advanced NSCLC, concurrent chemoradiotherapy may be offered to selected elderly patients as there is a higher risk for toxicity reported in the elderly population. Third-generation single-agent treatment is considered the standard of care for patients with advanced/metastatic disease. Platinum-based combination chemotherapy needs to be evaluated in prospective trials. Unfortunately, with the exception of advanced/metastatic NSCLC, prospective elderly-specific NSCLC trials are lacking and the majority of recommendations made are based on retrospective data, which might suffer from selection bias. Prospective elderly-specific trials are needed.

Radiation therapy in the elderly: more side effects and complications?

Aging is associated with physiological changes and comorbid illnesses, which may affect an individual's tolerance to radiation. There is the belief that a relationship exists between age and radiation toxicity and therefore non-curative schemes are offered to older patients. Preclinical studies show that normal tissue radiation-induced toxicity differs little with age. In the clinical setting, retrospective and some prospective studies have reported that elderly patients treated with radical radiotherapy alone or in combination with chemotherapy, who do not have comorbidities and retain a good performance status, show a benefit in treatment outcomes. However, an increase in acute effects or a lowered functional tolerance has also been reported. To select candidates for radical treatments, a specific geriatric assessment should be used to stratify elderly patients as a function of the physiological status. Only specifically designed prospective studies can define the role of radiation treatment in elderly patients with different physiological status.

[Treatment of non-small cell lung cancer in elderly patients]

Lung cancer is the most common cause of cancer death. With the aging of the population, more than 50% of patients with non-small cell lung cancer (NSCLC) are older than 65 years. Until recently, there was some scepticism regarding treatment of patients in this age group, prevailing the notion that whatever treatment was given, the balance between the benefits and the side effects was unfavourable. The organ failure dependent of age, the comorbidities, the polimedication and the fragility of elderly people, were responsible for this generalized opinion. In the last few years, this nihilistic approach has changed radically. When deciding what treatment strategy should be used in these patients, the biological age (based on performance status: PS and comorbidities) rather than the chronological age should be taken into account, and the modification of standard treatment plans should only be made when there is a valid reason. This applies equally to surgery, chemotherapy, radiotherapy and the new targeted agents, the therapeutic weapons available to treat this disease. Recently published studies, that specifically analysed elderly patients, proved that if treated adequately, elderly patients with a good PS and without major comorbidities have the same survival rates and quality of life as younger patients. The rising number of elderly patients with lung cancer led the authors to do a review of the literature on this topic.

Lung cancer in octogenarians: factors affecting long-term survival following resection

OBJECTIVE

To identify factors associated with long-term survival following pulmonary resection for lung cancer in patients 80 years of age or older.

METHODS

The medical records of all patients >or=80 years, who underwent pulmonary resection for lung cancer from 1985 to 2002, were reviewed.

RESULTS

There were 294 patients (192 men, 102 women). Median age was 82 years (range 80-94 years). Overall 1-, 2-, and 5-year survival was 80%, 62%, and 34%, respectively. Histologic subtype, diabetes, renal insufficiency, prior myocardial infarction, congestive heart failure or stroke were not significantly associated with differences in 5-year survival. Female gender was associated with increased survival (36.2% vs 32.7% at 5 years, p=0.04). Extent of preoperative forced expiratory volume in 1s (FEV1) limitation did not influence survival. However, there were no 5-year survivors amongst patients with dyspnea as their presenting chief complaint, whereas there was a 35% 5-year survival in patients presenting without dyspnea (p<0.001). Five-year survival by pathologic stage was IA, 48%; IB, 39%; IIA, 17%; IIB, 23%; IIIA, 9%; and IIIB, 0% (p<0.001). Five-year survival of patients undergoing a lobectomy was 42% versus 11% for pneumonectomy (p<0.001).

CONCLUSIONS

Meaningful long-term survival is obtainable in elderly patients undergoing surgical resection for lung cancer. Careful patient evaluation and selection is necessary to identify patients who will benefit most from resection. Shorter survival was observed in male patients and those presenting with dyspnea. As could be expected, survival was also dependent on extent of resection and initial pathologic stage.

Radiation therapy for older cancer patients

Cancer is the leading cause of death among the elderly. With the dramatic increase in life expectancy, treatment approach of older cancer patients poses major challenges. There is no consensus on treatment guidelines for elderly cancer patients with significant variability among physicians due to concerns for toxicity. The issue is further complicated by a lack of quality data on age-related issues of cancer management. This review highlights important factors relevant to treatment decision making in older cancer patients with special emphasis on radiation therapy for lung, prostate and breast cancer. The potential benefits of recent innovations and emerging radiotherapeutic technologies and their application to elderly cancer patients is also presented.

Pretreatment prognostic factors in patients with early-stage (I/II) non–small-cell lung cancer treated with hyperfractionated radiation therapy alone

PURPOSE

To investigate influence of various pretreatment prognostic factors in patients with early stage (I/II) non-small-cell lung cancer (NSCLC) treated with hyperfractionated radiation therapy alone.

PATIENTS AND METHODS

One hundred and sixteen patients were treated with tumor doses of 69.6 Gy, 1.2-Gy, twice-daily fractionation. There were 49 patients with Stage I and 67 patients with Stage II. Eighty patients had Karnofsky performance status (KPS) 90-100 and 95 patients had <5% weight loss. Peripheral tumors were observed in 57 patients. Squamous histology was observed in 70 patients and the majority of patients had concomitant disease (n=72).

RESULTS

The median survival time for all patients was 29 months; 5-year survival was 29%. The median time to local progression and the distant metastasis were not achieved, whereas 5-year local progression-free and distant metastasis-free survivals were 50% and 72%, respectively. Multivariate analysis identified KPS, weight loss, location, histology, and the reason for not undergoing surgery as prognostic factors for survival. KPS, location, and histology influenced local progression-free survival, whereas only KPS and weight loss influenced distant metastasis-free survival.

CONCLUSIONS

This retrospective analysis identified KPS and weight loss as the most important prognostic factors of outcome in patients with early-stage NSCLC treated with hyperfractionation radiation therapy.

Insight into the treatment of cancer in older patients: Developments in the last decade

In the last decades there has been an increased interest in the treatment of elderly cancer patients and a change in attitude of both clinicians and their patients has occurred. Drugs are now available that might be considered "elderly-friendly" and the enormous advances in surgical procedures and supportive treatments over the recent years have enabled adverse effects to be minimized. A Geriatric Assessment is increasingly used as a tool to define those patients who are more suitable for aggressive chemotherapy or, on the contrary, palliative treatment. For almost all cancers, older patients are better treated today than they were in the past, even though we are still far from optimal management. Despite the perceived barriers to including elderly patients in clinical trials, there are few data to support excluding them. We must not permit increased age in cancer patients to continue to be an important and independent risk factor for receiving inadequate care.

Radiation therapy alone in elderly with early stage non-small cell lung cancer

BACKGROUND

Radiation therapy (RT) alone is frequently used in elderly patients with medically inoperable early stage (I/II) non-small cell lung cancer (NSCLC). We retrospectively investigated the effectiveness of RT alone in this patient population treated in our institution.

MATERIAL AND METHODS

Between 1995 and 1999, a total of 33 patients were treated with RT alone in our institution, all being males. RT doses ranged 66-78 Gy (median, 70 Gy) using standard fractionation (2.0 Gy per fraction). The age range was 71-97 years (median, 75 years) with 11 patients being >or=80 years old. Twenty-two (67%) patients had a squamous cell carcinoma. There were 24 (73%) stage I and nine (27%) stage II patients.

RESULTS

Radiographic objective response rate was observed in 23 (70%) patients. The median survival time was 37.4 months and 3-year survival time was 50%, while the median cause-specific survival time was 48.1 months and a 3-year cause-specific survival rate was 55.3%. The median time to local recurrence was 36.8 months and a 3-year local recurrence-free survival rate was 50.2%, while the median time to distant metastasis was not achieved yet, the 3-year distant metastasis-free survival rate being 71.4%. One (3%) patient died of RT-induced acute lung toxicity, while only two (6%) patients experienced late grade 3 lung toxicity. No other high-grade toxicity was observed during this study.

CONCLUSIONS

RT alone was effective and low toxic in elderly with early stage (I/II) NSCLC and could be considered as treatment of choice in this patient population.

Radiation therapy in the elderly

The purpose of this review is to highlight aspects of radiation oncology specifically related to aging and caring for the older patient with cancer. Particular emphasis is placed on the preclinical and clinical studies focusing on the efficacy and toxicity of RT in this population. Special techniques are also reviewed that have particular relevance to the treatment of the elderly.

Concurrent hyperfractionated radiotherapy and low-dose daily carboplatin/paclitaxel in patients with early-stage (I/II) non-small-cell lung cancer: long-term results of a phase II study

PURPOSE

Feasibility and activity of concurrent hyperfractionated radiotherapy (Hfx RT) and low-dose, daily carboplatin and paclitaxel were investigated in patients with early-stage (I/II) non-small-cell lung cancer in a phase II study.

PATIENTS AND METHODS

Fifty-six patients started their treatment on day 1 with 30 mg/m2 of paclitaxel. Hfx RT using 1.3 Gy bid to a total dose of 67.6 Gy and concurrent low-dose daily carboplatin 25 mg/m2 and paclitaxel 10 mg/m2, both given Mondays through Fridays during the RT course, started from the second day.

RESULTS

There were 29 complete responses (52%) and 15 partial responses (27%), and 12 patients (21%), experienced stable disease. The median survival time was 35 months, and 3- and 5-year survival rates were 50% and 36%, respectively. The median time to local progression has not been achieved, but 3- and 5-year local progression-free survival rates were 56% and 54%, respectively. The median time to distant metastasis has not been achieved, but 3- and 5- year distant metastasis-free survival rates were 61% and 61%, respectively. The median and 5-year cause-specific survivals were 39 months and 43%, respectively. Acute high-grade (> 3) toxicity was hematologic (22%), esophageal (7%), or bronchopulmonary (7%). No grade 5 toxicity was observed. Late high-grade toxicity was rarely observed (total, 10%).

CONCLUSION

Hfx RT and concurrent low-dose daily carboplatin/paclitaxel was feasible with low toxicity and effective in patients with stage I/II non-small-cell lung cancer. It should continue to be investigated for this disease.

Undertreatment of Elderly Patients with Non–Small-Cell Lung Cancer

The absolute number of patients with lung cancer is rising as a result of our aging population. Until recently, clinicians have been reluctant to aggressively treat elderly patients with non-small-cell lung cancer (NSCLC) because of a lack of supportive data and concern for potential toxicity. Recently, evidence has emerged that suggests that, similar to younger patients, healthy elderly patients can benefit from therapy in all stages of NSCLC. This review will discuss the findings that indicate that chronologic age alone should not be a barrier to appropriate treatment for NSCLC, but consideration should be given to more important prognostic factors such as comorbidities and performance status.

Influence of age, comorbidity and performance status on the choice of treatment for patients with non-small cell lung cancer; results of a population-based study

BACKGROUND

In the Netherlands in 1997, 43% of patients with newly diagnosed lung cancer were over 70. Large age-specific differences in treatment exist. We examined whether age, comorbidity, performance status and pulmonary function influenced treatment.

PATIENTS AND METHODS

Data on patients with newly diagnosed non-small cell lung cancer (N = 803) were obtained: comorbidity, performance status, pulmonary function (FEV1) and initial treatment. Age-specific differences in treatment according to the guidelines were examined. Odds ratios were calculated by means of logistic regression analyses.

RESULTS

82% with stage I or II disease received treatment according to the guidelines; this applied to 48% with stage IIIA disease and to 54% with stage IIIB disease. For all stages, this proportion decreased with increasing age. In stage IV disease, 36% did not receive any treatment; this applied to 52% of the elderly patients (75+ years). Multivariate analyses showed associations between comorbidity and treatment choice, but none with performance status. Age of 75+ years appeared to be the most important factor for not receiving treatment according to guidelines.

CONCLUSION

A substantial proportion of elderly patients with non-small cell lung cancer did not receive standard treatment. Performance status and comorbidity seldom formed the underlying reason. Calendar rather than biological age seemed to play the most important role in choice of treatment for patients with non-small cell lung cancer.

Non-small cell lung cancer in the elderly

The population is aging both in developing and developed countries. What is clear is that currently over 50% of all patients with non-small cell lung cancer (NSCLC) are 65 years of age or older. When deciding a treatment strategy, the biological rather than the chronological age should be carefully assessed, and treatment should only be modified or withheld for very good reason. This applies equally to surgery, radiation therapy, and chemotherapy. Fortunately, recently published studies have focused on the issue and have provided strong evidence of improved progression-free survival, overall survival, and quality of life in elderly patients with appropriately treated NSCLC.

[Prognostic indicators in stage I non-small cell lung cancer]

INTRODUCTION

Determinating the prognosis of patients with stage I non-small cell lung cancer (NSCLC) is a challenge. Since up to 30% of patients who have undergone surgical resection experience recurrence, generally in distant organs, it is reasonable to postulate that neo-adjuvant or adjuvant treatments might be useful. Better knowledge of prognostic factors could perhaps define which patient populations should be targeted with such treatments.

STATE OF THE ART

Numerous potential prognostic factors, relating to the disease (TNM classification, histology, tumor size, blood vessels invasion, micro-metastasis, serum or molecular markers), the patient (gender, age, co-morbidity) as well as the treatment (delay, resection, lymph node dissection, neo-adjuvant and adjuvant treatments), are discussed.

PERSPECTIVES

These prognostic factors should be integrated into the design of future clinical trials of chemotherapy and/or radiotherapy attempting to evaluate the effectiveness of various combinations of neo-adjuvant or adjuvant therapies.

CONCLUSIONS

These factors may offer the opportunity to clinically and biologically characterize the different subgroups of patients, leading to a more rational, and perhaps individualized, choice of therapy.

Radiation therapy alone in early stage non-small cell lung cancer

Among the patients with early stage (I/II) non-small cell lung cancer (NSCLC), there are those who, due to medical comorbidities, advanced age, or refusal, never undergo surgery. For them, exclusive radiation therapy (RT) has been the treatment of choice, achieving median survival times of 30 months and 5-year survival of up to 42%. Doses of > or =65 Gy with standard fractionation (or its radiobiological equivalent when altered fractionation is used) are necessary for long-lasting local control of the disease, with smaller tumors having a more favorable prognosis. The issue of elective nodal irradiation (ENI) remains controversial, since failure patterns identified local failure as the predominant pattern. None of the potential pretreatment patient- and tumor-related prognostic factors has been shown to clearly influence survival. Toxicity is generally mild to moderate, although high doses (e.g., 80 Gy) may carry a risk for an excessive rate of side effects. Conformal treatment and consideration of comorbidities such as altered lung function may be essential, since simultaneous supportive treatment of acute sequelae (mainly acute esophagitis) is necessary. RT is an effective treatment modality in technically operable, but medically inoperable patients with early stage NSCLC and offers a long-lasting cure.

Clinical patterns and treatment outcome of elderly patients in clinical stage IB/II non-small cell lung cancer

BACKGROUND AND OBJECTIVES

Surgery is a standard treatment in patients with clinical stage IB/II non-small cell lung cancer (NSCLC). We often have difficulty in treating of elderly patients due to their insufficient physiological function. To better manage such elderly patients, the clinical characteristics and prognosis of patients with these stages, who were 75 years of age or older, were reviewed.

METHODS

From 1972 to 1999, 112 elderly patients with these stages were treated in our department. These patients comprised 88 men and 24 women. The histological types were 50 adenocarcinomas, 51 squamous cell carcinomas, 8 large cell carcinomas, and 3 adenosquamous carcinomas.

RESULTS

Seventy-four patients (66%) underwent a surgical resection, including 60 surgery alone, 14 combined modality therapy. Radiotherapy, with or without chemotherapy, was given to 30 patients (27%), and chemotherapy alone to 5 (4.5%). In addition, 3 (2.7%) were given no therapy. The survivals of the surgery group at 2 and 5 years are 53% and 21% and those of the radiotherapy group are 35% and 3%, respectively. A multivariate analysis in radiotherapy group shows the predominant prognostic factor to be adenocarcinoma. The 2-year survival of the radiotherapy group in patients with adenocarcinoma is 58%, while that of patients with squamous cell carcinoma is 22%.

CONCLUSIONS

These above observations suggest that radiotherapy is an alternative strategy for patients who cannot undergo surgery, especially with adenocarcinoma.

Curative approaches to lung cancer in the elderly

Lung cancer is a common disease in elderly patients, and the increase in the size of the elderly population will lead to an increased proportion of elderly among lung cancer patients in the future. The prognosis of lung cancer is still poor, but curative approaches are feasible for patients with local stage NSCLC and for some patients with limited disease (LD) SCLC. The evidence for these curatively-intended approaches is derived from studies that are usually performed with highly selected patients. Elderly patients are underrepresented, and in daily clinical practice elderly patients are less likely to be treated with full standard approaches. We used the data from studies that focused particularly on the elderly, or provided subgroup information on age, to analyze the feasibility of applying current standard approaches to the elderly. We also discuss alternative approaches. Age alone is a very uncertain prognostic criterion for outcome or tolerability of treatment. It is much more important to obtain a comprehensive geriatric assessment of each individual patient. When adequate patient selection is provided, standard treatment approaches appear to be feasible for elderly (>70 years) patients with good performance status.

The outcome of combined-modality therapy for stage III non-small-cell lung cancer in the elderly

PURPOSE

The North Central Cancer Treatment Group performed a phase III trial to determine whether chemotherapy plus either bid radiation therapy (RT) or daily (qd) RT resulted in a better outcome for patients with stage III non-small-cell lung cancer (NSCLC). No difference in survival was identified between the two arms. This secondary analysis was performed to examine the relationship between patient age and outcome.

PATIENTS AND METHODS

Two hundred forty-six patients were randomized to receive etoposide plus cisplatin and either RT qd or split-course RT bid. This retrospective study compared the outcomes of patients aged >/=70 years ("elderly patients") with those of younger individuals. Of the 244 assessable patients, 63 (26%) were elderly, and 181 (74%) were younger individuals.

RESULTS

The 2-year and 5-year survival rates were 39% and 18%, respectively, in patients younger than 70 years, compared with 36% and 13%, respectively, in elderly patients (P =.4). Grade 4+ toxicity occurred in 62% of patients younger than 70 years compared with 81% of elderly patients (P =.007). Grade 4+ hematologic toxicity occurred in 56% of patients younger than 70 years, compared with 78% of elderly patients (P =.003). Grade 4+ pneumonitis occurred in 1% of those younger than 70 years, compared with 6% of elderly patients (P =.02).

CONCLUSION

Toxicity, especially myelosuppression and pneumonitis, was more pronounced in the elderly patients receiving combined-modality therapy for locally advanced NSCLC. Despite increased toxicity, elderly patients have survival rates equivalent to younger individuals. Therefore, fit, elderly patients with locally advanced NSCLC should be encouraged to receive combined-modality therapy, preferably on clinical trials with cautious, judicious monitoring. Future studies should explore ways to decrease toxicity of therapy in elderly patients.

Do dose-volume metrics predict pulmonary function changes in lung irradiation?

PURPOSE

To examine the ability of standard dose-volume metrics to predict pulmonary function changes as measured by pulmonary function tests (PFTs) in a group of patients with non-small-cell lung cancer treated with nonconventional beam arrangements on a Phase I dose-escalation study. In addition, we wanted to examine the correlation between these metrics.

MATERIALS AND METHODS

Forty-three patients received a median treatment dose of 76.9 Gy (range 63-102.9). Eight patients also received induction chemotherapy with cisplatin and vinorelbine. They all had pre- and posttreatment PFTs >/=3 months (median 6.2) after treatment. The volume of normal lung treated to >20 Gy, effective volume, and mean lung dose were calculated for both lungs for all patients. Linear regression analysis was performed to determine whether correlations existed between the metrics and changes in the PFTs. Additionally, the three metrics were compared with each other to assess the degree of intermetric correlation.

RESULTS

No correlation was found between the volume of normal lung treated to >20 Gy, effective volume, and mean lung dose and changes in the PFTs. Subgroup analyses of patients without atelectasis before irradiation, Stage I and II disease, or treatment without induction chemotherapy were also performed. Again, no correlation was found between the dose-volume metrics and the PFT changes. The intermetric correlation was good among all three dose-volume metrics.

CONCLUSIONS

In this relatively small series of patients, dose-volume metrics that correlate with the risk of pneumonitis did not provide a good model to predict early changes in pulmonary function as measured with PFTs.

Treatment of lung cancer in the elderly. Part I: non-small cell lung cancer

There is a general trend worldwide of an increasing incidence of elderly population. Age is the greatest risk factor for cancer; therefore, this demographic shift is the main reason for an increase of cancer incidence. Lung cancer is a typical disease of the elderly patients. This review summarizes the issues of treatment of non-small cell lung cancer (NSCLC) in the elderly. Early stage NSCLC is usually treated with radical surgery, locally advanced NSCLC with radiotherapy (RT) and/or chemotherapy (CHT) and metastatic disease with CHT, but the evidence for these approaches is based on studies which are usually performed with highly selected patients while elderly patients are under-represented. We used the data from studies addressing particularly elderly or providing subgroup information on age to analyse the feasibility of current standard approaches for elderly and discuss alternative approaches. Surgery is an effective method in elderly patients with early stage NSCLC although some approaches bear a somewhat higher risk of operative morbidity and mortality. RT for early stage may be an alternative with curative potential. For locally advanced stage RT alone, or combined radiochemotherapy in selected cases, is feasible for elderly patients with locally advanced NSCLC when a careful assessment of pre-therapeutic status is made and appropriate drugs are selected. Advanced age alone also should not preclude CHT, although the risk of adverse effect may be higher in certain cases. New generation drugs seem to be particularly feasible and efficient in elderly patients. In general, age itself does not seem to preclude patients from standard treatments although in some cases co-morbidity forces to alternative approaches. Currently, single-agent CHT should be considered as the standard treatment of advanced NSCLC elderly patients.

Radiotherapy alone in technically operable, medically inoperable, early-stage (I/II) non-small-cell lung cancer

PURPOSE

To investigate the effectiveness of high-dose, curative radiotherapy (RT) given alone in technically operable, but medically inoperable, patients with early-stage (I-II) non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Computerized and manual searches were done to identify published reports dealing with curative RT for NSCLC. Relevant studies were identified and the information provided therein was extracted regarding patient and treatment characteristics, treatment outcome, and various pretreatment and treatment-related factors influencing outcome, as well as toxicity and quality-of-life issues.

RESULTS

Although a large variation of pretreatment and treatment characteristics was noted in the available studies, a median survival time of >30 months and a 5-year survival rate of up to 30% had been achieved. Accumulated experience seems to suggest that doses of at least 65 Gy with standard fractionation, or its equivalent when altered fractionation is used, are necessary for control of NSCLC. Smaller tumors seem to have a favorable prognosis, and the issue of elective nodal RT continues to be controversial. Analyses of patterns of failure have clearly identified local failure as the predominant pattern. Although a number of potential pretreatment patient- and tumor-related prognostic factors have been examined, none has been shown to clearly influence survival. Toxicity was usually low, but very high doses (e.g., 80 Gy) given with a conventional approach may carry a risk of an excessive rate of side effects.

CONCLUSION

High-dose, curative RT is an effective treatment modality in technically operable, but medically inoperable, patients with early-stage NSCLC.

Updates in surgical oncology for elderly patients

Elderly patients affected by solid tumours are frequently encountered on the surgical ward. Prejudice regarding operative risks and long term outcomes may alter their surgical management. Large series of elderly cancer subjects have been analysed and conclusive data are now available, to better tailor their management. Specific epidemiological data are presented in this review, screening programs critically considered, treatment procedures discussed, and the effectiveness of follow-up protocols is analysed together with cost effectiveness issues. Quality of life issues should not be neglected, and a continuous educational endeavour targeted at specialists and general practitioners is desirable.

Has 3-D conformal radiotherapy (3D CRT) improved the local tumour control for stage I non-small cell lung cancer?

AIMS AND BACKGROUND

The high local failure rates observed after radiotherapy in stage I non-small cell lung cancer (NSCLC) may be improved by the use of 3-dimensional conformal radiotherapy (3D CRT).

MATERIALS AND METHODS

The case-records of 113 patients who were treated with curative 3D CRT between 1991 and 1999 were analysed. No elective nodal irradiation was performed, and doses of 60Gy or more, in once-daily fractions of between 2 and 3Gy, were prescribed.

RESULTS

The median actuarial survival of patients was 20 months, with 1-, 3- and 5-year survival of 71, 25 and 12%, respectively. Local disease progression was the cause of death in 30% of patients, and 22% patients died from distant metastases. Grade 2-3 acute radiation pneumonitis (SWOG) was observed in 6.2% of patients. The median actuarial local progression-free survival (LPFS) was 27 months, with 85 and 43% of patients free from local progression at 1 and 3 years, respectively. Endobronchial tumour extension significantly influenced LPFS, both on univariate (P=0.023) and multivariate analysis (P=0.023). The median actuarial cause-specific survival (CSS) was 19 months, and the respective 1- and 3-year rates were 72 and 30%. Multivariate analysis showed T2 classification (P=0.017) and the presence of endobronchial tumour extension (P=0.029) to be adverse prognostic factors for CSS. On multivariate analysis, T-stage significantly correlated with distant failure (P=0.005).

CONCLUSIONS

Local failure rates remain substantial despite the use of 3D CRT for stage I NSCLC. Additional improvements in local control can come about with the use of radiation dose escalation and approaches to address the problem of tumour mobility.

Therapy for stage I and stage II non-small cell lung cancer

Despite complete resection of what seems to be all evident tumor, one third to three quarters of patients with stages I and II NSCLC ultimately succumb to this neoplasm. Patients who are cured of an original NSCLC or small cell cancer remain at risk for a new primary lung cancer. Although the importance of lifelong surveillance is clear, the extent and timing of optimal follow-up remain undefined. Although clinicians refer to the development after treatment of clinically discernible sites of tumor as "recurrence," it is probably more accurate to consider these foci as "persistence"--that is, the locoregional site was not sterilized by surgery, and the distant implants were present from the outset but undetected. Although data are sparse, induction and improved adjuvant therapy for early NSCLC may be helpful. Much further experience is needed. Further study and application of biologic indicators in addition to TNM staging likely will help identify patients at high risk for surgical failure who may benefit by combination treatment.

Inoperable localized stage I and stage II non-small-cell lung cancer

Early stage, medically inoperable non-small-cell lung cancer is a treatable disease. A thorough clinical work-up is necessary to optimize management for this group of patients. Thoracic radiation therapy has been used for such patients with achievement of durable local control and prolonged survival. To improve upon the results of standard fractionation radiation therapy, novel approaches are needed. Dose escalation may further enhance local tumor control and survival rates. Efforts to minimize irradiation to normal lung parenchyma are necessary. Multiple strategies to optimize the therapeutic ratio are being investigated. Elimination of elective nodal irradiation may reduce late toxicity of treatment but may compromise locoregional control. Other strategies, such as intensity-modulated radiation therapy with dose volume histograms will help minimize lung parenchyma irradiation, which will reduce the probability of radiation pneumonitis. Chemotherapy appears to play a minimal role in the treatment of inoperable limited disease, but researchers continue to conduct investigational trials with active chemotherapeutic agents in the hopes of reducing local and distant tumor failures.