Non-small-cell lung cancer in the elderly
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)
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Adjuvant treatment in resected non-small cell lung cancer: Current and future issues
2013, Critical Reviews in Oncology/HematologyCitation 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/HematologyCitation 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.
Efficacy and adverse effects of different immunotherapy in the elderly
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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.