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Early Non-Small-Cell Lung Cancer in the Elderly

Chapter 13 – Lung Cancer in the Elderly

Without treatment, the five-year overall survival (OS) rate in patients with stage I non-small-cell cancer (NSCLC) is between 6% and 14% with a five-year disease-specific survival rate of 23% for T1 tumours. Anti-cancer treatment can improve these figures but should be used carefully in the elderly.

Lung Cancer Surgery

Age alone should not be an exclusion criterion for surgery. Retrospective studies have shown no consistent differences in OS between elderly (≥70 years) and younger patients undergoing surgery for NSCLC and higher rates of surgery were associated with improved survival in elderly patients (>66 years) and early-stage disease. There are discrepancies in morbidity and post-operative mortality when comparing results from patients aged <70 years with those from patients aged >70 years due to risk factors. These risk factors include greater age, male gender, resections of multiple lobes, advanced stage, greater tumour size and certain comorbidities.

All elderly patients require a pre-operative assessment including a comprehensive geriatric assessment (CGA) and evaluation of comorbidities with correction of reversible conditions. In addition, pre- and post-operative pulmonary rehabilitation should be offered to improve functional status and quality of life (QoL).

Lobectomy is often considered the best curative option for early-stage NSCLC. Minimally invasive techniques may offer efficacy generally comparable with traditional thoracotomy procedures while reducing perioperative morbidity. Video-assisted thoracic surgery (VATS) allows lobectomy or limited surgery and may reduce the morbidity and perioperative mortality of elderly patients.

Wedge resection resulted in elderly patients with T1aN0 tumours in a similar OS compared with lobectomy, although there is a higher loco-regional recurrence rate in patients aged ≥75 years. Extended lung resection has long been associated with poorer outcomes in elderly (≥70 years) compared with younger patients and higher mortality rates are also associated with pneumonectomy, particularly right pneumonectomy.

After adequate selection, senior patients can undergo lung cancer surgery, although a slight increase in mortality should be anticipated.

Definitive Radiotherapy

Radiotherapy is a valid treatment option in patients unfit for or unwilling to undergo surgery. However, conventional radiotherapy results in local recurrence rates as high as 40% (range 6-70%), and three-year overall and cause-specific survival rates of 34% and 39%, respectively. Stereotactic radiotherapy has a local control rate of 90% and a five-year OS rate of 70.8%, but at a cost of acute (e.g. fatigue, nausea, and chest pain) and late toxicities (<10% of patients; radiation pneumonitis which is higher in elderly patients, rib fractures, chronic pain syndromes), which may impair QoL.

Stereotactic body radiotherapy (SBRT) may be preferable to external beam radiation therapy. Newer approaches such as radiofrequency ablation may find a place for patients with peripheral small tumours.

Radiotherapy should be proposed to patients with local disease who are not candidates for surgery.

Adjuvant Chemotherapy

Several large phase III randomised trials and meta-analysis have established the role of adjuvant cisplatin-based combination chemotherapy in early-stage NSCLC with an improvement of 5.3% in five-year survival in patients with stages II to IIIA disease.

However, there are no data of prospective, elderly-specific trials, but retrospective analysis of these studies showed a mixed picture with a benefit in some, a poorer outcome in OS in the eldest patient groups who had an increase in adverse events.

These retrospective data support the use of adjuvant chemotherapy in fit elderly patients, although data are insufficient to draw conclusions in patients aged >75 years.

In selected elderly patients, adjuvant chemotherapy might be of benefit, although there is a need for elderly-specific, prospective trials.

Adjuvant Radiotherapy

Post-operative radiotherapy in resected lung cancer with negative surgical margins showed no impact on survival, although some benefit has been seen in patients with pN2 disease.

In the elderly population, there are no indications that adjuvant radiotherapy is beneficial.

Chemoradiation

In patients with inoperable or unresectable NSCLC, chemoradiation is superior to radiotherapy alone. There are limited data from retrospective studies that show similar survival benefits in elderly patients compared with younger ones, although short-term haematological and non-haematological toxicity is significantly increased in elderly patients.

Even though specific data regarding sequential treatment in elderly patients are lacking, this approach is better tolerated than concurrent chemoradiation. The EORTC Elderly Task Force and Lung Cancer Group and SIOG, recommend that concurrent chemoradiation should be offered to elderly patients with unresectable locally advanced NSCLC but the treatment decisions should be based on close individual patient evaluation.

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