The 2017 American Society of Clinical Oncology (ASCO) Annual Meeting is taking place June 2–6 in Chicago. As part of this year’s coverage, we are speaking with Corey J. Langer, MD, the director of thoracic oncology at the Hospital of the University of Pennsylvania. At this year’s meeting, he will be speaking during an Education Session about how to approach the treatment of older patients with lung cancer.
—Interviewed by Leah Lawrence
Cancer Network: When it comes to treating lung cancer, at what age are patients classified as being in an “older” population?
Dr. Langer: It is a moving target. Traditionally, it has been 70 years, but if you look at clinical trials, some use 65 as a cutoff point, others 70, and others 75. I am not sure we can pin the specific age per say. We have done retrospective analyses, for instance, of trials looking at bevacizumab in combination with chemotherapy and the survival benefit we observed seems to hold up, up to and through age 75, but after that it disappears. It may be dependent on the agent that we are looking at, and it is certainly dependent on the physiology of the patient.
Cancer Network: Do older patients with lung cancer face any greater treatment burden than their younger counterparts?
Dr. Langer: That is a bit of an old wives’ tale, the notion that older folks may have more disease or more aggressive disease or, conversely, less aggressive disease. There doesn’t seem to be any age-specific disease burden. Younger individuals, particularly never smokers or minimal smokers, are more likely to have molecular abnormalities, driver mutations. Percentage-wise, the elderly tend to have fewer oncogenic drivers. Those who smoked heavily may have greater tumor mutation burden—not necessarily disease burden—and that group we see better responses and survival with newer immunotherapies, the checkpoint inhibitors in particular.
Cancer Network: What things must clinicians consider in the treatment of older patients? Does this vary by the type of lung cancer a patient has?
Dr. Langer: At a minimum, clinicians should take into account comorbidities, particularly those that affect the systemic agents that are chosen. They need to look critically at performance status. In my opinion, performance status trumps age. Younger individuals, say 50 or 55 years of age with a performance status of 2 or 3, are going to fare much less well compared with an older individual, age 70, 75, or 80, who is completely functional and has very few symptoms from cancer.
We also have to look at pharmacy and cases of polypharmacy that exist, and be aware of potential drug interactions that might occur, particularly from newer targeted therapies and immunotherapies. Many of these newer drugs have restrictions—for instance, pre-existing interstitial lung disease has been a contraindication to clinical trials, as well as autoimmune diseases and conditions as relatively innocuous as psoriasis. People with those diagnoses have not been able to go on clinical trials.
Ultimately, the decisions have to be based on a good dialogue and shared decision making with the patient and their family members. Some folks can be quite fit but may not want to deal with the potential toxicities of therapy. Their decisions and their life views have to be respected.
Cancer Network: Are older patients less likely to undergo surgical resection of their disease?
Dr. Langer: For earlier-stage patients who don’t have metastases or disease recurrence, historically, in the United States and the rest of the world, many thoracic surgeons have been a bit gun-shy about pursuing surgical interventions, but the same rules apply. If a patient has good performance status and decent cardiopulmonary reserves, their risks are minimally higher than younger individuals. There is no reason that age alone should be a contraindication to surgical resection.
There are some excellent series that look at octogenarians, even nonagenarians, who are fit and have been able to undergo definitive curative lung resection. Age is not in itself a restriction. Increasingly, particularly for older individuals or those with comorbidities or marginal pulmonary reserve, we are using stereotactic radiation as a substitute for surgery, with quite good results and long-term survival rates that rival or, in some cases, exceed those seen with surgical resection.
Cancer Network: What about novel therapies? Are older patients any less likely to be considered as candidates for any of the newly available targeted therapies or immunotherapies?
Dr. Langer: Age is not a restriction. Older individuals, in some cases, are less likely to have these oncogenic drivers. If you look at ALK as an example, which occurs in about 3% to 8% of individuals with advanced nonsquamous non–small-cell lung cancer (NSCLC), the median age is about 52 to 55. That is a lot younger than the median age of our lung cancer population, which is 65 to 70. That being said, older individuals are just as likely to respond to tyrosine kinase inhibitors as younger individuals.
If we look at newer immunotherapies—eculizumab, pembrolizumab, nivolumab—all of which are approved as second-line agents in advanced NSCLC after progression on platinums, many of these trials looked at Forest plots for age, usually looking at either 65 or 70 as the cutoff point, and outcomes were essentially identical. Newer agents, assuming no higher level of comorbidities, are just as safe and work just as well in this group.
Cancer Network: Finally, what are some important takeaway messages for our readers when it comes to treating older patients with lung cancer?
Dr. Langer: Respect your elders. Age alone is not a contraindication to treatment. Therapeutic outcomes approach or equal those seen in younger individuals, but be cognizant of the cumulative effect of comorbidities and polypharmacy on the efficacy and safety of many of the newer agents. Older individuals, in that regard, probably require a bit more attention to detail than younger counterparts, but the stakes are just as important. A 75- or 80-year-old who doesn’t have cancer, when we look at actuarial tables, has another 15 to 20 years left. Just because someone is old does not mean that the cancer diagnosis should be any contraindication to treatment.
Cancer Network: Thank you so much for speaking with us about this important topic.
Dr. Langer: Thank you very much.