Non-small cell lung cancer in the elderly

Demographic differentials of lung cancer survival in Bangladeshi patients

Background

Lung cancer is the leading cause of cancer-related mortality worldwide. Demographic differential has been linked with the treatment outcome and survival in recent literature, mostly from the developed world. Considering diversity in population characteristics across income strata, it’s worth assessing the link in low- and middle-income population as well. Current study aimed to assess the association of demographic characteristics with lung cancer survival in Bangladeshi lung cancer patients.

Methods & results

All newly diagnosed primary lung cancer cases attending the national institute of cancer research & Hospital (NICRH), a tertiary cancer care center in Dhaka, Bangladesh between 2018 and 2019 were considered for the study. Demographic information and clinical data were obtained from the patients’ medical records by a trained physician. Survival estimate was generated using the Kaplan-Meier method and compared across demographic and clinicopathological categories using the log-rank test. Hazard ratio and 95% CI for treatment options are generated fitting multivariable Cox proportional hazard regression.

Among 1868 patients, 84.6% were males and 15.4% were females, average (± standard deviation) age at diagnosis was 59.6±10.9 years, only 10.8% had not consumed tobacco of any form. Around two-thirds of the patient had Eastern Cooperative Oncology Group (ECOG) performance score ≥2, 29.5% had at least one comorbidity and 19.4% had metastasis at the time of presentation. Higher survival was associated with institutional education (HR 0.9; 95% CI 0.77, 0.99), and receipt of combined radiotherapy and chemotherapy (HR 0.56; 95% CI 0.46, 0.65; p <0.001). In contrast, lower survival was associated with older age between 60–69 years (HR 1.3; 95% CI 1.3, 1.5;), age ≥ 70 years (HR 1.4; 95% CI 1.1, 1.7), having any comorbidity (HR 1.1; 95% CI 1.0, 1.3), with ECOG score ≥ 3 (HR 1.41; 95% CI 1.01, 1.96) and receipt of radiotherapy treatments only (HR 1.6; 95% CI 1.3, 1.9).

Conclusion

Older age, presence of one or more comorbidity, poorer performance status, and treatment with only RT appeared as a significant predictor of poorer prognosis of lung cancer in Bangladeshi patients. In contrast, having institutional education and treatment with combined Radiotherapy and Chemotherapy appeared as a predictor of a better prognosis. The finding of this study could serve as a basis for future studies inquiring into novel approaches for certain subgroups of patients believed to be challenged in limited resources.

Nivolumab treatment of elderly Japanese patients with non-small cell lung cancer: subanalysis of a real-world retrospective observational study (CA209-9CR)

Objectives

We conducted a subanalysis of data from the multicentre, retrospective observational Nivolumab Japan Real World (CA209-9CR) study to evaluate nivolumab effectiveness and safety in elderly patients (aged ≥75 years) with advanced/metastatic non-small cell lung cancer.

Materials and methods

Medical record data of patients initiating nivolumab treatment between April 2016 and December 2016 were collected using electronic data capture from 23 cancer hospitals in Japan between March 2017 and August 2018. Nivolumab treatment data were collected to investigate the treatment patterns by age group (<75 and ≥75 years), and the effectiveness and safety of nivolumab treatment.

Results

Of the 901 patients evaluated, 178 (19.8%) were aged ≥75 years. Overall, patients received a median of five nivolumab treatments regardless of age group. Comparable progression-free survival was observed, with a median of 2.1 months in patients aged <75 years and 2.1 months in patients aged ≥75 years (p=0.5441). No significant differences were found in duration of response, overall response rate or disease control rate between the two age groups. Median overall survival in patients aged <75 and ≥75 years was 14.7 months and 12.3 months, respectively. Grade ≥3 adverse events (AEs) occurred in 29.2% and 28.1% of patients aged <75 and ≥75 years, respectively. Immune-related AEs decreased slightly with increasing age; time to onset and rates of improvement were similar for patients aged <75 and ≥75 years. The most common grade 3–4 AEs were interstitial lung disease in both age groups (4.0% in patients aged <75 years and 2.8% in those aged ≥75 years). Poor performance status was associated with worse outcomes in both age groups.

Conclusion

Based on Japanese real-world data, the effectiveness and safety of nivolumab were confirmed regardless of age.

Exceptional Survival Among Kentucky Stage IV Non-small Cell Lung Cancer Patients: Appalachian Versus Non-Appalachian Populations

PURPOSE

To determine differences in exceptional survival (ES)-survival of 5 years or more past diagnosis-between stage IV non-small cell lung cancer (NSCLC) patients residing in the Appalachian versus non-Appalachian regions of Kentucky.

METHODS

This was a population-based, retrospective case-control study of Kentucky patients, diagnosed with stage IV NSCLC between January 1, 2000, and December 31, 2011. The data were drawn from the Kentucky Cancer Registry.

FINDINGS

Findings from the multivariable logistic regression revealed no significant differences in the odds of ES between patients who resided in Appalachian versus non-Appalachian Kentucky. Being female and undergoing surgery only as the first course of treatment were associated with higher odds of ES. Increasing age, unspecified histology, having poorly differentiated or undifferentiated carcinomas, and receiving radiation therapy only as the first course of treatment were associated with decreased odds of ES.

CONCLUSION

Differences in the odds of ES among stage IV NSCLC patients were not related to residence in Appalachian versus non-Appalachian Kentucky. ES was associated with other nongenetic and treatment factors that warrant further investigations.

Association of Time-Varying Rest-Activity Rhythm With Survival in Older Adults With Lung Cancer

BACKGROUND

To the best of our knowledge, this is the first study to examine the relationship of rest-activity rhythm with survival in older adults with lung cancer and to consider variations in rest-activity rhythm over time.

OBJECTIVE

The aim of this study was to explore the relationship between rest-activity rhythm variations and survival in 33 older adults with lung cancer by considering rest-activity rhythm as a time-dependent covariate over time.

METHODS

In this prospective study with 5 repeated measurements, patients' rest-activity rhythm over 3 days was measured using actigraphy. The rest-activity rhythm was represented using the dichotomy index I (in-bed activity) < O (out-of-bed activity). The median I < O was used as the cutoff point, with an I < O of greater than or equal to 85.59% and less than 85.59% indicating robust and disrupted rest-activity rhythms, respectively. Data were analyzed using the Cox regression model with time-dependent repeated measurements of a covariate.

RESULTS

In the time-dependent multivariate Cox model, a disrupted rest-activity rhythm was independently associated with a higher risk of death than was a robust rest-activity rhythm (hazard ratio, 16.05; P = .009).

CONCLUSION

A time-varying rest-activity rhythm is incrementally associated with mortality in older adults with lung cancer and represents a rigorous and independent prognostic factor for their survival.

IMPLICATIONS FOR PRACTICE

Clinicians may need to pay more attention to the rest-activity rhythms of older adults with lung cancer during disease progression. Future studies should account for the variation in rest-activity rhythm over time.

ROMANA 3: a phase 3 safety extension study of anamorelin in advanced non-small-cell lung cancer (NSCLC) patients with cachexia

Background

Cancer anorexia–cachexia is a debilitating condition frequently observed in NSCLC patients, characterized by decreased body weight, reduced food intake, and impaired quality of life. Anamorelin, a novel selective ghrelin receptor agonist, has anabolic and appetite-enhancing activities.

Patients and methods

ROMANA 3 was a safety extension study of two phase 3, double-blind studies that assessed safety and efficacy of anamorelin in advanced NSCLC patients with cachexia. Patients with preserved Eastern Cooperative Oncology Group ≤2 after completing 12 weeks (w) on the ROMANA 1 or ROMANA 2 trials (0–12 weeks) could enroll in ROMANA 3 and continue to receive anamorelin 100 mg or placebo once daily for an additional 12w (12–24 weeks). The primary endpoint of ROMANA 3 was anamorelin safety/tolerability (12–24 weeks). Secondary endpoints included changes in body weight, handgrip strength (HGS), and symptom burden (0–24 weeks).

Results

Of the 703 patients who completed ROMANA 1 and ROMANA 2, 513 patients entered ROMANA 3 (anamorelin, N = 345, mean age 62.0 years; placebo, N = 168; mean age 62.2 years). During ROMANA 3, anamorelin and placebo groups had similar incidences of treatment–emergent adverse events (TEAEs; 52.2% versus 55.7%), grade ≥3 TEAEs (22.4% versus 21.6%), and serious TEAEs (12.8% versus 12.6%). There were 36 (10.5%) and 23 (13.8%) deaths in the anamorelin and placebo groups, respectively; none were drug-related. Improvements in body weight and anorexia–cachexia symptoms observed in the original trials were consistently maintained over 12–24 weeks. Anamorelin, versus placebo, significantly increased body weight from baseline of original trials at all time points (P < 0.0001) and improved anorexia–cachexia symptoms at weeks 3, 6, 9, 12, and 16 (P < 0.05). No significant improvement in HGS was seen in either group.

Conclusion

During the 12–24 weeks ROMANA 3 trial, anamorelin continued to be well tolerated. Over the entire 0–24w treatment period, body weight and symptom burden were improved with anamorelin.

Clinical trial registration numbers

ROMANA 1 (NCT01387269), ROMANA 2 (NCT01387282), and ROMANA 3 (NCT01395914).

Early treatment with metformin induces resistance against tumor growth in adult rats

It is known that antidiabetic drug metformin, which is used worldwide, has anti-cancer effects and can be used to prevent cancer growth. We tested the hypothesis that tumor cell growth can be inhibited by early treatment with metformin. For this purpose, adult rats chronically treated with metformin in adolescence or in adulthood were inoculated with Walker 256 carcinoma cells. Adult rats that were treated with metformin during adolescence presented inhibition of tumor growth, and animals that were treated during adult life did not demonstrate any changes in tumor growth. Although we do not have data to disclose a molecular mechanism to the preventive metformin effect, we present, for the first time, results showing that cancer growth in adult life is dependent on early life intervention, thus supporting a new therapeutic prevention for cancer.

Stereotactic body radiotherapy for very elderly patients (age, greater than or equal to 85 years) with stage I non-small cell lung cancer

BACKGROUND

Stereotactic body radiotherapy (SBRT) for non-small cell lung cancer (NSCLC) is primarily a treatment option for medically inoperable patients, who are often elderly. However, few studies report the effects of SBRT in elderly patients. Thus, we retrospectively analyzed clinical outcomes and feasibility following treatment of very elderly patients (age ≥ 85 years) with stage Ι NSCLC and younger patients (age < 85 years) with SBRT in our institution.

METHODS

From January 2006 to December 2012, 81 patients (20 very elderly; median age, 80 years; age range 64-93 years) with stage Ι NSCLC received SBRT. Prescription doses of 48 Gy were delivered in 4 fractions over 2 weeks or doses of 60 Gy were delivered in 10 fractions over 3 weeks.

RESULTS

Local control was achieved in 91.8% of all patients at 3 years (83.1% and 93.8% of very elderly and younger patients, respectively), and the 3-year overall survival (OS) rate was 69.4% (40.7% and 75.0% of very elderly and younger patients, respectively). OS rates were significantly shorter for the very elderly group than for the younger group, with a 3-year cause-specific survival (CSS) rate of 77.9% (50.4% and 81.6% of very elderly and younger patients, respectively) and a 3-year progression-free survival (PFS) rate of 59.5% (44.7% and 63.5% in very elderly and younger groups, respectively). Multivariate analysis revealed a significant correlation between T stage and OS. Grades 2 and 3 radiation pneumonitis (RP) occurred in 7 (8.6%) and 2 (2.5%) patients, respectively. Among patients of very elderly and younger groups, grade 2 RP occurred in 4 (20%) and 3 (4.9%) patients, and grade 3 occurred in 2 (10%) and 0 (0%) patients, respectively. No grade 4 or 5 toxicity was observed, RP was significantly more severe among very elderly patients.

CONCLUSIONS

SBRT for stage Ι NSCLC was well tolerated and feasible in very elderly patients. The efficacy of SBRT was comparable to that achieved in younger patients, although very elderly patients experienced significantly more severe RP. Although this study cohort included only 20 very elderly patients, the present data suggest that decreasing volumes of normal lung tissues exposed to ≥ 20 Gy and mean lung doses reduces the risk of RP in very elderly patients. The present data warrant studies of larger very elderly cohorts.

Assessment of cancer care in Indian elderly cancer patients: A single center study

Background and purpose:

This prospective study aimed to assess the profiles of elderly cancer patient to optimize cancer care in Indian setup. The profiles have been compared with that of younger patients in terms of epidemiological, clinical data, co-morbidity, treatment, toxicity, clinical outcome, and survival pattern.

Materials and Methods:

The study comprised cancer patients attending radiotherapy outdoor (November 2005 to June 2006). There were 104 patients of age ≥60 years (elderly group) and 121 patients of 45-59 years (younger group).

Results:

Elderly group had median age 65 years (60-88 years) with M:F = 1:1. The younger group had median age 50 years (45-59 years) with M:F = 1:2. Elderly had higher proportion of gastrointestinal and genito-urinary tract malignancies. Younger group had higher proportion of breast, lymphoma, and brain tumor. 13% had co-morbidity, 50% received treatment, 27% were treated with radiotherapy with or without surgery, and two-third of these cases belong to elderly group. Majority tolerated treatment well. 10% had significant grade of toxicity. 57% of elderly patients did not accept and one-fourth of all cases did not complete the prescribed treatment. 88% cases were responders of which 70% showed complete response. There were no differences between two groups. At 12 months 35% of treated patients came for follow-up. At first 12 months, 60-70% were alive without disease.

Conclusion:

There were differences between two groups in terms of performance status, treatment acceptance, and treatment modality prescribed. Elderly patients deserve same opportunity as younger patients for treatment and survival options from the oncologist.

Age is a prognostic factor affecting survival in lung cancer patients

Despite all efforts at management, prognosis of advanced lung cancer is extremely poor, with a median survival time of ~1 year. The number of cancer patients aged >70 years is significantly increased among the cancer patient population. The aim of this study was to investigate the clinical importance of age in lung cancer. Data from 110 patients with histologically confirmed lung cancer, who were treated and followed up in the Institute of Oncology, University of Istanbul, were recorded from medical charts. There were 100 (91%) males with a median age of 59 years (range, 35-88 years). The majority of patients had non-small cell lung cancer (NSCLC; 84%) and metastatic stage (56%). The rate of positive response to chemotherapy was lower in elderly patients (P=0.01) and the incidence of anemia was higher compared with that in younger patients (P=0.02). The majority of mortalities occurred in elderly patients (P=0.01). The median survival time of elderly patients was significantly lower compared with that of younger patients (37.8 vs. 57 weeks; P=0.009). The 1-year survival rates in younger and elderly patients were 67.3 and 42.5%, respectively. In multivariate analysis, elderly patients also had significantly poorer survival (P=0.023). In the group of elderly patients, analyses revealed that significant prognostic factors, including stage of disease and serum lactate dehydrogenase (LDH) levels, were associated with survival. Elderly patients diagnosed with small cell lung cancer had a poorer outcome compared with those with NSCLC (P=0.009), and older patients with elevated serum LDH levels had a shorter survival time compared with those with normal levels (P=0.042). In conclusion, age is one of the major prognostic factors affecting survival in lung cancer patients; therefore, patients should be managed according to age in clinical practice.

Carbon ion radiotherapy for elderly patients 80 years and older with stage I non-small cell lung cancer

Surgical resection is the standard treatment for stage I non-small cell lung cancer (NSCLC). However, elderly patients with NSCLC often suffer from other conditions, such as chronic obstructive pulmonary disease (COPD) or cardiovascular disease, and are not suitable candidates for surgery. Different modalities to treat stage I NSCLC have been developed, such as stereotactic radiotherapy (SRT), proton beam radiotherapy and carbon ion radiotherapy (CIRT). Between April 1999 and November 2003, we treated 129 patients with stage I NSCLC using CIRT. In this study, we focused on 28 patients aged 80 years and older who underwent CIRT, and analyzed the effectiveness of CIRT in treating their lung cancer and the impact on their activity of daily life (ADL). The 5-year local control rate for these patients was 95.8%, and the 5-year overall survival rate was 30.7%, but there were no patients who started home oxygen therapy or had decreased ADL. Our data demonstrate that CIRT was effective in treating elderly patients with stage I NSCLC.

Results and Impact of Routine Assessment of Comorbidity in Elderly Patients with Non–Small-Cell Lung Cancer Aged > 80 Years

BACKGROUND

Elderly patients now represent a bigger proportion of patients with non-small-cell lung cancer (NSCLC). However, data from clinical trials are limited for this age group, and the elderly are often excluded from optimal treatment for several reasons, including comorbidity.

PATIENTS AND METHODS

We reviewed a 10-year experience on proven patients with NSCLC aged > 80 years; comorbidity was assessed using the Charlson Comorbidity index (CCI). The main objective was the impact of comorbidity on survival outcome.

RESULTS

Of 109 managed patients aged > 80 years, 74 patients had a proven diagnosis of NSCLC. Performance status was < 2 in 58 patients and TNM classification of malignant tumors was I-II, IIIA-IIIB, and IV in 18, 27, and 29 patients, respectively. Comorbidity was present for 49 patients. Charlson Comorbidity Index ranged from 4 to 12 with 31 patients having a CCI >or= 6. Sixteen patients received supportive care only, whereas 23 patients were operated on, 12 received radiation therapy, and 23 had chemotherapy. Eight grade 3/4 toxicities were reported (3 patients discontinued treatment). Multivariate analysis demonstrated a significant increase in the risk of death for patients with a poor Eastern Cooperative Oncology Group performance status (hazard ratio, 2.64; 95% confidence interval, 1.3-5.36; P = 0.007) and an advanced TNM stage (hazard ratio, 3.31; 95% confidence interval, 1.99-5.5; P < 0.00001). Although statistic significance was not reached, a difference in overall survival was shown between patients with a CCI < 6 and CCI >or= 6 (12.2 months vs. 8.2 months; P = 0.08).

CONCLUSION

These results support a role for the CCI as a routine means to assess comorbidity, because patients with fewer comorbidities tolerate and derive survival benefit of optimal NSCLC management. These findings must be confirmed in prospective studies.

Elderly patients with squamous lung carcinoma: faring better or worse?

INTRODUCTION

Nonsmall cell lung cancer is increasingly diagnosed at an advanced age and squamous cell carcinoma is the commonest histological type encountered in older patients. The clinical course, management, and outcome of squamous lung cancer in the elderly have not been thoroughly studied to date.

PATIENTS AND METHODS

We retrospectively analyzed 236 squamous cell lung cancer patients diagnosed in two reference hospitals and compared key epidemiological, clinical, and management features between elderly (>70 years) and younger patients. Sixty-four were aged more than 70 years at diagnosis while 172 were up to 70 years of age.

RESULTS

There were no differences between the two groups in gender or stage distribution. No differences were observed in the nature or duration of presenting symptoms, the appearance of pleurisy, atelectasis or vascular invasion, the incidence of distant metastatic spread, or the response to combination chemotherapy. Elderly patients were less fit (performance status 2/3 30 vs 20%, p=0.03), developed hemoptysis more often (56 vs 42%, p=0.04), and presented with smaller tumor primaries (median 4 vs 8 cm, p=0.004). When metastases were present, older patients exhibited a tropism for bony (64 vs 29%, p=0.03) and rarity of brain (5 vs 14%, p=0.03) deposits. Though elderly subjects received chemotherapy (63 vs 82%, p=0.003) or radiotherapy (29 vs 48%, p=0.009) less often than their younger counterparts, they tolerated it well and achieved comparable median time to treatment failure and overall survival (median 17 vs 18 months, log-rank p=0.22). Platinum-based chemotherapy and potentially curative management were applied less often in older patients.

CONCLUSIONS

Older patients are less fit, develop bony but not brain metastases, receive antineoplastic treatment less often, and survive as long as younger patients. Squamous lung carcinoma may follow a more indolent clinical course in the elderly, a hypothesis worth validating by case-cohort studies and molecular profiling, with the hope to rationally individualize patient treatment.

Topotecan in the treatment of elderly patients with relapsed small-cell lung cancer

BACKGROUND

Almost 70% of all patients with lung cancer in the United States are>65 years of age, and the incidence of small-cell lung cancer (SCLC) increases with age until the eighth decade of life. However, elderly patients are underrepresented in clinical trials and are often suboptimally treated. The validity of age as a prognostic factor for toxicity or survival remains controversial.

PATIENTS AND METHODS

To investigate the safety and efficacy of topotecan (an approved treatment for relapsed SCLC) in older patients, we performed a retrospective analysis in patients >or= 65 years of age versus patients < 65 years of age from 5 large topotecan trials. In all 5 trials, patients received topotecan 1.5 mg/m2 per day via a 30-minute intravenous infusion on days 1 through 5 of a 21-day cycle. Efficacy and tolerability outcomes were assessed for both age groups.

RESULTS

Topotecan was similarly tolerated in both age groups, with generally manageable hematologic toxicity. The incidence, duration, and onset of severe hematologic toxicities did not vary significantly with age. In the<65 age group, grade 4 neutropenia and leukopenia were reported in 72% and 32% of patients, respectively; in the >or= 65 age group, grade 4 neutropenia and leukopenia were reported in 77% and 31% of patients, respectively. Grade 4 thrombocytopenia was less common in the<65 age group. Nonhematologic toxicities, median time to progression, and overall survival were comparable between groups.

CONCLUSION

This is the first demonstration of the safety and efficacy of topotecan in older patients with recurrent SCLC. Future studies are needed to fully characterize the role of topotecan in the treatment of older patients.

Non-small-cell lung cancer in the elderly

The world population is getting increasingly older. In Western countries, lung cancer in the most frequent cancer and more than 50% of patients who contract non-small-cell lung cancer (NSCLC) are close to 70 years old. It is therefore fundamentally important that we identify an overall strategy of screening, diagnosis and therapy designed specifically for elderly patients. NSCLC research still has relatively little material dedicated exclusively to the elderly, but recently interest has been growing, possibly due to the positive results of the most recent trials (Elderly Lung Cancer Vinorelbine Study Group (ELVIS), Southern Italy Cooperative Oncology Group (SICOG), Multicenter Italian Lung Cancer in the Elderly Study (MILES)). In particular, the integration of geriatric and oncological information has led to better recognition of elderly candidates for more aggressive therapy which is usually reserved for younger patients, while recognizing more fragile patients who need only support therapy.