The aged patient with lung cancer. Management recommendations

Treatment of lung cancer in older patients

Lung cancer is a disease of older persons. It is the most common cause of cancer death in men and women in the United States. A comprehensive evaluation of medical comorbidities and functional status is important in all patients but perhaps more so in older adults, and it should be included in the assessment of older patients who have lung cancer. Age, per se, should not be a limiting factor to treatment, because a large body of evidence demonstrates that fit older patients who have lung cancer can safely undergo the same treatments as their younger counterparts with equally good results.

A retrospective analysis comparing patients 70 years or older to patients younger than 70 years with non-small-cell lung cancer treated with surgery at Indiana university: 1989-1999

Surgery remains the cornerstone of therapy for medically operable patients with early-stage non-small-cell lung cancer (NSCLC). However, there are few reports on the short-term morbidity and long-term survival following surgery in elderly patients with NSCLC. The surgical experience in 280 patients with NSCLC at Indiana University from 1989-1999 are reported with a comparison of patients who are >or= 70 years versus < 70 years of age. Preoperative characteristics, operative procedures, postoperative courses, and survival were compared between the age groups. Fifty percent of elderly patients had squamous cell carcinoma and 36.2% had adenocarcinoma, versus 41.3% and 44.4% in younger patients, respectively. In both groups, most patients had T1 or T2 tumors and N0 disease. The majority of patients in both age groups had a lobectomy. However, more patients younger than 70 years had chest wall resections and were more likely to undergo a pneumonectomy (19.5% vs. 6.9%). The median number of postoperative hospital days was shorter for younger patients (9 days vs. 11 days). Overall, more complications occurred in older patients, but no significant difference in cardiac or pulmonary complications was observed between the groups. There was no significant difference in survival between the age groups. This single-institution series demonstrates that surgical intervention for appropriately selected elderly patients with NSCLC results in similar complication rates and long-term survival when compared to their younger counterparts.

Older people with non small cell lung cancer in clinical stage IIIA and co-morbid conditions. Is curative irradiation feasible? Final results of a prospective study

Radiotherapy (RT) is widely used in the management of lung cancer but age-oriented randomized trials are lacking in older-unfit patients. We started a prospective study to evaluate the toxicity and efficacy of definitive RT in very old-unfit patients with non-small cell lung cancer (NSCLC) in clinical stage IIIA, according to AJCC 1988. Forty patients, age > or = 75 years, Karnofsky Performance status (KPS) > or = 60, unfit to receive an aggressive combined treatment, were entered in the study. Each patient had one or more comorbidities, and the Charlson score was greater than two in 7/40. All patients were treated with radiation fields encompassing the primary tumor and grossly involved lymph nodes. A median radiation dose of 60 Gy/2 Gy day/5 days a week, was delivered. The 40 patients have been followed up, including those who died, for a potential median time of 4.6 years. As results, no treatment-related mortality, and clinically insignificant acute morbidity was recorded: in 28/40 cases a mild esophagitis occurred. Two patients showed a clinical radiation pneumonitis (RP). Late normal tissue damage was represented by lung fibrosis (40/40 patients). The treatment was efficacy since each patient obtained some clinical benefit from it. Median survival (MS) was 19 months (range 5-68); the 3 and 5-year actuarial survival was 18 and 12%, respectively. In conclusion, we think that older patients with concomitant illness can be submitted to curative 'involved field' irradiation and the results observed in this trial encourage to use curative RT in older subjects with local-regionally advanced NSCLC and co-morbid condition.

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.

Determinants of myelosuppression in the treatment of non-small cell lung cancer with cisplatin-containing chemotherapy

Data on 16 potential risk factors for myelosuppression were assessed in 134 patients who received either vindesine and cisplatin (VP) or mitomycin C, vindesine and cisplatin (MVP) for inoperable stage III or IV non-small cell lung cancer in a randomized trial. Determinant factors for myelosuppression were evaluated by using univariate analysis and the logistic regression model. Recursive partitioning and amalgamation (RPA) was also used to define patient subgroups frequently suffering from severe bone marrow toxicity. Overall, 33 (25%) of 134 patients experienced at least one episode of grade 4 leukopenia. In univariate analysis, age, body surface area, serum creatinine, and pretreatment hemoglobin concentration were associated with severe leukopenia. A multivariate analysis using the logistic regression method showed that only raised creatinine level was an independent predictor for grade 4 leukopenia (P = 0.049). The RPA model generated three distinct subgroups based on age, body surface area and regimen. The three subgroups were distinguished by the frequency of severe (grade 4) leukopenia (50%, 25%, and 2.4%, respectively) (P < 0.001). Grade 4 leukopenia occurred more frequently in patients in class 3 (age > or = 65 years and treatment with MVP). The RPA model was useful in identifying the risk factors for myelosuppression induced by cisplatin-based chemotherapy, and in defining patient subgroups with elevated risk of toxicity.

Full chemotherapy in elderly patients with small cell bronchial carcinoma

Data on small cell lung cancer (SCLC) in elderly patients with full chemotherapy are sparse. We present material of 345 patients treated with chemotherapy (CT) with no age limits. CT was given with 2 different types of 4-drug combinations, including cyclophosphamide, doxorubicin, vincristine, methotrexate, lomustine and etoposide. Radiotherapy 40 Gy was given to 85% of the limited disease (LD) and 15% of the extensive disease (ED) patients. In 345 consecutive SCLC patients (50% LD and 50% ED) with a median survival time (MST) of 10 months and a disease-free 5-year survival 3.8%. Multivariate analysis showed clear correlation between stage of disease and survival as well as between age and survival though less pronounced. One hundred and ten patients were > 70 years of age with a median survival time of 7.4 months (LD 12.3 and ED 4.6) and 235 patients < 70 years of age had a median survival time of 10.9 months (LD 14.4 and ED 7.5) and a disease-free 5-year survival of 5.1%. The survival differences were statistically significant. Treatment toxicity was higher in patients > 70 years of age. Seventy-seven patients 70-75 years of age had an MST of 9.5 months (LD 13.2 and ED 6.2) and a disease-free 5-year survival of 1.3%. The survival differences between patients 70-75 years old and those < 70 years of age were small but statistically significant in LD at 5% level but not in ED. There were more septicemias per courses CT given in all patients 70-75 years of age and also more lethal septicemias in ED patients. Patients with LD SCLC 70-75 years of age might benefit from full treatment in terms of median and long-term survival.