Evidence-based management of cancer in the elderly

Final Results from SAUL, a Single-arm International Study of Atezolizumab in Unselected Patients with Pretreated Locally Advanced/Metastatic Urinary Tract Carcinoma

BACKGROUND AND OBJECTIVE

We assessed the safety of atezolizumab in unselected patients (including understudied populations typically excluded from clinical trials) with pretreated urinary tract carcinoma (UTC). The prespecified final analysis updates previously reported safety and efficacy data.

METHODS

The single-arm prospective SAUL study (NCT02928406) enrolled 1004 patients with locally advanced/metastatic urothelial/non-urothelial UTC that had progressed during/after one to three prior treatment lines for advanced UTC (or <12 mo after [neo]adjuvant therapy). Broad eligibility criteria allowed enrollment of patients with complex comorbidities approximating the real-world setting. Patients received atezolizumab 1200 mg every 3 wk until disease progression or unacceptable toxicity. The primary endpoint was safety. Secondary endpoints included duration of response and overall survival (OS).

KEY FINDINGS AND LIMITATIONS

The treated cohort included 10% of patients with poor performance status, 5% with creatinine clearance <30 ml/min, and 4% with autoimmune disease. At median follow-up of 55 mo, median atezolizumab duration was 2.8 mo (range 0-62); 68 patients (7%) continued atezolizumab for >4 yr. Treatment-related grade ≥3 adverse events occurred in 16% of patients (death in 1%); 8% discontinued atezolizumab for adverse events. Median OS was 8.6 mo (95% confidence interval 7.8-9.7) and 136 patients (14%) had OS longer than 4 yr. Limitations include the small sample size for some subgroups of special interest.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Long-term safety and efficacy data continue to show a benefit of atezolizumab in unselected patients with UTC. Remarkably, 14% of patients lived for >4 yr after starting atezolizumab. These results can inform multidisciplinary team discussions and treatment decision-making for patients with UTC with complex comorbidities.

PATIENT SUMMARY

The SAUL study looked at how well tolerated a drug called atezolizumab was in patients with urinary tract cancer who had already received up to three previous treatments for their cancer, including people who are usually not included in clinical trials because of other medical conditions. The length of survival after starting treatment was also assessed. Overall, the results show that atezolizumab was well tolerated. People for whom other therapies had failed lived for about 8.6 months on average after starting treatment, and 14% of the patients were still alive after 4 years.

Inhibiting bladder tumor growth with a cell penetrating R11 peptide derived from the p53 C-terminus

Urothelial carcinoma of the bladder (UCB) is the most common malignancy of the urinary tract, nearly half of which contains a mutation in TP53 gene. Hence, therapeutic approach by restoring functional p53 protein in cancer cells will be beneficial. Recent studies have demonstrated the inhibition of cancer cell growth by p53 reactivation using a peptide derived from the p53 C-terminus (p53C). However, the outcome of reactivating p53 in controlling bladder cancer development is limited by its efficiency and specificity of peptide delivery, especially in metastatic animal models. Herein, we report that the cell penetrating peptide (polyarginine, R11)-conjugated p53C can exhibit a preferential uptake and growth inhibit of UCB cells expressing either mutant or wild-type TP53 by the activation of p53-dependent pathway. R11-p53C peptide treatment of preclinical orthotopic and metastatic bladder cancer models significantly decreased the tumor burden and increased the lifespan without a significant cytotoxicity. Based on these results, we believe that R11-p53C peptide has therapeutic potential for primary and metastatic bladder cancer, and R11-mediated transduction may be a useful strategy for the therapeutic delivery of large tumor suppressor molecules to tumor cells in vitro and in vivo.

Randomized phase II/III trial assessing gemcitabine/carboplatin and methotrexate/carboplatin/vinblastine in patients with advanced urothelial cancer who are unfit for cisplatin-based chemotherapy: EORTC study 30986

PURPOSE

This is the first randomized phase II/III trial comparing two carboplatin-based chemotherapy regimens in patients with urothelial cancer who are ineligible ("unfit") for cisplatin chemotherapy.

PATIENTS AND METHODS

The primary objective of the phase III part of this study was to compare the overall survival (OS) of chemotherapy-naive patients with measurable disease and an impaired renal function (glomerular filtration rate < 60 but > 30 mL/min) and/or performance score of 2 who were randomly assigned to receive either gemcitabine/carboplatin (GC) or methotrexate/carboplatin/vinblastine (M-CAVI). To detect an increase of 50% in median survival with GC compared with M-CAVI (13.5 v 9 months) based on a two-sided log-rank test at error rates α = .05 and β = .20, 225 patients were required. Secondary end points were overall response rate (ORR), progression-free survival (PFS), toxicity, and quality of life.

RESULTS

In all, 238 patients were randomly assigned by 29 institutions over a period of 7 years. The median follow-up was 4.5 years. Best ORRs were 41.2% (36.1% confirmed response) for patients receiving GC versus 30.3% (21.0% confirmed response) for patients receiving M-CAVI (P = .08). Median OS was 9.3 months in the GC arm and 8.1 months in the M-CAVI arm (P = .64). There was no difference in PFS (P = .78) between the two arms. Severe acute toxicity (death, grade 4 thrombocytopenia with bleeding, grade 3 or 4 renal toxicity, neutropenic fever, or mucositis) was observed in 9.3% of patients receiving GC and 21.2% of patients receiving M-CAVI.

CONCLUSION

There were no significant differences in efficacy between the two treatment groups. The incidence of severe acute toxicities was higher for those receiving M-CAVI.

Risk factors for mortality in major digestive surgery in the elderly: a multicenter prospective study

OBJECTIVE

To identify the mortality risk factors of elderly patients (≥65 years old) during major digestive surgery, as defined according to the complexity of the operation.

BACKGROUND

In the aging populations of developed countries, the incidence rate of major digestive surgery is currently on the rise and is associated with a high mortality rate. Consequently, validated indicators must be developed to improve elderly patients' surgical care and outcomes.

METHODS

We acquired data from a multicenter prospective cohort that included 3322 consecutive patients undergoing major digestive surgery across 47 different facilities. We assessed 27 pre-, intra-, and postoperative demographic and clinical variables. A multivariate analysis was used to identify the independent risk factors of mortality in elderly patients (n = 1796). Young patients were used as a control group, and the end-point was defined as 30-day postoperative mortality.

RESULTS

In the entire cohort, postoperative mortality increased significantly among patients aged 65-74 years, and an age ≥65 years was by itself an independent risk factor for mortality (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.36-3.59; P = 0.001). The mortality rate among elderly patients was 10.6%. Six independent risk factors of mortality were characteristic of the elderly patients: age ≥85 years (OR, 2.62; 95% CI, 1.08-6.31; P = 0.032), emergency (OR, 3.42; 95% CI, 1.67-6.99; P = 0.001), anemia (OR, 1.80; 95% CI, 1.02-3.17; P = 0.041), white cell count > 10,000/mm³ (OR, 1.90; 95% CI, 1.08-3.35; P = 0.024), ASA class IV (OR, 9.86; 95% CI, 1.77-54.7; P = 0.009) and a palliative cancer operation (OR, 4.03; 95% CI, 1.99-8.19; P < 0.001).

CONCLUSION

Characterization of independent validated risk indicators for mortality in elderly patients undergoing major digestive surgery is essential and may lead to an efficient specific workup, which constitutes a necessary step to developing a dedicated score for elderly patients.

Immunotherapy for urothelial carcinoma: current status and perspectives

Intravesical instillation of bacillus Calmette Guérin (BCG) for the treatment of urothelial carcinoma (UC) of the bladder is based on the BCG-induced immune response, which eradicates and prevents bladder cancer. The results of recent studies have suggested that not only major histocompatibility complex (MHC)-nonrestricted immune cells such as natural killer cells, macrophages, neutrophils, etc., but also MHC-restricted CD8⁺ T cells play an important role and are one of the main effectors in this therapy. Better understanding of the mechanism of BCG immunotherapy supports the idea that active immunotherapy through its augmented T cell response can have great potential for the treatment of advanced UC. In this review, progress in immunotherapy for UC is discussed based on data from basic, translational and clinical studies. We also review the escape mechanism of cancer cells from the immune system, and down-regulation of MHC class I molecules.

Phase II study of sunitinib as first-line treatment of urothelial cancer patients ineligible to receive cisplatin-based chemotherapy: baseline interleukin-8 and tumor contrast enhancement as potential predictive factors of activity

BACKGROUND

A strong rationale supports the role of antiangiogenic drugs in urothelial cancer. This trial was designed to assess the activity of sunitinib as first-line treatment in patients with metastatic urothelial cancer ineligible for cisplatin and to explore molecular and imaging variables predictive of clinical benefit.

PATIENTS AND METHODS

This was a multicenter phase II trial with sunitinib 50 mg daily in 4/2-week schedule. Eligibility criteria were as follows: creatinine clearance 30-60 ml/min, Eastern Cooperative Oncology Group Pperformance Sstatus of one or less, and adequate hepatic and hematologic function. Twelve circulating cytokines were evaluated at baseline and sequentially using Luminex xMAP(®) (Austin, TX). Baseline and treatment-related changes in perfusion were evaluated in a patient subgroup using contrast-enhanced computed tomography.

RESULTS

On intention-to-treat analysis, 38 patients showed 3 (8%) partial responses (PRs) and 19 (50%) presented with stable disease (SD), 17 (45%) of them ≥3 months. Clinical benefit (PR + SD) was 58%. Median time to progression (TTP) was 4.8 months and median overall survival 8.1 months. Toxicity was consistent with previous reports for sunitinib. Low interleukin-8 (IL-8) baseline levels were significantly associated with increased TTP. Baseline tumor contrast enhancement with >40 Hounsfield units was associated with clinical benefit.

CONCLUSIONS

This study highlights the potential role of the angiogenic pathway as a therapy target in urothelial cancer. Baseline IL-8 serum levels and contrast enhancement of lesions warrant further study.

Randomized phase II/III trial assessing gemcitabine/ carboplatin and methotrexate/carboplatin/vinblastine in patients with advanced urothelial cancer "unfit" for cisplatin-based chemotherapy: phase II--results of EORTC study 30986

PURPOSE

There is no standard treatment for patients with advanced urothelial cancer who are ineligible ("unfit") for cisplatin-based chemotherapy (CHT). To compare the activity and safety of two CHT combinations in this patient group, a randomized phase II/III trial was conducted by the EORTC (European Organisation for Research and Treatment of Cancer). We report here the phase II results of the study.

PATIENTS AND METHODS

CHT-naïve patients with measurable disease and impaired renal function (30 mL/min < glomerular filtration rate [GFR] < 60 mL/min) and/or performance status (PS) 2 were randomly assigned to receive either GC (gemcitabine 1,000 mg/m(2) on days 1 and 8 and carboplatin area under the serum concentration-time curve [AUC] 4.5) for 21 days or M-CAVI (methotrexate 30 mg/m(2) on days 1, 15, and 22; carboplatin AUC 4.5 on day 1; and vinblastine 3 mg/m(2) on days 1, 15, and 22) for 28 days. End points of response and severe acute toxicity (SAT) were evaluated with respect to treatment group, renal function, PS, and Bajorin risk groups.

RESULTS

Three of 178 patients who were ineligible or did not start treatment were excluded. SAT was reported in 13.6% of patients on GC and in 23% on M-CAVI. Overall response rates were 42% (37 of 88) for GC and 30% (26 of 87) for M-CAVI. Patients with PS 2 and GFR less than 60 mL/min and patients in Bajorin risk group 2 showed a response rate of only 26% and 20% and an SAT rate of 26% and 25%, respectively.

CONCLUSION

Both combinations are active in this group of unfit patients. However, patients with PS 2 and GFR less than 60 mL/min do not benefit from combination CHT. Alternative treatment modalities should be sought in this subgroup of poor-risk patients.

Step by step development of clinical care pathways for older cancer patients: necessary or desirable?

Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.

Response and outcomes in elderly patients with stages IIIC–IV ovarian cancer receiving platinum–taxane chemotherapy

OBJECTIVE

Recent reports have suggested that only half of women age > or =65 with advanced ovarian cancer are treated with platinum-based chemotherapy. The objective of this study was to compare the response to platinum-taxane chemotherapy and subsequent outcomes between patients older and younger than 65 years of age with stages IIIC-IV epithelial ovarian cancer (EOC).

PATIENTS AND METHODS

A cohort study was performed of all patients with stages IIIC-IV EOC who had their primary surgery at our institution from 1998 to 2004 and subsequently began platinum-taxane chemotherapy. Main outcomes were response to primary chemotherapy, platinum resistance and progression-free (PFS) and overall survival (OS).

RESULTS

A total of 292 patients began primary platinum-taxane therapy after surgery and comprised our study group. Of these, 108 (37%) were > or =65 years old and 184 (63%) were <65. Stage of disease, optimal cytoreduction rate, number of chemotherapy cycles and chemotherapy regimen alterations were similar between groups. Patients > or =65 achieved a clinical complete response with a similar frequency to those <65 (70% vs. 79%) and had similar rates of platinum sensitivity at 6 months (61% vs. 65%). Patients > or =65 had equivalent PFS (P=0.99) and OS (P=0.36) to those <65. Age > or =65 years was not independently associated with impaired survival.

CONCLUSIONS

Patients > or =65 years of age demonstrated similar rates of initial response, platinum resistance, PFS and OS to younger patients. Elderly women who can tolerate primary cytoreductive surgery should receive combination platinum-taxane chemotherapy.

Treatment tolerance and efficacy in geriatric oncology: a systematic review of phase III randomized trials conducted by five National Cancer Institute-sponsored cooperative groups

PURPOSE

Elderly patients share the majority of the disease burden in cancer. Although 61% of new cancer cases occur among elderly, they comprise only 25% of the patients enrolled onto randomized clinical trials (RCTs). A systematic review to assess the accurate participation of elderly patients in RCTs has not been performed.

PATIENTS AND METHODS

We reviewed all consecutively completed phase III RCTs conducted by five National Cancer Institute-sponsored cooperative groups. Published papers and study protocols were used for data extraction. We used a cutoff age of 65 years to define elderly patients. For trials that did not exclusively enroll elderly, data were extracted on number of participants 65 years of age. Outcome between the innovative and the standard treatment was compared.

RESULTS

Of 345 studies, only one trial exclusively enrolled elderly patients (0.28%); 57% of the trials (n = 197) had no stratification by age, and 12% of the studies had a stratification age 65 years (n = 42). Overall survival in the trial exclusively enrolling elderly favored the newer treatments (hazard ratio [HR], 0.69; 95% CI, 0.47 to 1.02; P = .06). Additionally, in trials enrolling more than 40% of elderly, survival and event-free survival favored the innovative treatments (HR for survival, 0.91; 95% CI, 0.84 to 0.99; P = .03; HR for event-free survival, 0.85; 95% CI, 0.72 to 1.01; P = .07). Treatment-related mortality was similar in both the innovative and standard treatment groups (HR, 0.91; 95% CI, 0.47 to 1.78; P = .8).

CONCLUSION

Our data indicate that enrollment of elderly in experimental RCTs is not associated with increased harm to this patient population. Increased participation of elderly may help in finding new treatments that are clinically applicable specifically to this cohort of patients.

Gero-Oncology Nursing Research

PURPOSE/OBJECTIVES

To analyze the development of gero-oncology research through a critical review of nursing and other relevant research as well as the present state of practice.

DATA SOURCES

Journal articles, book chapters, and personal experience.

DATA SYNTHESIS

Cancer in older adults is viewed through two investigative perspectives. The assumptions, questions, theoretical frames, and research design that follow from these investigative perspectives do not adequately meet the need to examine the interplay of responses to aging, cancer, and nursing practice. The mismatch of need, knowledge, and resources marks older adults with cancer as a special population in need of far more sophisticated research. With the synthesis of a new perspective, gero-oncology nursing research becomes age focused, more precisely shaping theoretical, methodologic, and analytic approaches.

CONCLUSIONS

Uniform attachment of chronologic age or other simple age-related variables to investigations, which is the primary consideration of age-related research, is irrelevant for older adults who are diagnosed with, treated for, live with, survive, and die from cancer. Shaping the next phase of gero-oncology research with a focus on age precisely integrates theoretical, methodologic, and analytic approaches through language specific to older adults and cancer.

IMPLICATIONS FOR NURSING

Shifting perspectives in gero-oncology nursing research will better inform future practice.

Chemotherapy for elderly patients with advanced colorectal carcinoma

There is an increasing need to redefine treatment strategies in elderly patients with advanced colorectal carcinoma since they constitute more than 50% of newly diagnosed patients. Taking into account that the vast majority of clinical trials in advanced colorectal carcinoma include patients up to 75 years old, it seems reasonable to consider those patients over 75 years as elderly. In general, 20% of patients have favorable factors (fewer than four liver nodules less than 5 cm in size) and are suitable for local treatments (surgery or local-ablative therapies). Additionally, 40% of patients have poor performance status or are severely disabled owing to geriatric syndromes and/or comorbid diseases (advanced stage) that preclude any treatment strategies. The remainder of patients (fit elderly patients not suitable for radical treatments) constitute the focus of this review.

Geriatric neutrophils: implications for older adults

OBJECTIVES

To review the intersection of immunosenescence and neutropenia, focusing on innate immunity, and implications for research and practice for neutropenic older adults with cancer.

DATA SOURCES

Research studies, journal articles, and web sites.

CONCLUSION

Immunosenescence, age-related changes within the immune system renders older adults more vulnerable to infection. This vulnerability is magnified by cancer and its treatment. Unfortunately, there has been little consideration of immunosenescence as it relates to supportive care for this population.

IMPLICATIONS FOR NURSING PRACTICE

Studies detailing the impact of immunosenescence on neutropenia and outcomes for neutropenic older adults are necessary to advance clinical research and practice.

[Digestive surgery in the elderly]

The dramatic increase in digestive surgery among patients of advanced age is the logical consequence of the aging population demographics in developed countries. Surgery in the aged is not fundamentally different, but it demands precise and tailored assessment and management of surgical indications and surgical and anesthetic techniques. Advanced age is not a contraindication to even major digestive surgery, but every effort must be made to avoid urgent operations by attention to pre-existing symptoms which are all-too-often neglected in the aged. Intensive care may help to shorten the hospital stay which should ideally occupy only a minor portion of the numbered days of the patient (whose life expectancy may be significantly longer than one may intuitively foresee).

Treatment patterns by decade of life in elderly women (≥70 years of age) with ovarian cancer

OBJECTIVE

Elderly patients are less likely to receive surgery and platinum-based combination chemotherapy than younger patients. We evaluated multi-institutional management of ovarian cancer in the elderly.

METHODS

Charts of women with ovarian, primary peritoneal or fallopian tube cancer from 1/1996-6/2004, age > or =70 years were reviewed. Age, stage, medical co-morbidities, surgery, chemotherapy, treatment modification, toxicity and survival were analyzed. Chi-square, logistic regression and survival analysis were used.

RESULTS

Of 131 patients, 90 were ages 70-79 (group 1 = G1) and 41 were >80 years of age (group 2 = G2). Surgery was performed in 80 patients in G1; 25 patients in G2 (P = 0.001). Among patients who underwent surgery, optimal debulking and post-operative complications did not differ between groups. Ninety-five percent of patients received platinum-based therapy and 83% received combination platinum/paclitaxel in G1, compared to 90% and 41%, respectively, in G2 (P < 0.001). Of those receiving platinum therapy, 36% in G1 and 41% in G2 required dose reductions or termination of therapy. Forty percent of G1 and 50% of G2 required a delay of therapy; the majority occurring in patients receiving combination therapy. Hematological toxicity increased with use of combination therapy, but not with advancing age or Charlson score. Successful debulking surgery significantly impacted survival, and when controlling for this factor, age was not a significant variable.

CONCLUSION

The extreme elderly had a decreased likelihood of receiving surgery and combination chemotherapy despite equivalent co-morbidities. In this analysis, optimal surgical cytoreduction had the greatest impact on survival.

The prevalence and correlates of fatigue in older cancer patients

PURPOSE

to assess the prevalence and correlates of fatigue in cancer patients aged 60 and older during outpatient treatment with chemotherapy or pamidronate.

PATIENT AND METHODS

seventy-seven consecutive cancer patients with different tumors age 60+ served by the senior adult oncology program of the H. Lee Moffitt Cancer Center, were enrolled in the study. Inclusion criteria were: (1) age >-60 years; (2) histological diagnosis of malignancy; (3) no major psychiatric or neurological disorder that could interfere with the competition of the measures; (4) ability to understand and to speak English. Assessment included cognition, function, depression and fatigue. The instruments included geriatric depression scale, mini mental state examination and fatigue symptom inventory. The study used a cross-sectional design.

RESULTS

Fifty-six patients (72.7%) reported fatigue at the time of the assessment; seventy-six patients (99%) in the past week. Forty patients (52%) rated their average fatigue as greater than 5. Forty-two patients (54%) reported that they felt fatigue all seven days, for any part of the day in the week before the assessment. Sixty five (84%) patients rated fatigue as interfering with their general level of activity. The fatigue disruptiveness was higher for women than for man (P<0.007). Marital status and educational level were not significantly related to fatigue severity or fatigue disruptiveness (P> or =0.33). A significant positive correlation between depressive symptoms and fatigue severity (r = 0.29, P<0.01) was recorded. Depression was also significantly related to fatigue disruptiveness (r = 0.44, P<0.01). Cognitive status was not correlated with fatigue severity or fatigue disruptiveness. A negative correlation between haemoglobin level and fatigue severity (r = -0.30, P<0.01) and between haemoglobin level and fatigue disruptiveness (r = -0.28, P<0.01) was found. Having had medical care or counselling in the past for anxiety and depression was positively correlated with fatigue disruptiveness (r = 0.29, P<0.01).

CONCLUSION

Fatigue is a common symptom of older cancer patients treated with antineoplastic medical treatment. Female patient showed higher fatigue disruptiveness than male. In this study a positive correlation between depression and fatigue, and a negative correlation between haemoglobin and fatigue, were recorded.

The impact of performance status on survival in patients of 80 years and older with vulvar cancer

OBJECTIVE

There are no data available on the impact of performance status on outcome in patients with vulvar cancer. It was the objective of this study to determine the impact of performance status on survival in a group of elderly patients.

METHODS

A retrospective review of records of patients with vulvar cancer aged 80 years or greater and treated in a gynecological referral center was performed. Multiple clinical and pathological variables together with performance status were assessed and the impact on overall survival was determined both by univariate and multivariate analysis.

RESULTS

Of 75 patients aged 80 years or older, 57 (76%) had standard treatment. The patients who had standard treatment were characterized by an earlier clinical stage and a better performance status compared with patients who had nonstandard treatment. When preoperatively available parameters of all patients were assessed in relation to survival in the total group, Eastern Cooperative Oncology Group (ECOG) performance status was the only independent prognostic indicator for survival. When all clinical and histopathological variables were assessed in the subgroup who had standard treatment, both ECOG performance status and extracapsular lymph node involvement were independent prognostic variables for overall survival. Age was not a significant prognostic variable.

CONCLUSIONS

ECOG performance status is the only available pretreatment variable with independent prognostic value for survival in this group of elderly patients with vulvar cancer. These data show the importance of individualizing the treatment of patients with vulvar cancer. Performance status takes a more important place than age in the management process of these patients.

Treatment considerations for the elderly person with cancer

In an aging population, the number of patients with cancer continues to rise. Little research has focused on the treatment of cancer in the elderly. Therefore, the treatment for various cancers differs across the healthcare system. A uniform approach in assessing the elderly person with cancer is lacking. This article describes two case studies in the elderly population, focusing on two common cancers: acute myelogenous leukemia and breast cancer. Common side effects of treatment and determinants of treatment options are discussed. It is important that the elderly receive appropriate screening, early detection, treatment, and management of comorbidities.

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.