Advanced non-small-cell lung cancer in the elderly

Meta-analysis comparing doublet and single cytotoxic agent therapy as first-line treatment in elderly patients with advanced nonsmall-cell lung cancer

Objective

To perform a systematic review and meta-analysis comparing doublet versus single agent therapy in elderly patients with advanced nonsmall-cell lung cancer (NSCLC).

Methods

PubMed® and Cochrane databases, and American Society of Clinical Oncology, World Congress of Lung Cancer, and European Society of Medical Oncology abstracts were searched. Endpoints were overall survival (OS), 1-year survival rate (1-year SR), overall response rate (ORR), and grade 3/4 adverse events. Subgroup analyses were based on chemotherapy regimens and race.

Results

Out of 11 studies (13 randomized trials; n = 2782), doublet therapy was associated with significantly increased OS (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.83, 0.95), 1-year SR (risk ratio [RR] 1.15, 95% CI 1.04, 1.28), and ORR (RR 1.39, 95% CI 1.39, 1.86) versus single-agents. Chemotherapy regimen-based subgroup analyses favoured platinum-based doublet therapy for OS (RR 0.71, 95% CI 0.60, 0.84), 1-year SR (RR 1.28, 95% CI 1.11, 1.47), and ORR (RR 1.88, 95% CI 1.49, 2.38). Race-based subgroup analyses revealed increased benefit from doublet therapy in Asian populations for ORR (RR 1.70, 95% CI 1.29, 2.23) but not increased survival benefit. Higher incidences of grade 3/4 anaemia (RR 2.23, 95% CI 1.61, 3.09), thrombocytopenia (RR 2.47, 95% CI 1.17, 5.20), and fatigue (RR 1.36, 95% CI 1.06, 1.74) were observed with doublet versus single-agent therapy.

Conclusions

Doublet therapy was associated with significantly increased OS, 1-year SR and ORR compared with single agent therapy. Race may be considered when choosing doublet versus single-agent therapy as first-line treatment of NSCLC in elderly patients.

Nab-paclitaxel (abraxane)-based chemotherapy to treat elderly patients with advanced non-small-cell lung cancer: a single center, randomized and open-label clinical trial

BACKGROUND

The purpose of this study is to evaluate the clinical efficacy and safety of abraxane-based chemotherapy with/without nedaplatin in elderly patients with non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

From October 2009 to January 2013, 48 elderly patients (≥65 years) with NSCLC were investigated in this clinical trial. The patients were randomized and equally allocated into arms A and AP: (A) abraxane (130 mg/m(2), days 1, 8); (B) abraxane + nedaplatin (20 mg/m(2) days 1-3, q3w). The parameters of objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), overall survival (OS) and side effects were evaluated between two arms.

RESULTS

Over 80% of the patients completed four cycles of chemotherapy. The total ORR was 21.3%, DCR was 55.3%, PFS 4.5 months and OS 12.6 months. No significant difference was found between arms A and AP in terms of ORR (16.7% vs. 26.1%, P=0.665) or DCR (55.3% vs. 56.5%, P=0.871). The median PFS in arm A was 3.3 months [25-75% confidence interval (CI): 3.1-7.2] and 5.5 months (25-75% CI: 3.2-7.0) in arm AP with no statistical significance (P=0.640). The median OS in arm A was 12.6 months (25-75% CI: 5.7-26.2) and 15.1 months (25-75% CI: 6.4-35.3) in arm AP with no statistical significance (P=0.770). The side effects were mainly grade 1-2. The incidence of grade 3-4 toxicities was 29.1% in arm A and 62.5% in arm AP with a statistical significance (P=0.020).

CONCLUSIONS

Compared with combined therapy, abraxane alone chemotherapy was beneficial for elderly NSCLC patients with better tolerability and less adverse events, whereas did not significantly differ in terms of ORR, DCR, PFS or OS.

Carboplatin-containing regimens as front-line treatment for advanced non-small-cell lung cancer in two groups of elderly

OBJECTIVES

We evaluated the impact of a carboplatin-based doublet in two groups of elderly patients with advanced non-small cell lung cancers (NSCLC).

MATERIALS AND METHODS

A retrospective analysis of all consecutive elderly patients (≧70 year old) with advanced NSCLC who received a carboplatin-based doublet as front-line therapy at our medical oncology unit was performed.

RESULTS

In the study, 57 consecutive elderly patients with advanced NSCLC were included. Carboplatin was combined with vinorelbine in 41 patients (71·9%) and with gemcitabine in 16 patients (28·1%). Overall, a total of 227 cycles were administered to 57 patients - 142 cycles were administered to patients in group 1 and 85 cycles were given to patients in group 2 - median number of administered cycles per patient was 4 (range 1-6). Of the patients, 35 (62%, group 1) were 'young-old' (70-74-year old) and 20 (38%, group 2) were 'old-old' (75-82-year old). Toxicity was mild in both subgroups (grade 3-4 neutropenia in 17·1% of group 1 and in 9·1% of group 2). At the univariate analysis, the median overall survival (OS) was 10·07 months (P = 0·789, 95% CI: 8·49-11·64), 10·1 months in group 1 and 9·8 months in group 2.

CONCLUSIONS

This evaluation shows the safety and efficacy of a carboplatin-based doublet given as first-line chemotherapy in elderly advanced NSCLC patients. The combination with vinorelbine or gemcitabine is associated with a very good toxicity profile that does not seem to have a detrimental effect on efficacy.

Age-dependent decline in renal function in patients with lung cancer

The aim of this study was to clarify the effect of aging on renal function. Serum creatinine (SCr), blood urea nitrogen (BUN) and 24-h creatinine clearance (measured-CrCl) were examined in lung cancer patients and the measured-CrCl were compared with CrCl estimates by employing two commonly used equations. In total, 787 lung cancer patients who were diagnosed between 2001 and 2010 were retrospectively analyzed. SCr and urine creatinine, BUN and measured-CrCl were evaluated prior to treatment. The Cockcroft-Gault (CG) and modification of diet in renal disease (MDRD) formulae were also used to estimate CrCl. SCr, BUN and measured-CrCl showed a significant decline in the elderly. In the 787 lung cancer patients, a significant correlation coefficient was found between measured-CrCl and age. However, in patients aged 80 years or older, no significant correlation coefficient was found between measured-CrCl and age. In the comparison between the measured CrCl and the CrCls estimated by the two formulae, the CG-CrCl levels were lower than those of the measured-CrCl, whereas the MDRD-CrCl levels were higher. Age is a crucial factor influencing renal function in patients with lung cancer. Particularly in the elderly, a decline in CrCl and greater individual variability in CrCl, as well as discrepancies in measured-CrCl and estimated CrCls are significant factors.

Safety creatinine clearance level for platinum chemotherapy in lung cancer patients

The present study was carried out to evaluate whether measured-creatinine clearance (measured-CrCl) and Cockcroft and Gault-CrCl (CG-CrCl) are capable of appropriately detecting a decline in renal function in lung cancer patients, including elderly patients, and to clarify a CrCl level with which to discriminate between patients with or without renal impairment. The measured-CrCl prior and subsequent to platinum-based chemotherapy of lung cancer patients was retrospectively analyzed. Measured-CrCl and CG-CrCl were evaluated prior and subsequent to platinum-based chemotherapy for lung cancer. Measured-CrCl and CG-CrCl in 59 lung cancer patients including 25 patients aged ≥65 years were retrospectively analyzed. In patients treated with carboplatin-based chemotherapy, measured-CrCl was indicative of a decline in renal function, whereas CG-CrCl was not. The optimal measured-CrCl level was <60 ml/min post-pretreatment and >90 ml/min at pre-treatment. In cases with pre-treatment measured-CrCl levels of >90 ml/min, favorable renal function is necessary in order to carry out platinum-based chemotherapy in lung cancer patients, including the elderly.

A multicentre phase II randomised trial of weekly docetaxel/gemcitabine followed by erlotinib on progression, vs the reverse sequence, in elderly patients with advanced non small-cell lung cancer selected with a comprehensive geriatric assessment (the GFPC 0504 study)

BACKGROUND

Elderly cancer patients form a heterogeneous population in which therapeutic decision-making is often difficult. The aim of this randomised phase II trial was to evaluate the feasibility and activity of weekly docetaxel/gemcitabine (DG) followed by erlotinib after progression (arm A) vs erlotinib followed by DG after progression (arm B) in fit elderly patients with advanced non small-cell lung cancer (NSCLC).

METHODS

Elderly chemotherapy-naive patients with stage IIIB/IV NSCLC were selected after a comprehensive geriatric assessment (socioeconomic, cognitive, depression, ADL and IADL assessments). The primary endpoint was the time to second progression (TTP2). Overall survival (OS), the time to first progression (TTP1) and safety were secondary endpoints.

RESULTS

Between July 2006 and November 2008, 22 centres enrolled 100 patients. TTP2 was 7.5 and 5.8 months in arm A and arm B, respectively; TTP1 was 4.7 and 2.7 months; and the median OS time was 9.4 and 7.1 months; the respective 1-year survival rates were 36.2 and 31.4%. There was no major unexpected toxicity.

CONCLUSION

These results suggest that weekly DG, followed by erlotinib, is a promising treatment for fit elderly patients with NSCLC; the efficacy of the reverse sequence was insufficient to recommend it for EGFR-non-selected patients.

The disparity of health facilities in an urban area discourages proposed treatment application in inoperable lung cancer patients

Objectives:

Patients with a newly diagnosed non-small cell lung cancer (NSCLC) stage IIIB are offered chemoradiotherapy, as proposed by the current guidelines. This combination treatment is facilitated by the coexistence of corresponding departments in the same establishment. The geographical disparity of these health facilities influences patients’ willingness to be treated and may influence their survival. This is an observational study that compares the survival of two groups of patients with NSCLC stage IIIB: those treated with chemoradiotherapy versus those treated only with chemotherapy. These two comparable groups were formed exclusively by patients’ and/or their families’ decisions.

Methods:

One hundred fifteen consecutive NSCLC stage IIIB patients were included in the study. All were hospitalized in the biggest Chest Disease Hospital in Athens and were offered sequential chemoradiotherapy. Only 54 patients opted for the proposed treatment, while 61 decided to be treated with chemotherapy only, denying continuing their treatment in another health care unit (radiotherapy). Their survival and related factors were analyzed.

Results:

Mean overall survival was estimated 10 months (95% confidence interval [CI]: 7.96–12.04). Patients treated with chemoradiotherapy had almost double overall survival compared to those under chemotherapy (P = 0.001): 13.6 months (95% CI: 12.3–14.9) versus 7.5 (95% CI: 6.1–8.9). Patients aged ≤ 65 years (P < 0.001), smokers (P < 0.001), and those without a cancer history (P < 0.001) survived longer.

Conclusions:

The lack of a radiotherapy department in a hospital providing chemotherapy impedes the application of current guidelines advocating combined radiochemotherapy. When recommended radiotherapy after six chemo cycles, half of the patients are unwilling to be displaced and do not follow the recommendations. This has an impact on patient survival.