GRACE :: Lung Cancer


Doc, Am I Too Old for Chemo?

download as a pdf file Download PDF of this page

The average age at which lung cancer is diagnosed in the US is 71. Would it be fair to say that at least half of those who are diagnosed with lung cancer are elderly? How do we define “old”? How does age impact the effect of chemotherapy?

Two decades ago, analysis of “older patients” who received chemotherapy for advanced lung cancer revealed that chemotherapy improved survival in the elderly to the same extent as in patients who were younger. The down side was that older patients experienced more side effects from chemotherapy. It is easy to see how this result could lead to mixed feelings: live longer, but with side effects. In the 1990’s clinical trials directed towards the elderly began. The pivotal trial was called ELVIS (Elderly Lung cancer Vinorelbine Italian Study). This study compared the effect of chemotherapy (vinorelbine) against no chemotherapy in lung cancer patients ≥70 years of age. This direct comparison clearly demonstrated that chemotherapy not only improved survival but most importantly, quality of life.

How was this possible? We all recognize that controlling the cancer will control cancer related symptoms. The challenge with treatment is balancing the side effects of chemotherapy against the benefit gained by controlling lung cancer symptoms. However, vinorelbine (Navelbine) is a well tolerated chemotherapy that made it possible to improve quality of life. Subsequently, more trials in more modern times with more modern chemotherapy have repeatedly shown us that chemotherapy is feasible and worthwhile in the elderly.

Moving to early non-small cell lung cancer, post operative chemotherapy is the standard of care. The JBR10 clinical trial was one of the trials that compared postoperative chemotherapy to no postoperative chemotherapy and showed us that post-operative chemotherapy improves cure rates. This study also helped us understand the interaction of such treatment with age:

JBR.10 chemo by age

(Click to enlarge)

Patients older than the age of 65 years received less chemotherapy overall than the younger cohort, yet they benefited from post operative chemotherapy with increased survival. This study also showed us that chemotherapy did not seem to have a benefit in patients older than the age of 75, though this is a group of patients in whom deaths unrelated to cancer were common, unlike the younger population, so there were “competing risks”.

The caveat to clinical trial results is that patients enrolling onto clinical trials are “fit” and extrapolating results of these trials to the “unfit elderly” has obvious flaws. As treating oncologists we recognize that more important that age is one’s “fitness” or performance status: the ability to take care of oneself, participate in physical activity, the amount of time spent resting or the amount of time spent in bed. If you wonder why your oncologist asks you how many hours in a day you sleep, it is for this reason. There are 2 scales that help us assess peroformance status. One is called the Karnofsky scale, and the other is the Zubrod scale (which is also commonly referred to as the ECOG scale):

Performance Status Scales

Years of cancer care have provided the guidelines that chemotherapy should be administered only when the performance status is good and not poor. It is this functional status scale that is the most important when making treatment decisions with the elderly, eclipsing the importance of chronologic age.

In summary, chemotherapy when carefully tailored to the fit the performance status of elderly patients does provide the benefits of improved survival and quality of life. There doesn’t appear to be anything about age as a number that makes a patient “too old for chemo”.

3 Responses to Doc, Am I Too Old for Chemo?

  • Dr Pennell
    Dr Pennell says:

    Thank you for that excellent review!

    On a related topic, I would throw out two questions to Dr. Dubey (and Dr. West): 1) What do you offer fit, elderly patients? While single agent navelbine is appropriate for many, there is also evidence to show benefit from platinum doublet chemo in elderly patients. 2) How about Avastin? Subgroup analysis from the ECOG 4599 trial (Which led to the approval of Avastin) seems to indicate more toxicity and loss of the survival benefit from Avastin in this group.

    I myself always think about platinum doublet chemo for fit elderly patients, and think twice about adding Avastin ;-).

  • Dr West
    Dr. West says:

    Sorry I didn’t get around to this one yet. It’s a nagging question, because we definitely have data that a carbo-based doublet is a fine choice, and may well be superior to single agent therapy in both good PS elderly and also PS2 patients. On the other hand, many of us who treat a large proportion of elderly patients came away from that study feeling that there is still room to individualize because there may well have been some selection bias favoring more fit patients going on the trial, that the patients that the oncologist couldn’t imaging feasibly getting doublet chemo weren’t enrolled, even if they technically met the eligibility criteria.

    And the issue about avastin is also an open question. Of the patients on the ECOG trial, 24% were 70 or older, and the trial itself was positive, so you could say that if they were eligible and included and the overall trial was positive, the results should apply to elderly patients. Nevertheless, I think the retrospective analysis showing no improvement in survival and a disproportionate degree of toxicity was believable.

    This leaves me with the unscientific situation of completely individualizing in this situation. The factors that would influence me are (obviously) fitness of the patient, aside from their chronologic age, but also their preference to be more aggressive or more cautious, how much support they have, and perhaps other soft factors like whether there is tumor cavitation, mixed histology, etc. I have definitely treated fit elderly patients with carbo/taxol/avastin or carbo/alimta/avastin up to the 75-77 range, but in the later 70s and 80s I’d be much more cautious, even if they are fit. I have had a few very fit 79-80 year old patients who have become much less fit elderly patients after chemotherapy that you might predict from the literature would be well tolerated, but I suppose they didn’t read the book.

    I would say that in avastin-eligible patients I’d strongly consider carbo/taxol/avastin or carbo/alimta/avastin, and in those in whom I’d be disinclined to use avastin I’ve often given carbo/gem, or carbo/alimta as two carbo doublet options that I would anticipate being well tolerated (I’d likely prefer carbo/gem for a patinet with a squamous tumor and carbo/alimta for a non-squamous tumor). And if that patient was wary about the value of chemo, or their performance status was two on a good day but perhaps worse on a bad one, I’d be inclined to omit the carbo and give alimta, gemcitabine, or navelbine. I’ve used all of these options with patients in the last year or two.

    -Dr. West

  • Dr Dubey says:

    Hi Dr Pennell,
    Sorry I didnt get to your comment any earlier. And in someway, this was the easier path, becuase Dr. West answered the questions you had for me.

    I agree with what he said. I think vinorelbine was a good starting point in the 1990s. But we have more to offer since then. And I too beleive that performance status matters more that just age as a number. I have even had a few patients in the age range of 78-82 receive combination chemotherapy and do really well in terms of tolerating and responding to treatment. It really does vary from patient to patinet.

    I too beleive the avastin data in the elderly. Again functional status is important but I am not inclined on using avastin above the age of 75ish.

Leave a Reply

Ask Us, Q&A
Lung/Thoracic Cancer Expert Content


download as a pdf file Download PDF of this page

GRACE Cancer Video Library - Lung Cancer Videos




2015 Acquired Resistance in Lung Cancer Patient Forum Videos

download as a pdf file Download PDF of this page

Join the GRACE Faculty

Breast Cancer Blog
Pancreatic Cancer Blog
Kidney Cancer Blog
Bladder Cancer Blog
Head/Neck Cancer Blog
download as a pdf file Download PDF of this page

Subscribe to the GRACEcast Podcast on iTunes

download as a pdf file Download PDF of this page

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon

Subscribe to
   (Free Newsletter)

Other Resources

download as a pdf file Download PDF of this page

Biomedical Learning Institute