Lung Cancer: Treatment in the Elderly II
Stage I or II non-small cell lung cancer typically means that the cancer is confined to the lung and there is no or minimal lymph node involvement. The most effective treatment for patients with stage I or II disease is to surgically remove the cancer by cutting out all or part of the involved lung. Studies have shown that elderly patients with good lung and heart function and a good performance status can tolerate lung cancer surgery as well as younger patients with a similar chance for cure (3-7). Older patients may need to undergo a more rigorous evaluation of their heart and lung function prior to surgery to ensure that surgery can be performed safely and with an acceptable risk of long-term complications. For patients with stage I disease, 60-80% can be cured by surgical removal of the cancer. For those with stage II disease, 40-50% of patients can be cured by surgery. For more information on surgery, see the article in CancerNews titled "Lung Cancer: Who is a Candidate for Surgery?"
RADIATION THERAPY
Radiation therapy is the treatment of cancer by a beam of high energy x-rays directed at the part of the body affected by the cancer. Like surgery, it is a local treatment that only can kill cancer cells within the area being treated, not throughout the whole body. Some elderly patients may not be able to undergo surgical removal of stage I or II non-small cell lung cancer because of a significant medical problem, such as a recent heart attack or poor lung function due to emphysema. In these situations, radiation therapy targeted to the main lung tumor and to lymph nodes to which the cancer has spread may be the best treatment option for potential cure. However, the chance for cure in patients with stage I disease treated with radiation therapy is only 20-30%, significantly lower than that seen with surgery (8). For patients who can tolerate surgery and undergo complete removal of a stage I or II cancer, radiation therapy is not typically recommended because it has not been shown to improve the chance for cure and can cause potentially serious side-effects in patients with underlying lung disease.
CHEMOTHERAPY
Chemotherapy is a term that pertains to many different drugs, usually given through a vein, used to try to kill cancer cells wherever they might be in a patient's body. Chemotherapy is not typically used as the sole treatment for stage I or II non-small cell lung cancer because by itself it cannot cure the disease. Sometimes it is used after surgery as adjuvant therapy (meaning "in addition to" the primary treatment, in this case surgery). In several recent clinical trials, chemotherapy has been shown to decrease the chance for cancer recurrence and improve the chance for cure in some patients who have undergone complete surgical removal of stage IB, II, or IIIA non-small cell lung cancer. All of these studies were randomized trials in which half of the enrolled patients received chemotherapy after surgical removal of the tumor and the other half received no further therapy.
The first of these adjuvant trials, called IALT, demonstrated a 5% decrease in cancer recurrence rate and a 4% improvement in survival in patients treated with cisplatin-based chemotherapy compared to those receiving no further therapy after surgical removal of stage IB, II, or III non-small cell lung cancer (9). While the benefit of chemotherapy in this trial may seem small, a recurrence of the cancer is usually incurable, meaning that chemotherapy given after surgery can prevent some people from dying of the cancer. Importantly, patients over 75 years of age were not allowed to participate in this trial and the average age of patients enrolled was only 59 years. Therefore, it is not clear whether the benefit of chemotherapy seen in this trial would also occur in an older population of patients. The second of these trials, called JBR.10, demonstrated a 15% improvement in survival in patients treated with the chemotherapy combination of cisplatin plus vinorelbine compared to those receiving no further therapy after surgical removal of stage IB or II non-small cell lung cancer (10). The third recent adjuvant chemotherapy trial, called CALGB 9633, demonstrated a 12% improvement in survival in patients treated with carboplatin plus paclitaxel compared to those receiving no further therapy after surgical removal of stage IB non-small cell lung cancer (11). Although the JBR.10 and CALGB 9633 trials did not limit the age of potential participants, the average age of patients enrolled in both of these trials was 61 years and few patients were over 75 years of age. The most recent of the adjuvant trials, called the ANITA trial, demonstrated an 8% improvement in survival in patients treated with cisplatin plus vinorelbine compared to those receiving no further therapy after surgical removal of stage IB, II, or IIIA non-small cell lung cancer (11). As in the first trial mentioned above, patients over the age of 75 years were not allowed to participate in the ANITA trial.
Overall, adjuvant chemotherapy is now recommended for patients who have undergone complete removal of stage IB, II, or III non-small cell lung cancer and have recovered from surgery within two months without significant complications. Clearly, the oncologist must carefully evaluate every patient to ensure that the potential benefits of chemotherapy outweigh the risk of serious side-effects of treatment. If adjuvant chemotherapy is given, the chemotherapy should consist of four cycles of cisplatin or carboplatin in combination with another chemotherapy agent, usually vinorelbine, paclitaxel, or etoposide. While age alone should not be a deterrent to receiving adjuvant chemotherapy, the oncologist must keep in mind that very few elderly patients were involved in the clinical trials that determined the benefits of this treatment.
