Non-small-cell lung cancer in the elderly

https://doi.org/10.1016/j.critrevonc.2005.06.004Get rights and content

Abstract

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.

Introduction

Ageing of the population in the West has become an imposing social and health problem. Sixty percent of all neoplasms and two-thirds of all deaths occur in persons aged older than 65 years [1], [2]. More than 50% of patients with lung cancer are older than 65 years and 30% are older than 70 years [3], [4], [5]. Lung cancer is the principal cause of death from cancer and we have witnessed a particularly negative trend in women, due to the increased rates of smoking. The elderly are not only a particularly large sub-group, but are also prone to psychological, social, cultural and assistance problems that are not so significant for young patients. The age at which an adult can be considered ‘elderly’ has not been well defined but 70 years is conventionally considered a reference point. Thanks to the comprehensive geriatric assessment (CGA), we are learning to evaluate the elderly, not only for their advanced number of years, and performance status (PS), but also for their biological age. This helps in identifying co-morbidity factors and psychological–physiological problems as well as social security issues typical of this age band [6]. However, the CGA may be too lengthy for a busy clinical practice. Therefore, a number of screening instruments have been developed to select those older patients who may benefit from a full CGA (e.g. VES 13). Unfortunately their low participation in studies and the relatively few studies designed specially for them means that we do not have complete answers for many of the problems affecting the elderly with lung cancer [7]. A large proportion of our information is from retrospective analyses, and therefore their results should be treated with caution before considering them conclusive. Regarding treatment of advanced non-small-cell lung cancer (NSCLC), 1999 is considered a turning point with the publication of Elderly Lung Cancer Vinorelbine Study Group (ELVIS) by Gridelli et al. This study finally showed that also the elderly could benefit from chemotherapy as opposed to providing them only with the best supportive therapy, both in terms of survival and quality of life [8]. The Southern Italy Cooperative Oncology Group (SICOG) and the Multicenter Italian Lung Cancer in the Elderly Study (MILES) trials confirmed the conclusions of ELVIS trial and the benefit of a single-agent chemotherapy in elderly patients [32], [33].

Section snippets

Surgery

Surgery and radiotherapy are still the best options available for early-stage (I–II) NSCLC in the elderly [9]. The 5-year survival rate for patients with stage I NSCLC is better than 60%. In the older patient, decisions regarding surgical treatment involve an assessment of the patient's life expectancy (Table 1). Nevertheless, all thoracic surgeons carefully assess for comorbid disease as the patient ages, understanding that prolonged anesthesia and the risks involved in intensive care are

Locally advanced NSCLC

A combined-modality approach has become the cornerstone of therapy in locally advanced NSCLC. In this group, which generally includes patients with medically inoperable stage II/IIIA or unresectable stage IIIA/B disease, concurrent chemoradiation has shown a significant survival advantage in several large randomized trials. No definitive results exist in elderly patients and a combined-modality approach has to be considered investigational due to higher toxicities (neutropenia and esophagitis).

First-line chemotherapy

Chemotherapy has now been used as common practice for advanced NSCLC for a decade, i.e. from when the meta-analysis showed a small but significant advantage in terms of survival when compared to the best available support therapy. This advantage was, however, found only in the cisplatin-based regimens [21]. A more recent combination, substituting cisplatin with carboplatin (which is less nephrotoxic, neurotoxic and hemetisant, but more myelotoxic) has increased tolerance to the treatment,

Discussion

When considering elderly patients, we must bear in mind a series of specific parameters that characterize this age group. Indeed, apart from their functional state and comorbidity factors, other factors linked to their nutritional, cognitive, psychological and social welfare state become increasingly important when cancer is diagnosed. The present situation is not particularly encouraging. In a recent review by de Rijke et al, more than 52% of patients over 75 with stage IV NSCLC in Holland

Reviewers

Cesare Gridelli, M.D., Chief, Division of Medical Oncology, Director, Department of Oncology/Hematology, “S.G. Moscati” Hospital, via Circumvallazione 68, I-83100 Avellino, Italy.

Corey J. Langer, M.D., Fox Chase Cancer Center, Department of Medical Oncology, 333 Cottman Ave., Philadelphia, PA 19111-2412, USA.

Fausto Meriggi, Ph.D., was born June 4, 1963. He obtained his degree at the University of Brescia in 1988 and graduated in Medical Oncology in 1994 from the University of L’Aquila. He worked for two years as assistant in the Pneumology Department and then as assistant in Oncology Department of Poliambulanza, Brescia, Italy. He is a member of the American Society of Clinical Oncology (ASCO), the European Society of Medical Oncology (ESMO), the International Society of Geriatric Oncology (SIOG)

References (74)

  • K. Hotta et al.

    An overview of 48 elderly-specific clinical trials of systemic chemotherapy for advanced non-small cell lung cancer

    Lung Cancer

    (2004)
  • L. Repetto et al.

    Geriatric oncology: a clinical approach to the older patient with cancer

    Eur J Cancer

    (2003)
  • M. Extermann et al.

    Predictors of tolerance to chemotherapy in older patients: a prospective pilot study

    Eur J Cancer

    (2002)
  • C. Gridelli et al.

    Oral Vinorelbine given as monotherapy to advanced, elderly NSCLC patients: a multicentre phase II trial

    Eur J Cancer

    (2004)
  • C. Bokemeyer et al.

    EORTC guidelines for the use of erythropoietic proteins in anaemic patients with cancer

    Eur J Cancer

    (2004)
  • Proceedings of the National Conference on Cancer and the Older Person

    Cancer

    (1994)
  • E. Silverberg et al.

    Cancer Stat

    (1988)
  • C. Gridelli et al.

    Chemotherapy of non-small cell lung cancer in elderly patients

    Curr Med Chem

    (2002)
  • L. Repetto et al.

    Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group Performance Status in elderly cancer patients: an Italian Group for Geriatric Oncology study

    J Clin Oncol

    (2002)
  • L.F. Hutchins et al.

    Underrepresentation of patients 65 years of age or older in cancer-treatment trials

    N Engl J Med

    (1999)
  • Effects of vinorelbine on quality of life and survival of elderly patients with advanced non-small cell lung cancer

    J Natl Cancer Inst

    (1999)
  • J.H. Schiller

    Current standards of care in small-cell and non-small-cell lung cancer

    Oncology

    (2001)
  • K. Yamamoto et al.

    Surgical results of stage I non-small-cell lung cancer: comparison between elderly and younger patients

    Eur J Cardiothorac Surg

    (2003)
  • A.R. Jazieh et al.

    Prognostic factors in patients with surgically resected stages I and II non-small-cell lung cancer

    Ann Thorac Surg

    (2000)
  • P.B. Bach et al.

    The influence of hospital volume on survival after resection for lung cancer

    N Engl J Med

    (2001)
  • M.A. O’Rourke et al.

    Age trends of lung cancer stage at diagnosis. Implications for lung cancer screening in the elderly

    JAMA

    (1987)
  • Clinical characteristics, diagnosis and treatment of elderly patients with lung cancer at non-surgical institutions: a multicenter study

    Tumori

    (1990)
  • M. Montella et al.

    Has lung cancer in the elderly different characteristics at presentation?

    Oncol Rep

    (2002)
  • T. Okamoto et al.

    Clinical patterns and treatment outcome of elderly patients in clinical stage IB/II non-small cell lung cancer

    J Surg Oncol

    (2004)
  • Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials

    Br Med J

    (1995)
  • Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer

    N Engl J Med

    (2004)
  • H. Kato et al.

    A randomized trial of adjuvant chemotherapy with uracil-tegafur for adenocarcinoma of the lung

    N Engl J Med

    (2004)
  • Winton TL, Livingston R, Johnson D, et al. A prospective randomised trial of adjuvant vinorelbine (VIN) and cisplatin...
  • Strauss GM, Herndon J, Maddaus MA, et al. for CALGB, Radiation Therapy Oncology Group, and North Central Cancer...
  • K. Hotta et al.

    Role of adjuvant chemotherapy in patients with resected non-small-cell lung cancer: reappraisal with a meta-analysis of controlled randomized trials

    J Clin Oncol

    (2004)
  • Post-operative radiotherapy in non-small cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomized controlled trials

    Lancet

    (1998)
  • S.E. Schild et al.

    The outcome of combined-modality therapy for stage III non-small-cell lung cancer in the elderly

    J Clin Oncol

    (2003)
  • Cited by (13)

    • Adjuvant treatment in resected non-small cell lung cancer: Current and future issues

      2013, Critical Reviews in Oncology/Hematology
      Citation Excerpt :

      NSCLC is predominantly a disease of the elderly, with a median age at diagnosis of 70 years [27]. More than 70% of future lung cancer cases in the United States are likely to occur in adults age ≥65 years by 2030 [28], and the fact that the remaining life expectancy of a 70-year-old is approximately 15 years could justify the use of ACT in this population, particularly in early stages where potentially curative therapies exist [29]. However, the evidence of effectiveness of ACT in the elderly is low because the elderly population is under-represented in clinical trials (in the ANITA trial [10], patients over the age of 75 years were not included) and there is no clear consensus on the definition of “elderly” in all trials, which can add difficulty to the interpretation of the results.

    • Lung cancer surgery in the elderly

      2009, Critical Reviews in Oncology/Hematology
      Citation Excerpt :

      Many elderly patients do not receive standard surgery because they are considered unfit for treatment, due to inaccurate estimation of the existing surgical risk [9,10]. Many studies have reported the safety of pulmonary resection in carefully selected elderly patients, even in octogenarians [11,12]. Lung resection surgery should not be denied based on age alone (grade 1B evidence) [1], though we know age to be an independent prognostic factor of postoperative survival in lung cancer.

    • Recent Developments and Challenges in Molecular-Targeted Therapy of Non-Small-Cell Lung Cancer

      2023, Journal of Environmental Pathology, Toxicology and Oncology
    View all citing articles on Scopus

    Fausto Meriggi, Ph.D., was born June 4, 1963. He obtained his degree at the University of Brescia in 1988 and graduated in Medical Oncology in 1994 from the University of L’Aquila. He worked for two years as assistant in the Pneumology Department and then as assistant in Oncology Department of Poliambulanza, Brescia, Italy. He is a member of the American Society of Clinical Oncology (ASCO), the European Society of Medical Oncology (ESMO), the International Society of Geriatric Oncology (SIOG) and the Italian Association of Medical Oncology (AIOM). He is author or co-author of more 90 papers published in international scientific journals.

    View full text