EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIO
EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIOG) Experts' Opinion for the Treatment of non-Small-cell Lung Cancer in an Elderly Population
Non-small-cell lung cancer (NSCLC) represents a common health issue in the elderly population. Nevertheless, the paucity of large, well-conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The present paper reviews the currently available evidence regarding treatment of all stages of NSCLC in elderly patients. Surgery remains the standard for early-stage disease, though pneumonectomy is associated with higher incidence of postoperative mortality in elderly patients. Given the lack of demonstrated benefit for the use of adjuvant radiotherapy, it is also not recommended in elderly patients. Elderly patients seem to derive the same benefit from adjuvant chemotherapy as younger patients do, with no significant increase in toxicity. For locally advanced NSCLC, concurrent chemoradiotherapy may be offered to selected elderly patients as there is a higher risk for toxicity reported in the elderly population. Third-generation single-agent treatment is considered the standard of care for patients with advanced/metastatic disease. Platinum-based combination chemotherapy needs to be evaluated in prospective trials. Unfortunately, with the exception of advanced/metastatic NSCLC, prospective elderly-specific NSCLC trials are lacking and the majority of recommendations made are based on retrospective data, which might suffer from selection bias. Prospective elderly-specific trials are needed.
Non-small-cell lung cancer (NSCLC) remains the leading cause of cancer-related death in both men and women in Western countries, representing the 80% of lung cancer cases.
As a result of an increasing life expectancy, the incidence of lung cancer diagnosed in the elderly population is rising. About 50% of newly diagnosed NSCLC cases occur in patients aged >65 years, while 30%–40% of cases are diagnosed in patients aged >70 years. Data from the Surveillance, Epidemiology, and End Results (SEER) registry indicate that the median age at diagnosis in NSCLC patients is 69 years. Based on these observations, it is clear that NSCLC represents a significant health problem in elderly.
The cut-off point at which an adult is considered 'elderly' has not been well defined. Usually, age 70 years is considered a reference point and is commonly used in clinical trials in oncology. Based on available literature, especially at or around 70 years of age, a number of age-related physiologic changes occur, which increase the risk of toxicity related to systemic therapy; hence age 70 is widely accepted as cut-off for elderly-specific analyses.
Despite the high frequency of NSCLC in the elderly population, elderly patients are frequently underrepresented in clinical trials evaluating new cancer treatments. Indeed, statistically significant underrepresentation of the elderly was noted in registration trials for all cancer treatment except for breast cancer hormonal therapies, and this underrepresentation was more pronounced for patients aged ≥70 years. As a result, it is difficult to reach evidence-based clinical recommendations, which apply to the treatment of the elderly. Consequently, the elderly are often undertreated or receive therapies that have not been tested in relevant clinical trials. Furthermore, the likelihood of receiving any kind of treatment of NSCLC, particularly chemotherapy, decreases significantly with age. Potential explanations for this scenario are the belief that elderly patients are in general incapable of tolerating the treatment-related toxic effects and in addition the expectations for long-term benefits are limited not only on the part of physicians but also on the patients or their families. A systematic review of barriers to the recruitment of older patients to cancer clinical trials revealed barriers related to cancer trial design (e.g. protocol eligibility criteria with restrictions on comorbid conditions or organ function requirements to optimize treatment tolerability) and individual physicians skepticism (e.g. the perception that the patient would not be able to tolerate treatment due to comorbidities and advanced age). Furthermore, patient-related barriers have also been reported, such as difficulty in accessing university hospitals, lack of adequate information about the availability of clinical trials and the need to obtain their treating physician's endorsement to participate a clinical trial.
The purpose of this review was to focus on insights to optimize treatments for NSCLC in the elderly population. Proper integration of various modalities, i.e. surgery, radiotherapy (RT), chemotherapy and targeted therapy for all stages of NSCLC will be the key.
Abstract and Introduction
Abstract
Non-small-cell lung cancer (NSCLC) represents a common health issue in the elderly population. Nevertheless, the paucity of large, well-conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The present paper reviews the currently available evidence regarding treatment of all stages of NSCLC in elderly patients. Surgery remains the standard for early-stage disease, though pneumonectomy is associated with higher incidence of postoperative mortality in elderly patients. Given the lack of demonstrated benefit for the use of adjuvant radiotherapy, it is also not recommended in elderly patients. Elderly patients seem to derive the same benefit from adjuvant chemotherapy as younger patients do, with no significant increase in toxicity. For locally advanced NSCLC, concurrent chemoradiotherapy may be offered to selected elderly patients as there is a higher risk for toxicity reported in the elderly population. Third-generation single-agent treatment is considered the standard of care for patients with advanced/metastatic disease. Platinum-based combination chemotherapy needs to be evaluated in prospective trials. Unfortunately, with the exception of advanced/metastatic NSCLC, prospective elderly-specific NSCLC trials are lacking and the majority of recommendations made are based on retrospective data, which might suffer from selection bias. Prospective elderly-specific trials are needed.
Introduction
Non-small-cell lung cancer (NSCLC) remains the leading cause of cancer-related death in both men and women in Western countries, representing the 80% of lung cancer cases.
As a result of an increasing life expectancy, the incidence of lung cancer diagnosed in the elderly population is rising. About 50% of newly diagnosed NSCLC cases occur in patients aged >65 years, while 30%–40% of cases are diagnosed in patients aged >70 years. Data from the Surveillance, Epidemiology, and End Results (SEER) registry indicate that the median age at diagnosis in NSCLC patients is 69 years. Based on these observations, it is clear that NSCLC represents a significant health problem in elderly.
The cut-off point at which an adult is considered 'elderly' has not been well defined. Usually, age 70 years is considered a reference point and is commonly used in clinical trials in oncology. Based on available literature, especially at or around 70 years of age, a number of age-related physiologic changes occur, which increase the risk of toxicity related to systemic therapy; hence age 70 is widely accepted as cut-off for elderly-specific analyses.
Despite the high frequency of NSCLC in the elderly population, elderly patients are frequently underrepresented in clinical trials evaluating new cancer treatments. Indeed, statistically significant underrepresentation of the elderly was noted in registration trials for all cancer treatment except for breast cancer hormonal therapies, and this underrepresentation was more pronounced for patients aged ≥70 years. As a result, it is difficult to reach evidence-based clinical recommendations, which apply to the treatment of the elderly. Consequently, the elderly are often undertreated or receive therapies that have not been tested in relevant clinical trials. Furthermore, the likelihood of receiving any kind of treatment of NSCLC, particularly chemotherapy, decreases significantly with age. Potential explanations for this scenario are the belief that elderly patients are in general incapable of tolerating the treatment-related toxic effects and in addition the expectations for long-term benefits are limited not only on the part of physicians but also on the patients or their families. A systematic review of barriers to the recruitment of older patients to cancer clinical trials revealed barriers related to cancer trial design (e.g. protocol eligibility criteria with restrictions on comorbid conditions or organ function requirements to optimize treatment tolerability) and individual physicians skepticism (e.g. the perception that the patient would not be able to tolerate treatment due to comorbidities and advanced age). Furthermore, patient-related barriers have also been reported, such as difficulty in accessing university hospitals, lack of adequate information about the availability of clinical trials and the need to obtain their treating physician's endorsement to participate a clinical trial.
The purpose of this review was to focus on insights to optimize treatments for NSCLC in the elderly population. Proper integration of various modalities, i.e. surgery, radiotherapy (RT), chemotherapy and targeted therapy for all stages of NSCLC will be the key.
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