Adjuvant Chemotherapy in Elderly Patients with Non-Small-Cell Lung Cancer

Cesare Gridelli, MD, Paolo Maione, MD, Daniela Comunale, MD, and Antonio Rossi, MD

Disclosures

Cancer Control. 2007;14(1):57-62. 

In This Article

Abstract and Introduction

Abstract

Background: More than two thirds of patients who die of lung cancer in the United States are over 65 years of age. More than 50% of lung cancer patients are diagnosed over the age of 65 and about 30% over the age of 70.
Methods: The authors review recent data from large randomized trials on adjuvant chemotherapy in patients with NSCLC. They discuss age-related changes in organ function, comorbidities and frailty in the elderly, and chemotherapy treatment in elderly patients with NSCLC.
Results: Randomized trials suggest that postoperative chemotherapy improves survival after surgery in patients with stage IB to IIIA NSCLC, and awareness of the efficacy of this approach is growing in the scientific community. Clinical data obtained in the young population cannot be automatically adopted in the elderly counterpart. Elderly patients tolerate chemotherapy poorly because of comorbidity and organ failure, and after lung surgery they are considered at higher risk of chemotherapy-induced toxicity. The survival benefit obtained with platin-based chemotherapy may vanish or decrease in the elderly due to a potential higher toxic death rate or lower compliance to treatment.
Conclusions: Modified schedules or attenuated dose of platin-containing chemotherapy should be investigated in the adjuvant setting by specifically designed trials. Specifically designed prospective trials are needed to elucidate the role of this approach in the elderly.

Introduction

Every year, 1.2 million new cases of lung cancer are diagnosed worldwide,[1] and lung cancer is the leading cause of cancer death in most developed nations. The most common type of lung cancer is of non-small cell histology, representing approximately 80%. Non-smallcell lung cancer (NSCLC) may be considered typical of advanced age. More than 50% of lung cancer cases are diagnosed in patients over the age of 65 years and approximately 30% are diagnosed in those over the age of 70.[2,3] Age-adjusted incidence rates for 1990–1994 reported by the National Cancer Institute Surveillance Epidemiology End Results (SEER) program are 26.7 per 100,000 individuals less than 65 years of age, while the rate grows to 345.9 among those 65 years of age or greater. More than two thirds of patients who die of lung cancer in the United States are over 65 years of age.[4]

Although an earlier stage of disease at diagnosis has been previously described in elderly lung cancer patients,[5] a recent analysis on 1,035 cases has not confirmed this,[6] with early and advanced stages being equally represented in the elderly and younger population. Similarly, the same series found no correlation between age and performance status (PS) at presentation as previously reported by Brown et al,[7] who observed a higher PS score at presentation with increasing age in 563 patients with lung cancer. Recent data from eight Italian cancer registries collected within the Itacare project[8] show that the 5-year relative survival of patients with lung cancer patients appear to have a poorer prognosis compared with younger patients.

Relative survival of lung cancer patients is calculated as the ratio between observed survival of patients and the expected survival of the general population with the same age, sex, and race distribution. The ratio between 5-year relative survival of patients aged 65 or more and that of patients aged 55 to 64 is 0.55, indicating that prognosis for elderly patients with lung cancer is notably worse than for younger patients. Brown et al[7] reported data collected by a lung cancer registry, and age alone appeared to be a major factor in influencing treatment choices. Inappropriate treatment, particularly insufficient use of chemotherapy, increased with advancing age.

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