LUNG CANCER: TREATMENT OF NON-SMALL CELL LUNG CANCER IN THE ELDERLY
INTRODUCTION

Lung cancer is the leading 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, while 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 fashion, and are therefore discussed under the general heading of non-small cell lung cancer. The average age at diagnosis of lung cancer is 68 years, which means that 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.

WHAT DOES “ELDERLY?MEAN?

Prior to making treatment recommendations, the oncologist must assess an individual patient's ability to tolerate the various types of treatment that are available to treat cancer, including 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. In previous studies, the definition of an "elderly" patient has varied from 65 years of age or older to 75 years of age or older. A more functional definition of "elderly" has been proposed as follows:"when the health status of a patient begins to interfere with oncological (cancer) decision-making guidelines"(1). 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.
Another relevant issue 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 significantly 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. It is only in the past 10 years that trials have been specifically designed to evaluate the potential benefits and risks of treatment in elderly patients, but even in clinical trials designed for patients 70 years of age or older, the average age of treated patients tends to be in the early 70s with few patients over the age of 80 participating in such trials.

CHOOSING TREATMENT

Two of the most important pieces of 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. It also helps the oncologist guide treatment decision-making and offer general information to the patient regarding overall prognosis. 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 presents the most common staging system used by oncologists for patients with non-small cell lung cancer(2).

Table 1. International Staging System for Lung Cancer, 1997 Revision




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 commonly 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

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