Lung Cancer in Older Adults

How is Lung Cancer Treated in Elderly Patients?

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How is lung cancer in older adults treated and what is the prognosis?. istockphoto.com

How is lung cancer in older adults treated and is the prognosis worse than that of younger people? Is there a time when someone is too old for surgery or chemotherapy?

Lung Cancer in Older Adults

One of the myths of lung cancer has been that older adults don’t have the options for lung cancer treatment that young adults with lung cancer have. There seems to be a general thought that older adults are unable to tolerate the side effects of treatment, or that treatment should at least be “toned down.”

What do the studies really tell us? After all, we are hearing that 50 is the new 30, and 70 is the new 50.

There isn’t a precise definition of what age implies “older adults” or “elderly” patients with lung cancer, but many studies appear to use a cut-off of age 70. If you happen to be in this age group, please read on.  We are finding that chronological age is less important than other factors in determining response and ability to tolerate treatment. It is also a very exciting time, as many of the groundbreaking treatments that are being approved for lung cancer treatment, as well as those being tested in clinical trials, are often easier to tolerate than traditional chemotherapy.

How Common is Lung Cancer in Older Adults?

At the current time, over 40 people of people diagnosed with lung cancer are age 70 or older.

Problems with Using Chronological Age in Choosing Lung Cancer Treatments

There are two primary difficulties with using chronological age in considering lung cancer treatment.

First off, it’s been found that age alone doesn’t say much about how someone will tolerate these treatments. Performance status, a measure of “well-being” is also rather poor at predicting how well someone will do. Physicians are looking at other methods for determining how a person will tolerate treatment, such as comprehensive geriatric assessment (CGA).

These tools look at patient characteristics in order to predict tolerance to treatment and survival and include:

  • Nutritional status
  • The presence of other medical conditions
  • Activity level
  • Activity of daily living (ADL's)
  • Social support
  • Home environment

Another problem looking at chronological age is that we simply do not know that much. Most drugs and treatments have been studied in clinical trials on younger patients.

How Might Age Affect Lung Cancer Treatment?

It's important to first point out that age doesn't decrease the benefits of treatment, but treatments may not be as well tolerated for some older adults. The overall consensus also seems to be that age alone shouldn’t dictate what treatments can or cannot be used for lung cancer.

That said, there are several reasons why some elderly patients may not tolerate treatments as well as younger patients.

  • Older patients tend to have more co-existing medical conditions (co-morbidities) than younger patients. A history of heart disease, for example, could limit the use of some chemotherapy drugs. Likewise, conditions that limit lung function, such as emphysema, could make lung cancer surgery less optimal.
  • Older patients are more likely to have decreased kidney function or liver function, and many of the drugs used to treat cancer are filtered through the kidneys or liver.
  • Older patients often have less lean body mass, making them less tolerant of weight loss with certain treatments, and more at risk for cachexia.
  • Older patients often have less bone marrow reserve, raising the risk of complications related to bone marrow suppression from chemotherapy.

Predicting How Age Will Affect Treatment - Bottom Line

Older patients are at risk for both undertreatment due to fears about age-related tolerance of treatment, and toxicity due to over-treatment. It is important when choosing treatment to keep two things in mind: consider the outcome, and consider your expectations as a patient.

Lung Cancer Treatments in Older Adults

To look at treatment options, this article will break down lung cancer stages into early stage lung cancer, locally advanced lung cancer, and stage 4 (metastatic) lung cancer. While rarely people with small cell lung cancer are candidates for surgery, chemotherapy is usually the primary treatment.

There has been a general thought among some of the public that people beyond a certain age would not want to pursue aggressive treatment, and would rather have “supportive care” only, but this doesn’t seem to be the case. When questioned about surgery in one study, 50 percent of elderly patients placed a greater priority on survival than on symptom relief.

Early Stage Lung Cancer in Older Adults

  • Surgery Tolerance and Survival – While there seems to be a feeling among the public that surgery for lung cancer would be dangerous for older patients, studies don’t support this. In fact, there is not a consistent survival difference between older patients and younger patients who have surgery for non-small cell lung cancer. On top of this, higher rates of surgery are correlated with higher rates of survival for elderly patients with early stage lung cancer.
  • Types of Lung Cancer Surgery – While there seems to be a survival advantage of older patients who have surgery for early stage lung cancer, not all types of surgery for lung cancer are the same.  Studies looking at wedge resection or lobectomy as a treatment have found that many older adults are able to tolerate the surgery quite well. Studies have, however, found a higher mortality (death rate) for older adults receiving a pneumonectomy (removal of an entire lung,)  although it’s important to say that these studies provide statistics, and in some cases, a surgeon may think an older adult will benefit from this procedure. VATS (video-assisted thoracoscopic surgery) is a less invasive method of removing a lobe or part of a lobe and can be a good choice in selected patients (this procedure is not always possible.)
  • SBRT/Radiofrequency Ablation – For people with early stage lung cancer that is inoperable or if someone does not want to go through surgery, sometimes stereotactic body radiotherapy (SBRT) or radiofrequency ablation can be used to try and cure a lung cancer. The survival rate for older adults with SBRT is less than with surgery but better than it would be with supportive care alone. Radiation pneumonitis (inflammation of the lungs caused by radiation) is common in older patients with this procedure but is usually treatable.
  • Pulmonary Rehabilitation Pulmonary rehabilitation before or after lung cancer surgery can be beneficial for people of all ages, but especially for older adults.

Locally Advanced Lung Cancer in Elderly Patients

Age alone is not a contraindication (reason not to do) for removal of a lung cancer (resection) and adjuvant chemotherapy (chemotherapy designed to rid the body of micrometastases—cancer cells that may be present but are too small to be seen on imaging tests.) For older patients with stage 1, stage 2, and stage 3A lung cancer, surgery may be considered (see above under early stage lung cancer regarding surgery.)

In addition to surgery, adjuvant chemotherapy is often recommended for people with locally advanced lung cancer. There is a small amount of evidence that adjuvant chemotherapy for stage 2 or stage 3A lung cancer may improve survival in carefully selected older patients. Studies, however, did not find that post-operative radiation had a significant impact in this group. (Again, it’s important to state that these are statistics, and there may be good reasons a physician would recommend radiation therapy.)

Advanced or Metastatic (Stage 4) Lung Cancer in Older Adults

Since stage 4 lung cancer by definition has spread beyond the lungs, surgery is not usually recommended.

For people with lung adenocarcinoma, and people who have never smoked with any type of lung cancer, molecular profiling (genetic testing) to look for treatable gene mutations is very important. For people with an EGFR mutation, an ALK rearrangement (ALK-positive lung cancer) or a ROS1 rearrangement, targeted therapies may improve progression-free survival, and side effects of these medications are often milder and fewer than with traditional chemotherapy drugs.

Chemotherapy is usually the mainstay of treatment for stage 4 lung cancer, and with younger patients, a combination of two chemotherapy drugs is usually recommended. Most older patients are not treated with chemotherapy, yet there is a clear survival benefit for those who are able to tolerate the side effects. In addition, using a combination of two medications may result in greater survival odds than using a single chemotherapy drug alone.

New Treatments - Immunotherapy

The first immunotherapy drug for lung cancer was approved in 2015 and others are being studied in clinical trials Immunotherapy medications can be thought of simplistically as drugs that restore and activate our own immune system’s ability to fight off cancer. These medications do not work for everyone with lung cancer, take some time to begin working, but when effective, may sometimes result in long-term control of even advanced lung cancers. They are often tolerated more easily that traditional chemotherapy drugs as well.

Sources

Blanco, R. et al. A review of the management of elderly patients with non-small-cell lung cancer. Annals of Oncology. 2015. 26(3):451-463.

Chambers, A., Routledge, T., Pilling, J. and M. Scarci. In elderly patients with lung cancer is resection justified in terms of morbidity, mortality and residual quality of life?. Interactive Cardiovascular and Thoracic Surgery. 2010. 10(6):1015-21.

Davidoff, A., Tang, M., Seal, B. and M. Edelman. Chemotherapy and Survival Benefit in Elderly Patients With Advanced Non-Small Cell Lung Cancer. Journal of Clinical Oncology. 2010. 28(13):2191-2197.

Gaira, A. ad A. Jatoi. Non-Small-Cell Lung Cancer in Elderly Patients: A Discussion of Treatment Options. Journal of Clinical Oncology. Published online before print July 28, 2014.

Gridelli, C. et al. Treatment of Elderly Patients With Non-Small Cell Lung Cancer: Results of an International Expert Panel Meeting of the Italian Association of Thoracic Oncology. Clinical Lung Cancer. 2015 Mar 7. (Epub ahead of print)

Maione, P. et al. Treating advanced non-small cell lung cancer in the elderly. Therapeutic Advances in Medical Oncology. 2010. 2(4):251-260.

Quiox, E. Optimal pharmacotherapeutic strategies for elderly patients with advanced non-small cell lung cancer. Drugs & Aging. 2011. 28(11):885-94.

Rivera, C. et al. Surgical management and outcomes of elderly patients with early stage non-small cell lung cancer: a nested case-control study. Chest. 2011. 140(4):874-80.

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