Treatment of small cell lung cancer in the elderly

Comorbidity in limited disease small-cell lung cancer: Age-adjusted Charlson comorbidity index and its association with overall survival following chemoradiotherapy

Background

Combined, platinum-based thoracic chemoradiotherapy (TCR) is the current state-of-the-art treatment for patients with limited disease (LD) small-cell lung cancer (SCLC). There is only limited data available regarding the effect of comorbidities on survival following TRC. The purpose of this study is to assess the age-adjusted Charlson comorbidity index (ACCI) as a predictor of overall survival in LD-SCLC patients undergoing TCR.

Patients and methods

We retrospectively analyzed 367 SCLC patients diagnosed with LD-SCLC who received TCR between 2003 and 2017. We evaluated the ACCI (n = 348) as a predictor of overall survival (OS). In this cohort, 322 patients (88%) received platinum-based TCR (either cisplatin or carboplatin), and 37 (10%) patients received vincristine based TCR. Median radiation dose was 60 Gy (range 24-66 Gy). Additionally, 83% of patients (n = 303) received prophylactic cranial irradiation (PCI, 30 Gy in 2 Gy fractions). Kaplan-Meier survival analysis was performed for OS. For comparison of survival curves, Log-rank (Mantel-Cox) test was used. Univariate and multivariate Cox proportional-hazards ratios (HRs) were used to assess the influence of cofactors on OS.

Results

Patients with an ACCI > 6 had a significantly shorter OS compared with patients with an ACCI ≤ 6 (median 11 vs. 20 months; p = 0.005). Univariate analysis for OS revealed a statistically significant effect for ACCI > 6 (HR 1.7; 95% CI 1.2-2.4; p = 0.003), PCI (HR 0.5; 95% CI 0.3-0.7; p < 0.001), and Karnofsky performance status ≤ 70% (KPS) (HR 1.4; 95% CI 1.1-1.90; p = 0.015). In multivariate analysis, OS was significantly associated with PCI (HR 0.6; 95% CI 0.4-0.9; p = 0.022) and ACCI > 6 (HR 1.5; 95% CI 1.0-2.1; p = 0.049).

Conclusion

Comorbidity is significantly associated with survival in patients with LD-SCLC undergoing TCR. The ACCI may be a valuable tool to identify patients with a shorter survival and thus might be used for risk stratification and oncological decision making.

Trilaciclib prior to chemotherapy and atezolizumab in patients with newly diagnosed extensive-stage small cell lung cancer: A multicentre, randomised, double-blind, placebo-controlled Phase II trial

Trilaciclib is an intravenous CDK4/6 inhibitor administered prior to chemotherapy to preserve haematopoietic stem and progenitor cells and immune system function from chemotherapy-induced damage (myelopreservation). The effects of administering trilaciclib prior to carboplatin, etoposide and atezolizumab (E/P/A) were evaluated in a randomised, double-blind, placebo-controlled Phase II study in patients with newly diagnosed extensive-stage small cell lung cancer (ES-SCLC) (NCT03041311). The primary endpoints were duration of severe neutropenia (SN; defined as absolute neutrophil count <0.5 × 109 cells per L) in Cycle 1 and occurrence of SN during the treatment period. Other endpoints were prespecified to assess the effects of trilaciclib on additional measures of myelopreservation, patient-reported outcomes, antitumour efficacy and safety. Fifty-two patients received trilaciclib prior to E/P/A and 53 patients received placebo. Compared to placebo, administration of trilaciclib resulted in statistically significant decreases in the mean duration of SN in Cycle 1 (0 vs 4 days; P < .0001) and occurrence of SN (1.9% vs 49.1%; P < .0001), with additional improvements in red blood cell and platelet measures and health-related quality of life (HRQoL). Trilaciclib was well tolerated, with fewer grade ≥3 adverse events compared with placebo, primarily due to less high-grade haematological toxicity. Antitumour efficacy outcomes were comparable. Administration of trilaciclib vs placebo generated more newly expanded peripheral T-cell clones (P = .019), with significantly greater expansion among patients with an antitumour response to E/P/A (P = .002). Compared with placebo, trilaciclib administered prior to E/P/A improved patients' experience of receiving treatment for ES-SCLC, as shown by reduced myelosuppression, and improved HRQoL and safety profiles.

Comorbidity as a Prognostic Factor in Small Cell Lung Cancer

Aims and Background

Many factors have prognostic significance in small cell lung cancer (SCLC). The aim of this study was to define the prognostic factors influencing the response to therapy and the survival in SCLC.

Methods

A consecutive series of 90 patients with SCLC was analyzed retrospectively using 32 pretreatment and 3 treatment-related prognostic factors with respect to their influence on survival. Prognostic factors were evaluated by univariate analysis and by the Cox multivariate regression model. Patients who survived more than 2 months were included in the univariate analysis.

Results

The median survival of the whole population was 7 months, with a 1-year survival rate of 20%. In univariate analysis, prognosis was significantly influenced by gender, comorbidity, thoracic irradiation, receipt of more than 3 cycles of chemotherapy, response to chemotherapy, and performance status. The Cox model identified comorbidity (P = 0.03), receipt of more than 3 cycles of chemotherapy (P = 0.003) and response to chemotherapy (P = 0.002) as the only significant factors.

Conclusions

The prognosis of SCLC is poor, and comorbidity information should be included in prognostic studies.

Prophylactic cranial irradiation after definitive chemoradiotherapy for limited-stage small cell lung cancer: Do all patients benefit?

PURPOSE

Prophylactic cranial irradiation (PCI) can improve overall survival (OS) and suppress brain metastases (BM) in patients with limited-stage small cell lung cancer (LS-SCLC) after complete response to primary therapy. However, PCI can be toxic. We sought to identify characteristics of patients who may not benefit from PCI.

METHODS

We identified 658 patients who received chemoradiotherapy at MD Anderson in 1986-2012; 364 received PCI and 294 did not. Median follow-up time was 21.2months (range 1.2-240.8months). Cox proportional hazards regression, competing-risk regression, and Kaplan-Meier analyses were used to identify factors influencing OS and BM.

RESULTS

PCI reduced risks of death [HR 0.73, 95% CI 0.61-0.88, P=0.001] and BM [HR 0.54, 95% CI 0.39-0.76, P<0.001]. Having tumors ⩾5cm increased the risk of BM [HR 1.77, 95% CI 1.22-2.55, P=0.002] but not death [HR 1.16, 95% CI 0.96-1.40, P=0.114]. Among patients ⩾70years with ⩾5-cm tumors, PCI did not improve OS [2-year rates 39.4% vs 40.9%, P=0.739].

CONCLUSIONS

PCI remains standard therapy after complete response to chemoradiotherapy for LS-SCLC. However, older patients may be at risk from comorbidity or extracranial disease. Further work is warranted to identify patients who may not benefit from PCI.

The Younger Patients Have More Better Prognosis in Limited Disease Small Cell Lung Cancer

BACKGROUND

Factors associated with the prognosis of patients with small cell lung cancer (SCLC) is relatively unknown, than of those with non-small cell lung cancer. This study was undertaken to identify the prognostic factors of SCLC.

METHODS

The medical records of 333 patients diagnosed with SCLC at tertiary hospital from January 1, 2008, to December 31, 2012 were retrospectively reviewed. Patients were categorized by age (≤65 years vs. >65 years) and by extent of disease (limited disease [LD] vs extensive disease [ED]). Overall survival and progression free survival rates were determined. Factors associated with prognosis were calculated using Cox's proportional hazard regression model.

RESULTS

Most baseline characteristics were similar in the LD and ED groups. Eastern Cooperative Oncology Group (ECOG) performance status (PS), first chemotherapy regimen, and prophylactic cranial irradiation (PCI) differed significantly in patients with LD and ED. Mean ECOG PS was significantly lower (p<0.001), first-line chemotherapy with etoposide-cisplatin was more frequent than with etoposide-carboplatin (p<0.001), and PCI was performed more frequently (p=0.019) in LD-SCLC than in ED-SCLC. Prognosis in the LD group was better in younger (≤65 years) than in older (>65 years) patients, but prognosis in the ED group was unrelated to age.

CONCLUSION

This study showed that overall survival (OS) was significantly improved in younger than in older patients with LD-SCLC. Univariate and multivariate analyses showed that age, PCI and the sum of cycles were significant predictors of OS in patients with LD-SCLC. However, prognosis in the ED group was unrelated to age.

Oncologists’ End of Life Treatment Decisions

Background: Optimal treatment decisions for older end-stage cancer patients are complicated, and are influenced by oncologists’ attitudes and beliefs about older patients. Nevertheless, few studies have explored oncologists’ perspectives on how patient age affects their treatment decisions. Methods: In-depth interviews were conducted with 17 oncologists to examine factors that influence their chemotherapy decisions for adults with incurable cancer near death. Transcripts of recorded interviews were coded and content analyzed. Results: Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults were less likely to want or tolerate treatment, and felt highly motivated to treat younger patients. Discussion: Qualitative analysis of in-depth interviews resulted in a nuanced understanding of how patient age influences oncologists’ chemotherapy decisions. Such understanding may inform practice efforts aimed at enhancing cancer care at the end of life for older patients.

Treatment and survival of patients with small-cell lung cancer: small steps forward, but not for patients >80

BACKGROUND

Seventy-five percent of newly diagnosed patients with small-cell lung cancer (SCLC) are aged 60+ and quite a few are treated less aggressively because of fear of toxic effects. We described trends in treatment and survival of unselected SCLC patients.

PATIENTS AND METHODS

For the present study, all 13,007 SCLC patients aged 60+ diagnosed in The Netherlands from 1997 to 2007 were included.

RESULTS

Among patients with limited disease, the proportion receiving chemoradiation increased from 35% to almost 60% for those aged 60-69, from 28% to 48% in age group 70-74, from 17% to 33% in age group 75-79, but remained <10% for those aged 80+. Among patients with extensive disease, the proportion receiving chemotherapy (CT) decreased from 81% of patients aged 60-64 to 23% of those aged 85+, without substantial changes over time. Survival has only improved for patients <80 years.

CONCLUSIONS

CT (+radiotherapy) has improved survival for unselected SCLC patients <80. A better understanding of the impact of frailty on completion of treatment and toxic effects among patients aged 80+ would enable the treating physician to anticipate toxic effects better and to discuss risks and benefits of treatment with the patient.

Lung cancer in elderly patients: A retrospective analysis of practice in a single institution

Incidence of non-small cell lung cancer is increasing especially among elderly with about 40% arising in patients over 70 years old. Most of these elderly patients are under treated. Seventy-one patients with lung cancer over 70 years old were treated in Institut Paoli-Calmettes from January 2000 until December 2003 (male/female: 57/14). Median age was 75.5 years (70-92). OMS 0-1-2-3=4.2-60.6-25.4-4.2%, respectively. Comorbidities were represented by arterial hypertension, coronaropathy, cardiac failure, thrombo-embolism, respiratory failure, diabetes, vascular cerebral dysfunction, and renal failure. 29.6% of patients were without comorbidity, and 14.1% had at least three comorbidities. The averages of the Charlson comorbidity score and the Age-Charlson comorbidity score were 3.4 and 6.6, respectively. Histological characteristics: epidermoïd/adenocarcinoma/undifferentiated/small cells: 39.4%/26.8%/15.5%/9.9%. Most of them were advanced lung cancer: St IIIB=14 (19.7%) and St IV=37 (52.1%). Forty-six patients received chemotherapy (64.8%) with 40 patients (86.9%) with platin (carboplatin or cisplatin). The median number of treatment cycles was 4.1 (range 1-7). Two patients achieved complete response and 15 had partial response. The response rate was 39.6%. The 1-year survival rate was 48.5% and the estimated median survival time was 11 months (95%; 7-18 months) for all patients. The 1-year survival rate was 75% and 21.6% and the estimated median survival time was 25.9 months (95%; 12.6, ND) and 5.7 months (95%; 4.2-9.6) for stage IIIB and IV, respectively. Toxicities were judged acceptable with 19 hospitalizations after chemotherapy, for 16 patients who represent 34.8% of patients who received chemotherapy.

CONCLUSIONS

Chemotherapy is feasible in elderly patients with lung cancer. Patients should be evaluated for chemotherapy based on their performance status and comorbidities especially with geriatric assessment rather than age alone. The chemotherapy with platinum seems to be tolerable and effective.

Variation in the use of chemotherapy in lung cancer

Factors influencing the use of chemotherapy for the initial (6 months) treatment of lung cancer in South East England were investigated. The variables explored as possibly influencing the use of chemotherapy were sex, age, the year of diagnosis, the type of lung cancer, the stage, the index of multiple deprivation and the cancer network of residence. Chi2 analysis and multivariate logistic regression models were used to examine the effect of each of the variables on the use of chemotherapy. The results showed a highly significant trend in use of chemotherapy over time; the adjusted proportion of patients receiving chemotherapy increasing from 13.6% in 1994 to 29.3% in 2003. However, age, cancer network and type of lung cancer had the strongest influence on the use of chemotherapy. This finding is important when we consider that the NHS Cancer Plan aims at improving inequalities in cancer care in the UK.

Negligible influence of comorbidity on prognosis of patients with small cell lung cancer: a population-based study in the Netherlands

Management of small cell lung cancer (SCLC) among elderly is complex because of decreased organ functions and interactions with comorbidity. Since elderly patients are often excluded from clinical trials, little is known about the way they are treated and outcome. We evaluated the prognostic effects of rising age and comorbidity in unselected Dutch SCLC patients (Eindhoven Cancer Registry). Elderly patients received chemotherapy less often and the dose was also reduced more often. Cardiovascular diseases, hypertension or diabetes lowered the proportion receiving combined chemotherapy and radiotherapy among patients with limited disease. About 80% of the patients receiving chemotherapy suffered from a side effect, which was not related to age. After adjustment for age, gender, stage and treatment modality, comorbidity had a negligible prognostic effect. Chemotherapy (in combination with radiotherapy) seemed to improve survival, however, toxicity and quality of life in these patients should be evaluated thoroughly in future randomized studies.

A phase I study of 3-day topotecan and cisplatin in elderly patients with small-cell lung cancer

PURPOSE

The aim of this phase I study was to determine the maximum-tolerated dose (MTD) in elderly patients with small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Patients aged over 75 years with previously untreated SCLC were enrolled in this study. Both topotecan and cisplatin were administered on days 1-3 and repeated every 3 weeks. The starting dose of topotecan was 0.5 mg/m2/day, while cisplatin was fixed at the dose of 20 mg/m2/day. Patients with limited disease (LD) SCLC received thoracic irradiation after the completion of chemotherapy.

RESULTS

Twenty-one elderly patients were enrolled in this study and received a total of 59 cycles. The major hematological toxicity was neutropenia and non-hematological toxicities including diarrhea were generally mild and reversible. The MTD of topotecan was determined as 1.2 mg/m2/day. The recommended phase II study dose of topotecan was determined as 1.0 mg/m2/day with cisplatin 20 mg/m2/day daily for 3 days. An objective response was observed in 6 of 10 patients (60%) with LD-SCLC and 6 of 11 (55%) with extensive disease (ED) SCLC. The median survival time in patients with LD-SCLC and those with ED-SCLC were 16.0 and 11.0 months, respectively.

CONCLUSION

The combination chemotherapy of 3-day topotecan and cisplatin appears to be tolerable and effective in elderly patients with SCLC.

Treatment of Small Cell Lung Cancer in the Elderly

Small cell lung cancer (SCLC) accounts for approximately 20% of lung carcinomas. Chemotherapy is the cornerstone of treatment for SCLC. In limited disease, the median survival time is about 12-16 months, with a 4%-5% long-term survival rate; in extensive disease the median survival time is 7-11 months. More than 50% of lung cancer patients are diagnosed when they are over the age of 65, and about 30% are over 70. Elderly patients tolerate chemotherapy poorly compared with their younger counterparts, because of age-related progressive reductions in organ function and comorbidities. The standard therapy for limited disease is combined chemoradiotherapy, followed by prophylactic brain irradiation for patients achieving complete responses. In the elderly, the addition of radiotherapy to chemotherapy must be carefully evaluated, considering the slight survival benefit and potential for substantial toxicity incurred with this treatment. The best approach is to design clinical trials that specifically include geriatric assessment to develop active and well-tolerated chemotherapy regimens for elderly SCLC patients. Survival improvement for SCLC patients requires a better understanding of tumor biology and the subsequent development of novel therapeutic strategies. Several targeted agents have been introduced into clinical trials in SCLC, but a minority of these new agents offers a promise of improved outcomes, and negative results are reported more commonly than positive ones. This review focuses on the main issues in the treatment of elderly SCLC patients.

Platinum-Etoposide Chemotherapy in Elderly Patients With Small-Cell Lung Cancer: Results of a Randomized Multicenter Phase II Study Assessing Attenuated-Dose or Full-Dose With Lenograstim Prophylaxis—A Forza Operativa Nazionale Italiana Carcinoma Polmonare and Gruppo Studio Tumori Polmonari Veneto (FONICAP-GSTPV) Study

Purpose

Small-cell lung cancer (SCLC) is increasingly diagnosed in elderly patients, who are at higher risk of treatment-related morbidity and mortality. We conducted a randomized two-stage phase II study to assess the therapeutic index of two different platinum/etoposide regimens, attenuated-dose (AD) and full-dose (FD) plus prophylactic lenograstim.

Patients and Methods

SCLC patients older than 70 years were randomized to receive four courses of cisplatin 25 mg/m2 on days 1 and 2, and etoposide 60 mg/m2 on days 1, 2, and 3 every 3 weeks (AD); or cisplatin 40 mg/m2 on days 1 and 2, and etoposide 100 mg/m2 on days 1, 2, and 3 every 3 weeks, plus lenograstim 5 mg/kg days 5 through 12, every 3 weeks (FD). A combined primary end point named therapeutic success (TS), which took into account activity, toxicity, and compliance, was used.

Results

Ninety-five patients were enrolled. Seventy-five percent and 72% of the patients in the AD and FD arms, respectively, completed the treatment as per protocol. Response rate was 39% and 69% in the AD and FD arms, respectively, and 1-year survival probability was 18% and 39%, respectively. Treatment was well tolerated in both groups, with no grade 3 to 4 myelotoxicity in the AD arm, and 12% myelotoxicity in the FD arm. Overall, the observed TSs were 10 (36%) of 28 patients and 42 (63%) of 67 patients for AD and FD treatments, respectively.

Conclusion

In elderly patients with SCLC a full-dose cisplatin/etoposide regimen combined with prophylactic lenograstim is active and feasible, while attenuated doses of the same regimen are associated with a poor therapeutic outcome.

Recent advances in management of small-cell lung cancer

Small-cell lung cancer (SCLC) is a smoking-related disease with a poor prognosis. While SCLC is usually initially sensitive to chemotherapy and radiotherapy, responses are rarely long lasting. Frustratingly, most patients ultimately relapse, often with increasingly treatment resistant disease. Many strategies have been developed in an attempt to improve treatment outcomes, which have plateaued since the introduction of combination chemotherapy in the 1980s. These include trials of maintenance therapy, and dose intensification, the latter by means of increasing dose density, growth factor support and high dose chemotherapy with autologous stem cell rescue. None have been shown to improve patient survival. On the other hand, the integration of concurrent thoracic radiation and prophylactic cranial irradiation has improved the survival outcomes in patients with limited disease. In extensive disease, irinotecan combined with cisplatin has shown promise in improving survival over conventional platinum/etoposide chemotherapy schedules and a confirmatory study is awaited. The future of SCLC treatment may however lie with molecularly targeted therapies, such as antiangiogenesis agents and signal transduction inhibitors, which are being studied at present.

In lung cancer patients, age, race-ethnicity, gender and smoking predict adverse comorbidity, which in turn predicts treatment and survival

OBJECTIVE

This study evaluates the relationship between sociodemographic/exposure factors and comorbidity, and their impact on lung cancer treatment and survival. STUDY AND DESIGN SETTING: Data for 1,155 patients were abstracted from the Josephine Ford Cancer Center Tumor Registry and medical records. Associations were analyzed by linear, logistic, and Cox regression.

RESULTS

Approximately 88% of patients had > or = 1 of 56 comorbidities assessed. In multivariate analysis, comorbidity count was associated with older age, pack-years smoked, heavy alcohol use, lower socioeconomic status (SES), and female gender. Approximately 63% of patients had > or = 1 of 18 adverse prognostic comorbidities (AC), and significant independent predictors of AC were age, pack-years, African-American race/ethnicity, and gender. In multivariate analysis, comorbidity count and AC predicted nonreceipt of surgery in localized disease (OR(> or = 1 vs. 0 AC)=0.38, 95% 0.18, 0.81) and chemotherapy in advanced disease (OR > or = 1 vs. 0 AC)=0.72, 95% 0.51, 1.00). In adjusted analysis, comorbidity predicted survival in localized (hazard ratio (HR)(> or = 2 vs. 0 AC)=2.99, 95% CI 1.75, 5.10) and advanced lung cancer (HR(> or = 2 vs. 0 AC)=1.56, 95% CI 1.25, 1.94).

CONCLUSION

Comorbidity has important deleterious effects on lung cancer outcomes and significant predictors of comorbidity included age, smoking, race/ethnicity, SES, alcohol, and gender.

Do age and comorbidity impact treatment allocation and outcomes in limited stage small-cell lung cancer? a community-based population analysis

PURPOSE

The effects of age and comorbidity on treatment and outcomes for patients with limited stage small-cell lung cancer (L-SCLC) are unclear. This study analyzes relapse and survival in a community-based population with L-SCLC according to age and comorbidity.

METHODS

A retrospective review was performed on 174 patients with L-SCLC referred to the British Columbia Cancer Agency, Vancouver Island Centre, between January 1991 and December 1999. Patient and treatment characteristics, disease response, relapse, and survival were compared among three age cohorts: <65 years (n = 55, 32%), 65-74 years (n = 76, 44%), and > or =75 years (n = 43, 25%); and according to Charlson comorbidity scores 0, 1, and > or =2. Multivariate analysis was performed to identify independent prognostic factors associated with treatment response and survival.

RESULTS

Patient factors that significantly differed with age were functional status classified by Eastern Cooperative Oncology Group performance status and number of comorbidities. Increasing age was significantly associated with fewer diagnostic scans. Combined modality chemoradiotherapy (CRT) was given in 86%, 66%, and 40% of patients ages <65, 65-74, and > or =75 years, respectively, (p <0.0001). Thoracic irradiation use was comparable among the age cohorts (p >0.05), but chemotherapy use varied significantly with less intensive regimens, fewer cycles, and lower total doses with advancing age (p <0.05). Prophylactic cranial irradiation (PCI) was used in 41 patients, only 3 of whom were age >70 years. Overall response rates to primary treatment significantly decreased with advancing age: 91%, 79%, and 74% in patients ages <65, 65-74, and > or =75 years, respectively (p = 0.014). Treatment toxicity and relapse patterns were similar across the age cohorts. Overall 2-year survival rates were significantly lower with advancing age: 37%, 22%, and 19% (p = 0.003), with corresponding median survivals of 17, 12, and 7 months among patients ages <65, 65-74, and > or =75 years, respectively. On multivariate analysis, age and Charlson comorbidity scores were not significantly associated with treatment response and survival. Independent prognostic factors favorably associated with survival were good performance status, normal lactate dehydrogenase, absence of pleural effusion, and > or =four cycles of chemotherapy.

CONCLUSION

Increasing age was associated with decreased performance status and increased comorbidity. Older patients with L-SCLC were less likely to be treated with CRT, intensive chemotherapy, and PCI. Treatment response and survival rates were lower with advancing age, but this may be attributed to poor performance status and suboptimal treatment rather than age.

Treatment of lung cancer in elderly part II: 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 a main reason for an increase of cancer incidence. Lung cancer is a typical disease of the elderly patients. Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancer cases. This review summarises the issues of treatment of SCLC in elderly. The number of randomised phase III trials concerning treatment of SCLC in elderly patients are very limited. Although currently most treatment decisions are based on lower grades of evidence, some conclusions can be drawn from the current studies. Age alone is a very uncertain prognostic criteria for outcome or tolerability of treatment. Much more important is the geriatric assessment of each individual patient. Current treatment standards for limited disease (LD)-SCLC (polychemotherapy plus local thoracic irradiation and additional prophylactic cranial irradiation in case of complete remission) seems to be also feasible for 'fit' elderly (>70 years) LD-SCLC patients with a good performance and full functional capacities. There are preliminary data indicating that a similar outcome in elderly patients can probably be achieved a with reduced number of treatment schedules (e.g. 2 instead of 4 cycles in combination with radiotherapy. Surgical resection is also feasible in selected elderly patients with very early stage SCLC, where this maybe an appropriate approach, although no phase III data are available, which demonstrated the benefit of additional surgery compared to chemotherapy alone in early stage SCLC. In patients with extensive disease-SCLC age alone does not necessarily restrict the use of multiagent regimen, although the risk of haematological toxicity seems to be higher than in the younger patients. When standard treatment is not feasible due to co-morbidity or loss of functional capacity, several alternative combination regimens are available, which appear to be slightly superior to single agent treatment, although randomised data for elderly on that issue are sparse. Carboplatin and etoposide seems currently the most appropriate two-drug combination in elderly patients, but there are a variety of active and low toxic third generation agents like taxanes, gemcitabine and vinorelbine which are active in both, non-small cell lung cancer and SCLC. For the comparison of trials in elderly patients it will be of key importance to include a comprehensive and standardised geriatric assessment in such studies.

Carboplatin plus vinorelbine plus G-CSF in elderly patients with extensive-stage small-cell lung cancer: a poorly tolerated regimen. Results of a multicentre phase II study

PURPOSE AND METHODS

A multicentre phase II trial (single-stage design) was undertaken to test the activity and toxicity of carboplatin (AUC 5 according to Calvert, day 1) plus vinorelbine (25 mg/m(2) days 1 and 8) with lenograstim support, every 3 weeks in the first line treatment of elderly patients, aged 65 or more, affected by extensive small-cell lung cancer (SCLC). The primary end-point of the trial was the objective response rate. Twenty-three responses among 37 patients were considered necessary to proceed to a phase III trial.

RESULTS

Twenty-eight patients were enrolled (median age 70 years). Treatment was remarkably toxic. Three patients died while on treatment. Eleven patients (39.3%, 95% exact confidence interval (CI): 21.5-59.4) had an objective response, that was complete in 2 cases. Median time to progression was 5.1 months (95% CI: 3.3-6.7). Median survival was 7.9 months (95% CI: 4.8-14.4).

CONCLUSION

Carboplatin plus vinorelbine is poorly tolerated and not sufficiently active to warrant phase III comparison with standard chemotherapy regimens in elderly patients with extensive SCLC.

Chemotherapy of lung cancer in the elderly

In the last few years it has become evident that the elderly lung cancer patient represents a peculiar individual with regard to both the tolerance to the tumor and its treatment. Age per se cannot be considered an adverse prognostic factor, however, the physiologic impairment of the functions of important organs like liver, kidney, bone marrow etc., may render more unpredictable the treatment-related toxicity, and moreover, the higher incidence of concomitant diseases which occurs with aging certainly translates in a worse survival outcome. As a consequence, a careful multidimensional evaluation (functional, emotional, socioeconomic status, comorbidities, etc.) should be preliminarily performed in patients eligible for chemotherapy treatment. Several approaches have been tested in elderly lung cancer patients. Different therapeutic attitudes exist, which first take into account the kind of histology (small cell lung cancer, SCLC and non-small cell lung cancer, NSCLC). Of course a more aggressive approach can be sometimes justified in an elderly SCLC patient in view of the high responsiveness of this disease, while more concerns exist about the use of aggressive chemotherapy regimen in elderly patients with NSCLC histology. In view of these considerations, more clinical trials are being planned to specifically assess the role of chemotherapy in this subset of patients.A brief review of the most important phase II and III trials conducted in elderly patients with either SCLC or NSCLC is provided here. A description of the most important still unsolved issues will be made, and an outline of the ongoing clinical trials in these patients will be provided.

Management of small-cell lung cancer in the elderly

More than 50% of lung cancer patients are diagnosed over the age of 65 and about 30% over 70. Small-cell lung cancer (SCLC) accounts for 20-25% of lung carcinomas. Chemotherapy is the cornerstone of treatment for SCLC. Usually in the elderly it is difficult to administer the same chemotherapy administered to younger patients because elderly patients tolerate chemotherapy poorly. The empirical reduction of drug doses may be criticized. The best approach is to design specific trials in order to develop active and well-tolerated chemotherapy regimens for SCLC elderly patients. The standard therapy in limited disease is combined chemo-radiotherapy followed by prophylactic brain irradiation for patients achieving a complete response. In the elderly, the addition of radiotherapy to chemotherapy must be accurately evaluated, considering the slight survival improvement and the potential relevant toxicity.

Carboplatin-etoposide combination in small cell lung cancer patients older than 70 years: a phase II trial

BACKGROUND

No standard treatment is defined for elderly patients with small cell lung cancer (SCLC). Carboplatin and etoposide are highly active agents against SCLC. In this study, we evaluated the activity and toxicity of a combination of these two agents.

PATIENTS AND METHODS

Thirty-four untreated patients with limited or extensive SCLC and median age of 73.9 years entered the study. Chemotherapy consisted of carboplatin i.v. on day 1 (AUC 5 using Calvert's formula) and etoposide 100 mg/m(2) given orally on days 1-5, every 4 weeks, and thoracic irradiation was given to limited disease patients after chemotherapy.

RESULTS

The overall response rates was 59% (95% CI: 43-76). The median survival for all patients was 37 weeks (range 3-76 weeks). The toxicity was mainly haematological with grade 3-4 neutropenia in 59% of courses, febrile neutropenia in 15% of courses, and toxic death in 9% of patients.

CONCLUSION

The results of this regimen are disappointing with worse response and survival, and more haematological toxicity than expected and previously reported, despite the use of Calvert's formula. Possible explanations are the use of etoposide per os rather than i.v., the frequent comorbidities of older patients and the inclusion of patients with poor prognosis factors.

Etoposide phosphate with carboplatin in the treatment of elderly patients with small-cell lung cancer: a phase II study

BACKGROUND

Although the average age of lung cancer patients is increasing, many elderly patients remain undertreated, mainly because of the fear of higher treatment toxicity in this category of patients. We conducted a study to evaluate the efficacy and tolerability of a combination therapy with carboplatin (C) and etoposide phosphate (EP) in elderly patients with Small-Cell Lung Cancer (SCLC).

PATIENTS AND METHODS

Previously untreated patients older than 70 years with stage IIIB/IV SCLC received a combination of EP (100 mg/m2 D1, D2, D3) and C (D1, dose calculated according to the Calvert formula). Response rate, survival and toxicity were assessed.

RESULTS

Thirty-eight patients (mean age 76 years, range 70-88 years) received a total of 162 cycles. Eighteen patients (47%) received the six scheduled cycles. Thirty patients were evaluable for efficacy (2 CR and 20 PR). The median survival was 237 days and the one-year probability of survival was 26%. The most common adverse effect was transient grade 3 or 4 neutropenia, observed during 57% of evaluable cycles, while five episodes of febrile neutropenia also occurred, with one fatal (bacteremia). It is noteworthy that no renal or liver toxicity was observed, and no mucitis was noted. Unfortunately, a relatively high proportion of patients died shortly after the start of the study. Although most deaths seemed unrelated to the treatment, the possibility of its exacerbatory effect on comorbidities, especially cardiovascular, cannot be excluded.

CONCLUSION

The two-drug regimen of carboplatin and etoposide phosphate is feasible in most elderly patients with an acceptable toxicity, and the overall results suggest that patients even older than 70 years may benefit from full treatment. Therefore, consideration should be given to offering active treatment to most patients with SCLC, regardless of age but with special attention paid to comorbidities.

Trends in incidence and prognosis of the histological subtypes of lung cancer in North America, Australia, New Zealand and Europe

BACKGROUND

Since the incidence of the histological subtypes of lung cancer in industrialised countries has changed dramatically over the last two decades, we reviewed trends in the incidence and prognosis in North America, Australia, New Zealand and Europe, according to period of diagnosis and birth cohort and summarized explanations for changes in mortality.

METHODS

Review of the literature based on a computerised search (Medline database 1966-2000).

RESULTS

Although the incidence of lung cancer has been decreasing since the 1970s/1980s among men in North America, Australia, New Zealand and north-western Europe, the age-adjusted rate continues to increase among women in these countries, and among both men and women in southern and eastern Europe. These trends followed changes in smoking behaviour. The proportion of adenocarcinoma has been increasing over time; the most likely explanation is the shift to low-tar filter cigarettes during the 1960s and 1970s. Despite improvement in both the diagnosis and treatment, the overall prognosis for patients with non-small-cell lung cancer hardly improved over time. In contrast, the introduction and improvement of chemotherapy since the 1970s gave rise to an improvement in - only short-term (<2 years) - survival for patients with small-cell lung cancer.

CONCLUSIONS

The epidemic of lung cancer is not over yet, especially in southern and eastern Europe. Except for short-term survival of small cell tumours, the prognosis for patients with lung cancer has not improved significantly.

Advances in the systemic treatment of cancers in the elderly

Cancer is a disease of the elderly. More than 50% of all cancers and deaths occur in people over 65 years. Older cancer patients are less likely to be referred to centers or to be given adequate chemotherapy. The elderly are under-represented in Phase I and II trials. Some of this hesitancy to give chemotherapy is related to the increased presence of co-morbid conditions in the elderly. Toxicity is another concern. This review summarizes data from literature on the effectiveness, outcome, and toxicity of chemotherapy in selected tumors. Information is presented on age related effects. In addition, a summary of new agents and biologics is presented that needs to be looked at for age related effects. Some comments are made on the pharmacokinetic impact of physiologic changes in the elderly on chemotherapy drugs. As the world's population ages, we need to include the elderly in trials to get data on age related effects. Most of the information presented shows that effective chemotherapy can be given safely to the elderly and the outcomes and toxicity are equivalent for many of the common solid tumors.

Treatment and outcomes for elderly patients with small cell lung cancer

It is estimated that approximately half of the 500 000 people diagnosed with lung cancer worldwide every year are aged >70 years. Thus, this disease represents a major problem in the elderly and one that will indeed increase as the median age of the population increases. For small cell lung cancer (SCLC), which accounts for approximately 20% of cases of lung cancer, the primary treatment is chemotherapy and in the majority of cases the primary aim is to control the disease which generally would have spread beyond the lungs at the time of presentation. A small number of 'standard' chemotherapy regimens (combined with radiotherapy for patients with limited disease) have been shown to improve survival and quality of life and are widely used. Much of the work investigating the relationship between age and treatment outcomes has been based on clinical trial data and may itself be inherently biased due to trial eligibility criteria excluding elderly patients. However, there is no good evidence that elderly patients fare worse with treatment than their younger counterparts in terms of response rates and survival. Nevertheless with increasing age comes increasing concomitant illnesses which may account for the widely observed increases in drug toxicity, and this may be the primary consideration in selecting the treatment option. Thus for many elderly patients, carboplatin/ etoposide may be the treatment of choice because it is perhaps the least toxic of the standard regimens. Whatever regimen is chosen, the key to treatment effectiveness seems to be to deliver the first 3 or 4 cycles without delay or dosage reduction. Although palliation of symptoms remains a major goal in the treatment of all patients with SCLC there is a dearth of data on whether elderly patients are equally well palliated as their younger counterparts. There is no good evidence that age per se should be a factor in deciding whether patients should receive standard treatment rather than a more gentle approach, and more elderly patients should be included in clinical trials. The key areas where more information is required regarding the treatment and outcomes of elderly patients with SCLC are the assessment of palliation, and comprehensive reviews of all patients diagnosed with the disease, not just those included in trials.

Predictive and prognostic factors in small cell lung cancer: current status

Clinical and laboratory parameters can predict response to chemotherapy and long term survival in small cell lung cancer, and may predict those at risk of early treatment related toxicity. This paper reviews the predictive models that have been developed to divide patients into prognostic groups for response and survival on the basis of clinical and laboratory parameters. These factors may be used for the stratification of patients in clinical trials and to help clinicians make appropriate treatment decisions for individual patients. A number of treatment-related factors can also affect outcomes. The evidence for interventions to prevent treatment deaths in high risk patients, such as prophylactic antibiotics, dosage modification or colony stimulating factor support are also reviewed.

Small-cell lung cancer in the elderly--is age of patient a relevant factor?

Different management procedures for diagnosis and treatment of small-cell lung cancer (SCLC) and other tumours in the elderly have been reported, but there is a lack of data from a communal hospital perspective. Information on clinical parameters such as weight loss, co-morbidity, performance status and investigative procedures for staging of disease and inclusion in clinical trials was recorded for patients in the province of Albacete (Spain). Patients' ages were categorized in two groups: under 70 years and 70 years or more, and a comparison of treatment variables, toxicities, response and time to event measures was carried out. Ninety-five patients were referred to our Unit for treatment. Of these patients, 62% were under 70 years of age and 38% were in the older age category. Clinical variables and staging procedures did not differ between groups. Trial assignment showed a bias in favour of younger patients (11 vs. 1, p = 0.02). No differences in the number of patients without treatment were found, but the older group presented fewer cases of optimal (> or = 4 cycles) therapy, less chemotherapy delivery (smaller mean total doses of cisplatin and etoposide) and smaller mean total dose of radiotherapy (57/45 Gy). The response to treatment (46%/50%) toxicity registered and overall survival did not differ between age categories. Age does not seem to be a relevant prognostic factor in this disease. Carefully calculated dose reductions for chemotherapy in elderly patients based on initial performance status and/or toxicity during treatment may be a useful policy without detrimental implications on outcome.

The influence of age on the delivery, tolerance, and efficacy of thoracic irradiation in the combined modality treatment of limited stage small cell lung cancer

PURPOSE

To assess the impact of age on the delivery, tolerance, and efficacy of thoracic irradiation (TI) for limited small cell lung cancer (L-SCLC).

METHODS AND MATERIALS

This is a retrospective review of data from 608 patients 80 years or less with L-SCLC, who participated in two previously reported randomized trials (BR3 and BR.6) of the National Cancer Institute of Canada. All patients received the same chemotherapy, consisting of cyclophosphamide, doxorubicin, vincristine (CAV), and etoposide cisplatin (EP) delivered either in sequential or alternating sequence. In BR.3, TI was given after chemotherapy with randomization to 25 Gy in 10 fractions or 37.5 Gy in 15 fractions. In BR.6, TI (40 Gy in 15 fractions) was given concurrently with EP with randomization to either the early (with cycle 2, week 4) or late (with cycle 6, week 16) arm.

RESULTS

A total of 665 patients entered these two trials. Of these, 608 patients were eligible for analysis, 300 in BR.3 and 308 in BR.6. Five hundred and twenty patients were under age 70 and 88 patients were 70 years or older. Baseline characteristics between the two groups were comparable. In BR3, 179 patients (60%) participated in radiotherapy randomization (61% young, 52% elderly), and 176 patients actually received TI. In BR.6, randomization occurred at study entry for all patients, and 282 (91.6%) patients received TI (92% young, 88% elderly). More patients of both age groups randomized to receive late TI did not receive TI (13% and 14%) than those randomized to the early TI arm (3%) of BR.6. We could identify no tendency to reduce field sizes to minimize toxicity in either age group at higher doses of TI. Once TI was started, there was no difference between the two age groups with regards to the proportion of patients who completed TI, although elderly patients were less likely to complete high dose TI. Of those who completed TI, there was no difference in the time to complete TI, mean dose delivered or in the incidence of acute and late TI-related toxicities. No statistical difference in response rate, local relapse rate, or overall survival was seen between young and older age groups.

CONCLUSION

In summary, in the dose range examined, age does not appear to impact on the delivery, tolerance or efficacy of TI in the combined modality management of L-SCLC. Potentially curative combined modality treatment should not be withheld on the basis of age.

Prevalence of co-morbidity in lung cancer patients and its relationship with treatment: a population-based study

BACKGROUND

With the rising mean age of lung cancer patients, the number of patients with serious co-morbidity at diagnosis is increasing. As a result, co-morbidity may become an important factor in both the choice of treatment and survival. We studied the prevalence of serious co-morbidity among newly diagnosed lung cancer patients and its association with morphology, stage and treatment.

PATIENTS

A total of 3864 lung cancer patients registered in the population-based registry of the Comprehensive Cancer Centre South between 1993 and 1995.

RESULTS

During the study period, the mean age of patients was 67 years (range: 29-93). The most frequent concomitant diseases were cardiovascular diseases (23%), chronic obstructive pulmonary diseases (COPD) (22%) and other malignancies (15%). The prevalence of concomitant diseases was highest for men (60%), patients with squamous-cell carcinoma (64%) and those with a localised tumour (66%). The resection rate for patients < 70 years, with a localised non-small-cell lung tumour, was especially low for those with COPD (67%) or diabetes (64%) compared with patients without concomitant diseases (94%). The association between co-morbidity and chemotherapy for patients with small-cell lung cancer was limited.

CONCLUSIONS

The prevalence of co-morbidity, especially cardiovascular diseases and COPD, among lung cancer patients is about twice as high as in the general population. Co-morbidity seems to be associated with earlier diagnosis of lung cancer, but it may also lead to less accurate staging and less aggressive treatment. Thus, prognosis is likely to be negatively influenced by co-morbidity.

Improvement and plateau in survival of small-cell lung cancer since 1975: a population-based study

BACKGROUND

Cytotoxic therapy appears to have improved short-term survival for patients with small-cell lung cancer, but little is known about the results for unselected patients and trends in long-term survival.

PATIENTS AND METHODS

One thousand seven hundred ninety-six patients with small-cell lung cancer diagnosed between 1975 and 1994 in southeastern Netherlands. We studied treatment policy for and survival of unselected patients since 1975, when cytotoxic therapy emerged.

RESULTS

The proportion patients receiving chemotherapy, with or without irradiation, almost tripled from 30% to 82% for patients younger than 70 years of age and from 15% to 56% for those over 70, whereas the proportion receiving only radiotherapy decreased from 36% to 5% in both age groups. The short-term (< 2 year) survival rate improved markedly between 1975 and 1989, especially for patients younger than 70 (median survival increased from five to 10 months). Two-year survival remained poor (8%). Two percent of all patients younger than 70 years at diagnosis survived for at least eight years, but these patients still represent an excess five-year mortality of 39%.

CONCLUSIONS

In southeastern Netherlands short-term survival of patients with small-cell lung cancer improved markedly up to the end of the 1980s, but a major impact on cure rates has not been achieved.

Optimal duration of chemotherapy in small cell lung cancer: a randomized study of 4 versus 6 cycles of cisplatin-etoposide

With the purpose of investigating whether the 6-course standard dose treatment of etoposide-platinum (EP) in small cell lung cancer could be reduced to 4 courses without compromising patient's survival, 70 patients were randomized to receive either 4 or 6 cycles of etoposide 120 mg/m2 i.v. days 1-3 and cisplatin 80 mg/m2 day 1. With the intention of comparing these two durations as primary treatment policies, patients were randomized on admission and not after the fourth course. From the 69 evaluable patients 34 received EPx4 cycles and 35 EPx6 cycles. Objective response for EPx4 was achieved by 21 patients (62%, 95% CI 44%-78%) compared to 24 patients (69%, 95% CI 51%-83%) of the EPx6 group. Median times to progression were 6 mo (4-19) and 7 mo (4-40) respectively (P=0.06) in the two groups. Median survivals were 8.5 mo (4-28.5) and 9.5 mo (4-51) (p=0.04) respectively. No differences in the survival of limited-disease patients were shown with 10.5 mo (6-28.5) and 12 mo (8-51) respectively, in the two groups. Patients with extensive disease had a trend favoring prolonged chemotherapy with a median survival of 9 mo (5-16) versus 6.5 mo (4-16.5) for those in the EPx4 group (p=0.09). Toxicity was not significantly more severe in the EPx6 group. In conclusion, patients achieving complete response within 4 cycles may not need continued chemotherapy, but patients with extensive disease may benefit from 2 more cycles.

Carboplatin, etoposide, and accelerated hyperfractionated radiotherapy for elderly patients with limited small cell lung carcinoma: a phase II study

BACKGROUND

It is not clear how well elderly patients with limited small cell lung carcinoma tolerate intensive chemotherapy, and they have often been treated with palliative intent. As an alternative strategy, the authors designed and employed a short term combination regimen consisting of carboplatin and etoposide with accelerated hyperfractionated radiotherapy.

METHODS

Seventy-five patients ages > or = 70 years with a Karnofsky performance status of > or = 60 and no other major medical problems, were enrolled in this study and 72 were evaluable. The protocol consisted of intravenous carboplatin (400 mg/m2) given on Days 1 and 29, oral etoposide (50 mg/m2) given on Days 1-21 and 29-49, and accelerated hyperfractionated radiation at a dose of 1.5 gray (Gy) administered twice daily (total dose, 45 Gy) starting on Day 1.

RESULTS

The median follow-up period was 61 months. The response rate was 75%, and complete response was observed in 57% of the patients. The median survival time was 15 months, and the 2- and 5-year survival rates were 32% and 13%, respectively. Acute Grade 3 leukopenia, thrombocytopenia, and esophagitis were observed in 8.3%, 11%, and 2.8% of the patients, respectively. Only one patient experienced Grade 4 acute toxicity (thrombocytopenia). No late toxicity of Grade 3 or higher was observed.

CONCLUSIONS

This combined treatment program was tolerable and produced promising long term results. Elderly patients should not universally be treated with palliative intent. Further studies exploring a potentially more effective regimen are warranted.

Remission of cancer chemotherapy-induced emesis during antidepressant therapy with nefazodone

OBJECTIVE

To emphasize the importance of treating a major depressive episode in an elderly patient with small cell lung cancer (SCLC).

METHOD

A case report is described to illustrate the importance of treating depression in an elderly patient with SCLC undergoing chemotherapy.

RESULTS

During the course of antidepressant therapy with nefazodone, the patient also experienced a remission of cancer chemotherapy-induced emesis.

CONCLUSIONS

This case report suggests that the remission of emesis could be related to the 5-hydroxytryptamine (5-HT) antagonistic property of nefazodone.

Limited-stage small cell lung cancer: a case report

Because small cell lung cancer (SCLC) is very responsive to chemotherapy, an attempt at treatment is warranted even in poor-prognosis patients with limited-stage disease. Concurrent thoracic radiotherapy and prophylactic cranial irradiation should be considered in such cases. A case report of an elderly, debilitated patient with limited-stage SCLC is presented, and his management is discussed.

The clinical impact of teniposide in the treatment of elderly patients with small-cell lung cancer

Teniposide (VM26) has been claimed to be active with a moderate toxicity in elderly patients affected by small-cell lung cancer (SCLC). Twenty-two patients with SCLC older than 65 years received VM26 as first-line chemotherapy at a dose of 60 mg/m2 on 5 consecutive days every 3 weeks. Age distribution ranged from 67 to 80 years (median 72 years). Fourteen patients were men and eight were women. Twelve patients had limited disease (LD) and ten extensive disease (ED). One patient (LD) had a complete response, and four (3 LD, 1 ED) achieved a partial response for an overall response rate of 22.7% (95% CI 6-40%). The most frequent toxicity was myelosuppression: 20 and 15% of patients had grade 3 leukopenia and thrombocytopenia, respectively. Our results seem to suggest that VM26 by this schedule is moderately effective in elderly patients with SCLC, and it cannot be recommended as a routine treatment.

An analysis of the outcomes of treatment of small cell lung cancer in the elderly

BACKGROUND

Many cases of small cell lung cancer will occur in the elderly population but optimal management of the disease in this age group remains uncertain.

AIMS

To evaluate treatment of small cell lung cancer in the elderly in Australia and to compare treatment received and outcomes with those of younger patients. To draw insights from these observations into the optimal management of small cell lung cancer in the elderly.

METHODS

A retrospective review of treatment charts and case notes for 51 elderly patients and 102 younger patients was undertaken.

RESULTS

Elderly patients had similar baseline parameters with respect to disease stage and performance status. Elderly patients were mostly treated uniformly with combination chemotherapy, but suffered more dose reductions than younger patients. Benefits of chemotherapy were seen even in patients with poor performance status. Despite the dose reductions, response rates and survival times for elderly patients were usually similar to younger patients.

CONCLUSIONS

Combination chemotherapy is beneficial to elderly patients with small cell lung cancer. Optimal therapy for the elderly may be different from that for younger patients and should be defined through prospective randomised clinical trials.