Lung Cancer in the Elderly: So Many Patients, So Little Time!

Between 1980 and 1998, lung cancer mortality rates decreased for persons younger than 55 years and increased for those older than 65, reflecting generational patterns in smoking prevalence. Consequently, most lung cancer occurs now in patients older than 65 years. Furthermore, this neoplasm is not uncommon among the oldest old, that is, persons older than 85. Several questions of general interest to clinicians emerge from this relatively new epidemic of lung cancer among the elderly: Y Will the patient die of cancer or with cancer? Y Will age affect his or her prognosis? Y Can the patient tolerate usual treatment regimens? Y What is the balance of quality of life and survival in patients with incurable disease (who are the majority of persons with lung cancer)? In a very elegant and exhaustive review in this issue, Hurria and Kris address these questions and provide important practical answers. The first question they explore is the assessment of the older person; that is, the determination of physiologic rather than chronologic age. This distinction is necessary because aging represents a progressive loss in functional reserve that varies from person to person and within the same person from function to function. Because aging is multidimensional, a comprehensive assessment accounting for function, comorbidity, and personal and social resources is the appropriate instrument to evaluate the older person. The benefits of this approach include being able to estimate life expectancy and tolerance of treatment and to identify conditions that are reversible but may interfere with cancer treatment if left unattended. Based on the results of multiple, large patient series, the authors conclude that age alone is not a significant prognostic factor. In fact, according to the European Organization for Research and Treatment of Cancer (EORTC), increased age was a good prognostic factor for response to chemotherapy. These conclusions should be mitigated because the percentage of patients 80 years or older who were enrolled in the studies was probably negligible. As the prevalence of dysfunction and comorbidity increase with age, we may assume that older age would be associated with poorer prognosis. Even so, it is important to identify those unusually healthy older persons who may tolerate aggressive treatments. Although age is associated with increased risk for surgical and radiation complications, these forms of treatment seem overall to be advantageous to older persons, and age should not impede their use in patients without other contraindications. Of interest, patients older than 70 years were more likely to experience severe complications from pneumonectomy, and this procedure should be avoided whenever possible. Areas of controversy related to management of non–small cell lung cancer include the use of combined-modality treatment (chemotherapy and radiation) in locally advanced disease and the best regimen of chemotherapy for metastatic disease. Whereas concomitant chemoradiation improves disease-free survival, overall survival, and quality of life of patients who are 60 years and younger, those 70 and older seem to have a better quality of life with sequential treatment. In the case of metastatic disease, although chemotherapy provides better survival and quality of life than supportive care, controversy lingers over the use of single-agent versus combination treatment. The Multicenter Italian Lung Cancer in the Elderly Study compared the combination of vinorelbine and gemcitabine with either agent alone, failing to show an advantage for the combination. It should be noted, however, that the combination did not contain a platinum congener that current wisdom considers part of any standard chemotherapy regimen for lung cancer. In the Eastern Cooperative Oncology Dr. Balducci is Medical Oncologist and Program Leader, Senior Adult Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.