Lung Cancer: Treatment in the Elderly
Lung cancer is the major cause of cancer-related death in the United States for both men and women. In the United States, 80% of patients with lung cancer have non-small cell lung cancer, and the remaining 20% have small cell lung cancer. Non-small cell lung cancer is a "catch all" term for a group of cancers originating in the lung that includes adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. All of these diseases are treated in a similar way. The average age at diagnosis of lung cancer is 68 years, and more than half of all patients with non-small cell lung cancer are older than 65 years of age and one-third are over 70 years old.
Prior to making treatment recommendations, the oncologist must assess an individual patient's ability to tolerate the various types of treatment that are available, as surgery, radiation therapy, and chemotherapy, used either alone or in combination with each other. Patient age must be considered because some treatments may not be tolerated as well by older patients as by younger individuals.
The definition of an "elderly" patient in a funtional meaning has been proposed as follows:"when the health status of a patient begins to interfere with oncological (cancer) decision-making guidelines". This definition also takes into account the fact that a patient's other medical problems could interfere with treatment of the cancer. Age, by itself, does not generally prevent the use of the best available therapy. However, with increasing age comes a higher propensity for chronic illnesses that may impair a patient's functional ability and alter his or her ability to tolerate aggressive anticancer treatment. Debility caused by the cancer or by other illnesses may change the balance between the potential risks and benefits of a specific treatment.
A major problem that must be faced is that although lung cancer is very common in elderly patients, most of the available data regarding the optimal treatment of lung cancer comes from clinical trials in which the vast majority of patients are younger than 65 years of age. Few elderly patients are enrolled into clinical trials, perhaps due to the greater chance that they may have other medical problems that exclude them from a trial or due to potential bias on the part of their physicians or the elderly patients themselves against enrollment in trials studying investigational, and potentially more aggressive, therapies.
The most important information needed to decide on the appropriate treatment for patients with non-small lung cancer are the stage of the disease and the performance status of the patient. Cancer staging is a way to describe the extent of the disease. In non-small cell lung cancer, staging is done by looking at the size of the tumor, involvement of lymph nodes within the chest, and the presence of cancer spread to areas outside of the chest, such as the brain, liver, bones, or adrenal glands.
Table 1. International Staging System for Lung Cance
The performance status of a patient helps an oncologist define how the lung cancer or other medical problems are affecting the patient's ability to function. The worse the performance status, the more likely it is that the patient will have significant complications during aggressive treatment. Table 2 presents one performance status scale used by oncologists to gauge an individual patient's level of daily functioning. Patients with non-small cell lung cancer and a performance status of 3 or 4 are usually not candidates for surgery or chemotherapy. In addition to evaluating general performance status, a careful assessment of heart function, lung function, and other chronic illnesses may be required before treatment recommendations can be made.
Table 2. Zubrod or Eastern Cooperative Oncology Group (ECOG) Performance Scale
Autor: Gregory P. Kalemkerian, M.D.
