Safety and feasibility of radiotherapy treatment in elderly non-small-cell lung cancer (NSCLC) patients
Introduction
Lung cancer is the leading cause of cancer deaths in the United States and worldwide (Jemal et al., 2008) and it is a typical cancer of elderly patients. Incidence data from the National Cancer Institute's (NCI) surveillance epidemiology and results (SEER) have shown that older persons have a 10 times greater risk of developing lung cancer than those with an age of less than 65 years.
As the survival of elderly population increases in developed countries worldwide, it is expected that oncologists will be increasingly confronted with the therapeutic challenge of an elderly patient presenting with NSCLC. Unfortunately, at diagnosis most of these patients are judged to have an unresectable disease or an inoperable disease because of age and associated medical conditions. In literature, RT with or without chemotherapy is considered the cornerstone of treatment in unresectable NSCLC (Okawara et al., 2006) and an adjuvant treatment with or without chemotherapy in operable NSCLC for positive margin and stage N2 (PORT, 1998).
Furthermore, two recent randomized trials (West and Albain, 2005, Van Meerbeeck et al., 2007) comparing surgery to RT after induction chemotherapy in patients with stage IIIA-N2 NSCLC, concluded that surgical resection does not improve overall survival or progression-free survival compared with RT. So, RT should be considered the preferred local-regional treatment for locally advanced NSCLC. However, a general consensus on how to treat elderly patients with locally advanced or inoperable NSCLC is still far from being achieved. The elderly are under-represented in clinical trials, account for only 25% of patient enrollment (Talarico et al., 2004). The older (age ranged 75–84) and the oldest (Carreca et al., 2005) patients (>85) are the most under-represented, and consequently, the data related to treatment-tolerance and results in this subset of patients are scarce. This is true for all tumor types but it is of particular relevance in lung cancer where the median age at diagnosis is 71 years (Ries et al., 2008).
As regards co-morbidities, elderly patients are an extremely heterogeneous population. Subjects can vary from very fit to not being able to live independently due to co-morbidities. It is not so clear whether the toxicity of treatment is justified by the gain in life prolongation or whether co-morbidities can influence the acute and late toxicities due to RT. Nevertheless, patients who have reached their 80th year of life still have a mean life expectancy of 7 years for men and 9 years for women (Lichtman, 2005). In order to clarify this issue, we decided to analyze retrospectively, whether elderly cancer patients could benefit from a RT regimen routinely used in younger patients as NSCLC treatment.
Section snippets
Patients characteristics
Data were collected between January 2002 and December 2007 from 51 patients aged over 65 years, who received RT for NSCLC in our RT department staged to be American Joint Committee on Cancer (AJCC) Stage IIIA or IIIB. In all patients, the clinical workup included a detailed medical history, physical examination, blood tests, electrocardiogram, bronchoscopy, pulmonary function test, thoracic and upper abdomen computed tomography (CT) scan. A CT or a magnetic resonance imaging (MRI) of the head
Features of patients at baseline
Fifty-one consecutive patients were included in the study: 43 males (84.3%) and 8 females (15.7%). Four subjects out of 51 (7.8%) were over 85 years of age, 28 (54.9%) ranged between 76 and 84 years and 19 (37.3%) between 65 and 80 years. Patients characteristics and treatment data are shown in Table 1. In this cohort, a stage III A was observed in 54.9% and stage III B in 45.1%. Forty-one (84.3%) patients had at least one co-morbidity (Table 2). The classification of patients co-morbidities by
Discussion
NSCLC is a predominant disease in elderly patients, with a median age at diagnosis of 71 years, and 20% of lung cancer-related deaths occurs in patients aged ≥80 years (Jemal et al., 2003). For many years, however, elderly patients were thought to be less tolerant to cancer treatment than younger patients and chronological age has often been considered as a risk factor. RT rates, in patients IIIA and IIIB NSCLC, vary widely by age from 85% (age <59 years) to 45% (age >75 years) (De Rijke et
Conflict of interest statement
None.
Acknowledgements
The whole cost of the study was supported by our Institutions. The authors want to thank Daniela Furlan for the expert assistance in the revision and preparation of the manuscript.
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