Only a minority of elderly patientswith advanced non–small-cell lung cancer(NSCLC) have been offered palliativechemotherapy, as indicated by clinicalsurveys beginning in the 1980s.Lilenbaum’s thorough review of thetreatment of locally advanced and metastaticNSCLC studies in two specialpopulations (elderly and Eastern CooperativeOncology Group [ECOG]performance status [PS] 2 patients)highlights a new trend seen with theadvent of better-tolerated chemotherapyregimens.
Only a minority of elderly patientswith advanced non-small-cell lung cancer(NSCLC) have been offered palliativechemotherapy, as indicated by clinicalsurveys beginning in the 1980s.Lilenbaum's thorough review of thetreatment of locally advanced and metastaticNSCLC studies in two specialpopulations (elderly and Eastern CooperativeOncology Group [ECOG]performance status [PS] 2 patients)highlights a new trend seen with theadvent of better-tolerated chemotherapyregimens.Key Studies
For patients older than age 70 yearswith no major comorbidities, the authorrefers to US cooperative groupstudies to justify the use of a platinum-based doublet-as would be usedin the younger patient population.Alternatively, elderly patients withsevere comorbidities and a lowerperformance status could be treatedwith single-agent therapy, such as vinorelbine(Navelbine) or gemcitabine(Gemzar), as shown in Gridelli's ElderlyLung Cancer Vinorelbine ItalianStudy (ELVIS) that assessed for the first time the benefit of a newer chemotherapyagent in older patients.Also of note, given that the majorityof elderly lung cancer patients presentwith unresectable disease, Schild andcolleagues discovered that fit elderlypatients with locally advancedNSCLC also enjoyed a survival advantagewhen treated with combinedmodalitytherapy.Functional vs Chronologic Age
The decision to treat an elderlyNSCLC patient with palliative chemotherapywill depend more on thepatient's functional age than chronologicage. Lilenbaum recognizes thata favorable functional status portendsa good response to chemotherapy.Functional status is one of severalcomponents that comprise a comprehensivegeriatric assessment. Othersinclude the patient's comorbidmedical conditions, cognition, psychologicalstatus, social functioningand support, medication history, andnutritional status.The "frail" older patient will likelypose the greatest challenge in choosinga palliative treatment course. Comprising10% to 25% of people overage 65, frail patients are described ashaving one or more of the followingcharacteristics: age over 85, seriouscomorbid medical conditions, dependencein activities of daily living, andat least one of the common geriatricsyndromes (delirium, dementia, urinaryor fecal incontinence, failure tothrive, a history of an osteoporoticfracture, or social neglect or abuse).To date, there is no standard definitionof "frailty" that can be used foranticipating and preventing adversetreatment-related outcomes.For the individual elderly patient,the clinician should have a thorough discussion regarding the benefits andtoxicities of the proposed regimen, aswell as which, if any, second-linechemotherapy agents would be pursuedupon progression of disease.There is no evidence of improved survivalor quality of life associated withsecond- or third-line chemotherapy foradvanced NSCLC in this patientpopulation.For patients with impaired performancestatus, a phase III trial of erlotinib(Tarceva) as second-line therapyfor patients with non-small-cell lungcancer revealed an improved mediansurvival among ECOG PS 2 patientsreceiving erlotinib compared with placebo(4.3 vs 3.3 months). Comparatively,PS 3 patients who receivederlotinib fared worse than those whoreceived a placebo (median survival:1.9 vs 3.1 months).Conclusions
With 60% of all cancers occurringamong individuals over age 65, andwith the percentage of people over 65surpassing 20% by 2003, future cooperativetrials should place greateremphasis on elderly cancer patients.Non-small-cell lung cancer patients,with their inherent predisposition towardpulmonary and cardiovascularcomorbidities, can be particularlyvulnerable to the side effects of bothdoublet and singlet chemotherapyregimens.When caring for the elderly patientwith NSCLC, open-ended communicationis essential. Compared with theiryounger counterparts, elderly patientsoften maintain different attitudes regardingillness, death, and dying.
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