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

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.

TREATMENT OF PATIENTS WITH STAGE III DISEASE

Stage III disease usually means that the cancer has directly extended outside the lung into other structures within the chest or has spread to the lymph nodes outside of the lung within the middle of the chest, called the mediastinum. The mediastinum is the area in the chest between the lungs where the heart, major blood vessels, esophagus, and windpipe are located. Unfortunately, stage III non-small cell lung cancer is more difficult to cure than earlier stage disease. Surgery is usually not an option due to the extent of disease and its proximity to vital organs. Most patients with stage III disease are treated with a combination of radiation therapy and chemotherapy. However, the particular type of treatment recommended for an individual patient is dependant on his or her performance status, degree of prior weight loss, and overall medical condition.
For patients with significant functional impairment, radiation therapy alone may be recommended. Although the chance for cure with radiation alone is small (13), the addition of chemotherapy may add an unacceptable risk of side-effects and further debility in these patients. Patients who are able to care for themselves, but require some assistance, or who have had significant weight loss may be candidates for chemotherapy followed by radiation therapy. This sequential form of chemotherapy and radiotherapy offers a better chance for cure than radiation therapy alone, but also introduces potential side-effects from chemotherapy. Patients who are in good physical condition and have had minimal weight loss, may be candidates for radiation therapy and chemotherapy given together at the same time. This treatment offers the best chance for cure, with 15-20% of patients alive 5 years after the diagnosis (14, 15). However, concurrent radiation and chemotherapy is also associated with greater short-term and long-term side-effects that may not be tolerated by patients who are frail, have had significant weight loss, or have other major medical problems. There are several acceptable ways of combining chemotherapy and radiation therapy, but the optimal method has not yet been defined. Radiation is typically administered once a day, Monday though Friday, for 6 weeks. Chemotherapy can be given as two cycles of intermittent treatment with combinations of drugs such as cisplatin plus etoposide or carboplatin plus etoposide, or treatment once a week during radiation therapy with a combination such as carboplatin plus paclitaxel. The combination of carboplatin plus etoposide probably offers the most tolerable risk of side-effects (16). The common side-effects of concurrent chemotherapy plus radiation therapy include fatigue, drops in the blood counts that can increase the risk of infection or bleeding, irritation of the esophagus that can cause difficulty swallowing, and inflammation of the lungs that can cause cough or shortness of breath.
No clinical trials have yet been designed to specifically study the treatment of elderly patients with stage III non-small cell lung cancer. Some trials that included both young and elderly patients have compared the effects of the treatment on elderly patients versus the younger ones. One such analysis was done of a trial comparing sequential to concurrent chemotherapy plus radiation therapy (17). All patients enrolled in this trial had a good performance status, but only 17% were elderly (70 years old or older). The elderly patients on this trial were just as likely to complete treatment and obtained as much benefit from treatment as younger patients. Although the elderly patients had a higher risk of short-term side-effects, specifically low blood counts and esophageal irritation, they did not have any greater risk of long-term complications. Another analysis was done of a study comparing chemotherapy plus concurrent chemotherapy given once or twice a day in which 26% of patients were 70 years old or older (18). Again, the chance for cure was similar in younger and elderly patients, but the risks of side-effects, particularly low blood counts and inflammation of the lungs, was higher in elderly patients. Overall, these data suggest that concurrent chemotherapy plus radiotherapy is both tolerable and beneficial in elderly patients with stage III non-small cell lung cancer who are in good overall physical condition.

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