Safety and feasibility of radiotherapy treatment in elderly non-small-cell lung cancer (NSCLC) patients

https://doi.org/10.1016/j.archger.2009.03.008Get rights and content

Abstract

The purpose of this study was to evaluate the feasibility and activity of radiotherapy (RT) treatment in elderly patients with locally advanced lung cancer. From January 2002 to December 2007, 51 consecutive patients (43 men and 8 women) aged ≥65 received RT for locally advanced lung cancer, 22 with radical intent and 16 in adjuvant setting. Thirty-six patients received chemotherapy. Variables considered were age, co-morbidities, evaluated according to the adult co-morbidity evaluation index (ACE-27), surgery vs. no surgery, radiation dose and chemotherapy. The median age was 74.7 years (range 65–91). Of the patients, 15.7% had no co-morbidity, 41.2% mild, 25.5% moderate, and 17.6% had severe co-morbidities. Sixteen subjects (31.4%) underwent surgery. All patients completed the planned radiation schedule, while chemotherapy was reduced in 16 patients. At a median follow-up of 22 months, the 2- and 3-year overall survival rates were 46.5% and 35.4%, respectively. Patients with no or mild co-morbidities (p < 0.0001) and a good performance status (p < 0.0001) had a better survival. The actuarial progression-free survival at 2 and 3 years was 41.4% and 38.2%, respectively. Acute lung toxicity rates were different between patients with different ACE-27 indexes, whereas late toxicity was not influenced. In conclusion, in elderly patients, the compliance with RT is good and the rate of toxicity is acceptable. Patients with no or mild co-morbidities have a significantly better survival. The increasing severity of co-morbidities may sufficiently shorten the remaining life expectancy, cancel the gains obtained by RT and increase the acute lung toxicity. Further prospective trials are needed to confirm these results.

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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