THERAPEUTIC APPROACHESManagement of unfit older patients with advanced NSCLC
Introduction
Lung cancer is the most common cancer in the world and the leading cause of cancer-related deaths in Western countries.1 Non-small-cell lung cancer (NSCLC) constitutes between 80% and 85% of all lung cancers; small-cell lung cancer makes up the remaining 15–20%. Unfortunately, at the time of diagnosis, the majority of patients already have metastatic disease and a systemic, palliative treatment is the primary therapeutic option.
More than 50% of cases of advanced NSCLC are diagnosed in patients over the age of 65 years age.2, 3 Recent SEER data in the United States suggest that the median age at diagnosis is 70 years.4 Of special interest, in the last decade, the incidence and the mortality from lung cancer has decreased among individuals aged 50 and younger, but has increased among those aged 70 and older.5 Clearly, lung cancer in the older individual is an increasingly common problem faced by the oncologist. Performance Status (PS) 2 patients usually account for a small proportion of patients enrolled in trials of first-line treatment for advanced NSCLC6 but represent a significantly higher proportion (up to 30–40%) when population-based surveys are conducted.7 Thus, unfit older patients represent a significant proportion of advanced NSCLC patients, for whom specific prospective data are very scarce. Consequently, medical treatment of this special population is often empirical and further prospective investigation is absolutely warranted. Unfortunately among elderly patients only data regarding PS 2 patients, subgroup that can be considered including vulnerable patients, are available. Therefore in the present paper we will deal with this patients population. For frail elderly patients, group with poorer clinical conditions and PS 3–4, to date in absence of data best supportive care alone is recommended.
Section snippets
Elderly patients and PS 2 patients
Elderly cancer patients often present with medical and physiological challenges that make the selection of their optimal treatment daunting. Unfortunately, as a result, these patients are often under-treated.8 Aging is inextricably associated with physiological changes in functional status, organ function, and drug pharmacokinetics. Aging is associated with decreases in marrow reserve, drug clearance, and lean body mass, Furthermore, concomitant co-morbidities that affect functional status,
Chemotherapy
Oncologists must choose amongst several treatment options for elderly patients with advanced NSCLC: best supportive care without chemotherapy, single-agent chemotherapy with a third-generation drug; non-platinum-based combination chemotherapy; platinum-based combination chemotherapy; or new biologic agents.
Single-agent chemotherapy was one of the first approaches to be evaluated in this setting, and third-generation monotherapy with vinorelbine, gemcitabine and taxanes (paclitaxel and
Conclusions
Clinical data obtained in a younger population cannot be automatically extrapolated to the great majority of non-selected elderly patients with lung cancer. This is particularly true for unfit older patients. Elderly patients have more co-morbidities and tend to tolerate aggressive chemotherapy and radiotherapy more poorly than their younger counterparts. Much of the data available today is based on retrospective studies of trials which included also patients with good performance status and of
Conflict of interest statement
Honoraria as speaker bureau and Advisory Board member for Eli Lilly, Sanofi Aventis, Roche, Merck-Serono.
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