The paper by Gridelli and colleagues nicely covers the landscape of local lung cancer management in the elderly, but it fails to define what exactly "elderly" means. Under the scholarly words is the quiet assumption that somehow old people are different. The truth of the matter is that hale and hardy older people do just as well with standard treatments as their younger counterparts. Even some people with controlled comorbidities appear quite well, so performance status alone does not reveal the truth about treatment tolerance. We all know that out-of-control or marginal comorbidities make treatment in any age group a challenge.

Some clinicians have simplified this problem by counting the patient's medications, and once they surmount seven, declaring the person "comorbid." (Since it takes me an hour each month to sort my own multiple medications, I'm defeated by this method!) The problem with those over age 70, and more so in those over age 80, is that many who appear fit have too little reserve, which we have no way of knowing. Their pulmonary function tests and chemical profiles do not lie, but we can be misled by those that offer no complaints and seem fit as a fiddle.

On the other hand, just because someone is 80 does not mean that they cannot withstand aggressive treatment. Much depends on what superannuated folks expect and what we are willing to provide. Unlike those of us baby boomers in later middle age, many at 80 are wiser about risking morbidities and more fatalistic about disease. Those who take care of the old need to be more vigilant than usual—one cycle of chemotherapy may remove this last veil hiding all of the wrinkles and warts of old age that our sophisticated tests missed.

Regardless of what definition of elderly we agree upon, one must inform patients of the risks of aggressive treatment and the penalties of allowing nature to take its course. Too often the option of doing no intentional harm provides the unintended consequence of cancer left untreated.

Early-Stage Disease

Most suggest that surgery provides the "best option" for cure for patients with lung cancer. Thoracotomy and pneumonectomy are assaults that may seem to offer the best chance of cure for the very fit, but sometimes at a price, especially in the elderly. All operations have some associated mortality, which is regularly measured in the young and extrapolated to older populations. Gridelli and coauthors comment on video-assisted thoracic surgery (VATS) and its lesser morbidity. Wedge resections and segmentectomies are compromises used for patients with limited pulmonary function. These compromises seem rational when one sees the small differences in survival and balances those against the risks of operative mortality.

Data from surgical trials always represent patients selected for their apparent fitness to undergo surgery. Comparisons to groups that do not undergo surgery and seem matched in age or tumor factors are never lined up with comorbidities. Surgical techniques now include robotic arms that allow for smaller incisions and less morbidity, but all of these cases must be fit enough to undergo thoracotomy if something goes wrong.

At the International Association for the Study of Lung Cancer (IASLC) meeting in Barcelona this past July, the two hottest topics were dealing with target motion[1] and the medically inoperable patient.[2-4] In the latter setting, the issues of dose, target, and fractionation (dose/time) are each different from that in classic use. Doses have been both precipitously[5] and cautiously escalated[4] with attention to targets that do not include elective nodes that markedly increase normal tissue exposure.