Elderly Lung Cancer Patients and Radiochemotherapy: A Review

Francesco Fiorica, Antonio Stefanelli, Silvia Princivalle, Giuliana Pascale, Francesco Cartei

Department of Radiation Oncology, University Hospital Ferrara, Ferrara, Italy.

DOI: 10.4236/jct.2012.324047                

Abstract

More than 60% of lung cancer patients in Europe and the USA are older than 65 years at the time of diagnosis. Despite this, elderly patients are generally under-represented in clinical trials. That being so, a general consensus on how to treat elderly patients is still far from being achieved. In this review, we address some of the issues and challenges surrounding the treatment of older cancer patients and radiochemotherapy. We discuss the existing evidence related to radio-chemotherapy in the elderly, focusing primarily on the lung cancer (NSCLC and SCLC) most commonly seen in older patients, and making general treatment recommendations.

Keywords

Radiochemotherapy; Lung Cancer; Elderly Patients; Geriatric Oncology; Clinical Trials

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	A. Jemal, F. Bray, M. M. Center, J. Ferlay, E. Ward and D. Forman, “Global Cancer Statistics,” A Cancer Journal for Clinicians, Vol. 61, No. 2, 2011, pp. 69-90. doi:10.3322/caac.20107
[2]	S. M. Lichtman, “Management of Advanced Colorectal Cancer in Older Patients,” Oncology, Vol. 19, No. 5, 2005, pp. 597-602.
[3]	M. S. Aapro, “The Frail Are Not Always Elderly,” Journal of Clinical Oncology, Vol. 23, No. 10, 2005, pp. 2121-2122. doi:10.1200/JCO.2005.10.976
[4]	S. Baka, L. Ashcroft, H. Anderson, M. Lind, P. Burt, R. Stout, I. Dowd, D. Smith, P. Lorigan and N. Thatcher, “Randomized Phase II Study of Two Gemcitabine Schedules for Patients with Impaired Performance Status (Karnofsky Performance Status ≤ 70) and Advanced Non-Small-Cell Lung Cancer,” Journal of Clinical Oncology, Vol. 23, No. 10, 2005, pp. 2136-2144. doi:10.1200/JCO.2005.01.003
[5]	L. Balducci, “Geriatric Oncology,” Critical Reviews in Oncology/Hematology, Vol. 46, No. 3, 2003, pp. 211-220. doi:10.1016/S1040-8428(03)00020-9
[6]	S. K. Pal and A. Hurria, “Impact of Age, Sex, and Comorbidity on Cancer Therapy and Disease Progression,” Journal of Clinical Oncology, Vol. 28, No. 26, 2010, pp. 4086-4093. doi:10.1200/JCO.2009.27.0579
[7]	I. F. Tannock, “Treatment of Cancer with Radiation and Drugs,” Journal of Clinical Oncology, Vol. 14, No. 12, 1996, pp. 3156-3174.
[8]	E. E. Vokes and R. R. Weichselbaum, “Concomitant Chemoradiotherapy: Rationale and Clinical Experience in Patients with Solid Tumors,” Journal of Clinical Oncology, Vol. 8, No. 5, 1990, pp. 911-934.
[9]	A. Aupérin, C. Le Péchoux, E. Rolland, W. J. Curran, K. Furuse, P. Fournel, J. Belderbos, G. Clamon, H. C. Ulutin, R. Paulus, T. Yamanaka, M. C. Bozonnat, A. Uitterhoeve, X. Wang, L. Stewart, R. Arriagada, S. Burdett and J. P. Pignon, “Meta-Analysis of Concomitant versus Sequential Radiochemotherapy in Locally Advanced Non-Small-Cell Lung Cancer,” Journal of Clinical Oncology, Vol. 28, No. 13, 2010 pp. 2181-2190. doi:10.1200/JCO.2009.26.2543
[10]	M. Pijls-Johannesma, D. De Ruysscher, J. Vansteenkiste, A. Kester, I. Rutten and P. Lambin, “Timing of Chest Radiotherapy in Patients with Limited Stage Small Cell Lung Cancer: A Systematic Review and Meta-Analysis of Randomised Controlled Trials,” Cancer Treatment Reviews, Vol. 33, No. 5, 2007, pp. 461-473. doi:10.1016/j.ctrv.2007.03.002
[11]	T. Y. Seiwert, J. K. Salama and E. E. Vokes, “The Concurrent Chemoradiation Paradigm—General Principles,” Nature Clinical Practice Oncology, Vol. 4, No. 2, 2007, pp. 86-100. doi:10.1038/ncponc0714
[12]	M. A. Gosney, “Clinical Assessment of Elderly People with Cancer,” The Lancet Oncology, Vol. 6, No. 10, 2005, pp. 790-797. doi:10.1016/S1470-2045(05)70389-2
[13]	S. Greenfield, D. M. Blanco and R. M. Elashoff, “Development and Test of a New Index of Comorbidity Index,” Clinical Research, Vol. 35, No. 346, 1987.
[14]	J. F. Piccirillo, R. M. Tierney, I. Costas, L. Grove and E. L. Spitznagel Jr., “Prognostic Importance of Comorbidity in a Hospital-Based Cancer Registry,” The Journal of the American Medical Association, Vol. 291, No. 20, 2004, pp. 2441-2447. doi:10.1001/jama.291.20.2441
[15]	M. D. Miller, C. F. Paradis, P. R. Houck, S. Mazumdar, J. A. Stack, A. H. Rifai, B. Mulsant and C. F. Reynolds III, “Rating Chronic Medical Illness Burden in Geropsychiatric Practice and Research: Application of the Cumulative Illness Rating Scale,” Psychiatry Research, Vol. 41, No. 3, 1992, pp. 237-248. doi:10.1016/0165-1781(92)90005-N
[16]	B. Singh, M. Bhaya, J. Stern, J. T. Roland, M. Zimbler, R. M. Rosenfeld, G. Har-El, F. E. Lucente, “Validation of the Charlson Comorbidity Index in Patients with Head and Neck Cancer: A Multi-Institutional Study,” The Laryngoscope, Vol. 107, No. 11, 1997, pp. 1469-1475. doi:10.1097/00005537-199711000-00009
[17]	J. Gomez-Millan, “Radiation Therapy in the Elderly: More Side Effects and Complications?” Critical Reviews in Oncology/Hematology, Vol. 71, No. 1, 2009, pp. 70-78. doi:10.1016/j.critrevonc.2008.11.004
[18]	A. Jemal, R. Siegel, E. Ward, T. Murray, J. Xu, C. Smigal and M. J. Thun, “Cancer Statistics,” A Cancer Journal for Clinicians, Vol. 53, No. 1, 2003, pp. 5-26. doi:10.3322/canjclin.53.1.5
[19]	S. D. Ramsey, N. Howlader, R. D. Etzioni and B. Donato, “Chemotherapy Use, Outcomes, and Costs for Older Persons with Advanced Non-Small-Cell Lung Cancer: Evidence from Surveillance, Epidemiology and End Results-Medicare,” Journal of Clinical Oncology, Vol. 22, No. 24, 2004, pp. 4971-4978. doi:10.1200/JCO.2004.05.031
[20]	M. Werner-Wasik, C. Scott, J. D. Cox, W. T. Sause, R. W. Byhardt, S. Asbell, A. Russell, R. Komaki, J. S. Lee, “Recursive Partitioning Analysis of 1999 Radiation Therapy Oncology Group (RTOG) Patients with Locally-Advanced Non-Small-Cell Lung Cancer (LA-NSCLC): Identification of Five Groups with Different Survival,” International Journal of Radiation Oncology, Biology, Physics, Vol. 48, No. 5, 2000, pp. 1475-1482. doi:10.1016/S0360-3016(00)00801-4
[21]	S. E. Schild, S. J. Mandrekar, A. Jatoi, W. L. McGinnis, P. J. Stella, R. L. Deming, J. R. Jett, Y. I. Garces, K. L. Allen and A. A. Adjei, “The Value of Combined-Modality Therapy in Elderly Patients with Stage III Nonsmall Cell Lung Cancer,” Cancer, Vol. 110, No. 2, 2007, pp. 363-368. doi:10.1002/cncr.22780
[22]	W. J. Curran Jr., R. Paulus, C. J. Langer, R. Komaki, J. S. Lee, S. Hauser, B. Movsas, T. Wasserman, S. A. Rosenthal, E. Gore, M. Machtay, W. Sause and J. D. Cox, “Sequential versus Concurrent Chemoradiation for Stage III Non-Small Cell Lung Cancer: Randomized Phase III Trial,” Journal of the National Cancer Institute, Vol. 103, No. 19, 2011, pp. 1452-1460. doi:10.1093/jnci/djr325
[23]	C. J. Langer, C. Hsu and W. J. Curran, “Elderly Patients with Locally Advanced Non-Small Cell Lung Cancer Bene?t from Combined Modality Therapy: Secondary Analysis of Radiation Therapy Oncology Group (RTOG) 94-10,” Program Proceedings—American Society of Clinical Oncology Program Oncol, Vol. 21, No. 29a, 2002.
[24]	C. M. S. R. Lima, J. E., Herndon II, M. Kosty, G. Clamon and M. R. Green, “Therapy Choices among Older Patients with Lung Carcinoma: An Evaluation of Two Trials of the Cancer and Leukemia Group B,” Cancer, Vol. 94, No. 1, 2002, pp. 181-187. doi:10.1002/cncr.10174
[25]	S. Semrau, G. Klautke, J. C. Virchow, G. Kundt and R. Fietkau, “Impact of Comorbidity and Age on the Outcome of Patients with Inoperable NSCLC Treated with Concurrent Chemoradiotherapy,” Respiratory Medicine, Vol. 102, No. 2, 2008, pp. 210-218. doi:10.1016/j.rmed.2007.09.009
[26]	F. Fiorica, F. Cartei, S. Ursino, A. Stefanelli, Y. Zagatti, S. Berretta, S. Figura, D. Maugeri, E. Zanet, D. Spartà, C. La Morella, U. Tirelli and M. Berretta, “Safety and Feasibility of Radiotherapy Treatment in Elderly Non-Small-Cell Lung Cancer (NSCLC) Patients,” Archives of Gerontology and Geriatrics, Vol. 50, No. 2, 2010, pp. 185-191. doi:10.1016/j.archger.2009.03.008
[27]	J. P. Pignon, R. Arriagada, D. C. Ihde, D. H. Johnson, M. C. Perry, R. L. Souhami, O. Brodin, R. A. Joss, M. S. Kies, B. Lebeau, et al., “A Meta-Analysis of Thoracic Radiotherapy for Small-Cell Lung Cancer,” The New England Journal of Medicine, Vol. 327, No. 23, 1992, pp. 1618-1624. doi:10.1056/NEJM199212033272302
[28]	P. Warde and D. Payne, “Does Thoracic Irradiation Improve Survival and Local Control in Limited-Stage Small-Cell Carcinoma of the Lung? A Meta-Analysis,” Journal of Clinical Oncology, Vol. 10, No. 6, 1992, pp. 890-895.
[29]	H. Quon, F. A. Shepherd, D. G. Payne, P. Coy, N. Murray, R. Feld, J. Pater, A. Sadura and B. Zee, “The Influence of Age on the Delivery, Tolerance, and Efficacy of Thoracic Irradiation in the Combined Modality Treatment of Limited Stage Small Cell Lung Cancer,” International Journal of Radiation Oncology, Biology, Physics, Vol. 43, No. 1, 1999, pp. 39-45. doi:10.1016/S0360-3016(98)00373-3
[30]	A. R. Yuen, G. Zou, A. T. Turrisi, W. Sause, R. Komaki, H. Wagner, S. C. Aisner, R. B. Livingston, R. Blum and D. H. Johnson, “Similar Outcome of Elderly Patients in Intergroup Trial 0096: Cisplatin, Etoposide, and Thoracic Radiotherapy Administered Once or Twice Daily in Limited Stage Smallcell Lung Carcinoma,” Cancer, Vol. 89, No. 9, 2000, pp. 1953-1960. doi:10.1002/1097-0142(20001101)89:9<1953::AID-CNCR11>3.3.CO;2-Y
[31]	S. E. Schild, P. J. Stella, B. J. Brooks, S. Mandrekar, J. A. Bonner, W. L. McGinnis, J. A. Mailliard, J. E. Krook, R. L. Deming, A. A. Adjei, A. Jatoi and J. R. Jett, “Results of Combined-Modality Therapy for Limited-Stage Small Cell Lung Carcinoma in the Elderly,” Cancer, Vol. 103, 11, 2005, pp. 2349-2354. doi:10.1002/cncr.21034
[32]	C. Jara, J. L. Gómez-Aldaraví, R. Tirado, V. A. Meseguer, C. Alonso and A. Fernández, “Small-Cell Lung Cancer in the Elderly—Is Age of Patient a Relevant Factor?” Acta Oncologica, Vol. 38, No. 6, 1999, pp. 781-786. doi:10.1080/028418699432941
[33]	E. Dajczman, L. Y. Fu, D. Small, N. Wolkove and H. Kreisman, “Treatment of Small Cell Lung Carcinoma in the Elderly,” Cancer, Vol. 77, No. 10, 1996, pp. 2032- 2038. doi:10.1002/(SICI)1097-0142(19960515)77:10<2032::AID-CNCR10>3.0.CO;2-W
[34]	J. J. Ludbrook, P. T. Truong, M. V. MacNeil, M. Lesperance, A. Webber, H. Joe, H. Martins and J. Lim, “Do Age and Comorbidity Impact Treatment Allocation and Outcomes in Limited Stage Small-Cell Lung Cancer? A Community-Based Population Analysis,” International Journal of Radiation Oncology, Biology, Physics, Vol. 55, No. 5, 2003, pp. 1321-1330. doi:10.1016/S0360-3016(02)04576-5
[35]	E. Nou, “Full Chemotherapy in Elderly Patients with Small Cell Bronchial Carcinoma,” Lung Cancer, Vol. 16, No. 2, 1997, pp. 277-277. doi:10.3109/02841869609109912
[36]	B. Jeremic, Y. Shibamoto, L. Acimovic and S. Milisavljevic, “Carboplatin, Etoposide, and Accelerated Hyperfractionated Radiotherapy for Elderly Patients with Limited Small Cell Lung Carcinoma: A Phase II Study,” Cancer, Vol. 82, No. 5, 1998, pp. 836-841. doi:10.1002/(SICI)1097-0142(19980301)82:5<836::AID-CNCR6>3.0.CO;2-H
[37]	N. Murray, C. Grafton, A. Shah, K. Gelmon, E. Kostashuk, E. Brown, C. Coppin, A. Coldman and R. Page “Abbreviated Treatment for Elderly, Infirm, or Noncompliant Patients with Limited-Stage Small-Cell Lung Cancer,” Journal of Clinical Oncology, Vol. 16, No. 10, 1998, pp. 3323-3328.