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Treating Elderly and Poorer Performance Status Patients with Small Cell Lung Cancer
The fact is that lung cancer, like many others, is a disease disproportionately affecting older populations, with the median age now in the 69-70 range.
(Click to enlarge)
But our trials in lung cancer only rarely involve patients over 70. This leaves us with serious questions about the best way to treat older and poor performance status patients. It’s also important to note that elderly doesn’t mean poor performance status. There are remarkably healthy older patients, now more than ever, and there are also debilitated patients under 70 as well:
But a lot of patients with SCLC are elderly and/or frail when they present for treatment, and the question is whether they should be treated the same as younger patients or whether plans should be modified. Continue reading
Avastin in Older Patients: Survival Benefit Not Seen
As described in one of my first posts, Avastin was approved by the US FDA for the first line treatment of advanced NSCLC in patients with non-squamous cancers, no history of coughing up blood, and no brain metastases, based on the positive trial ECOG 4599 (abstract here) that demonstrated a survival benefit for carbo/taxol/avastin compared with carbo/taxol alone. The trial included only active patients with a good performance status, and we saw that while patients lived longer on average with avastin, they also had increased side effects. This leaves us with some open questions about whether sicker and/or older patients would be well served by the combination of chemo with avastin. This year at ASCO we learned something about the value of avastin in an older population.
A friend of mine, Dr. Suresh Ramalingam from the University of Pittsburgh Medical Center, presented data from the ECOG 4599 broken down by patient age (abstract here). To review, the trial divided about 878 patients between carbo/taxol and carbo/taxol/avastin for up to 6 cycles, and then the patients on the avastin arm received maintenance avastin if they didn’t show progression after 6 cycles of chemo/avastin:
(click to enlarge) Continue reading
Radiofrequency Ablation (RFA) for Lung Tumors
Several people have asked about the technique of radiofrequency ablation, or RFA, for lung tumors. RFA is a pretty specialized approach in which a needle probe is inserted through the skin, under visual guidance using a CT or ultrasound, to go directly into a tumor. The tip is then pushed out and splays into a shape like the frame of an umbrella, and then an electric current is turned on to superheat the tip of the probe. In some cases, the probe is moved around to cover a broader area and destroy a larger tumor, but the procedure works particularly well for smaller tumors. It also works best for tumors that are more peripheral, along the outer edges of the lung. Here’s what the CT images look like during a procedure.
(click to enlarge) Continue reading
Lobectomy vs. Limited Resection: Different Approach Based on Age?
While the prevailing standard of care for resectable lung cancer is a lobectomy or pneumonectomy, we want the surgery to be as appropriate as possible for patients. That means not short-changing patients by doing a lesser surgery than they need to do as well as possible with the cancer, but also not overtreating patients with a more aggressive surgery than they need. There are two main variables that potentially alter the equation and may make a sublobar resection a more appropriate consideration. The first is in cases in which the patient has competing risks of survival and/or medical problems that make a more aggressive surgery less necessary or more morbid (side effect-ridden, longer time for recovery, etc.) than average, or both. The second situation is when the cancer has more favorable features than most, so even in healthier patients it may not be necessary to do a more extensive surgery. I’ll explore the first scenario now.
As I mentioned in a previous post introducing the different types of lung surgery, an influential trial by the now defunct Lung Cancer Study Group indicated that survival is superior in patients who receive a pneumonectomy or lobectomy compared to those who receive a segmentectomy or wedge resection (abstract here). However, there was actually no difference in survival in the first three years, wit
h improvement only emerging with longer follow-up. This suggests that patients with competing health risks may not be as well served by a more aggressive surgery. Thoracic surgeons have therefore asked whether elderly patients may do as well or better with a sub-lobar resection that involves less blood loss and recovery time without a significant compromise of cancer-related survival. One important study suggest that’s the case. Continue reading
Adjuvant Chemo in Older Patients: Feasible and Beneficial?
Chemotherapy after surgery has become increasingly well established as beneficial for many patients who have undergone surgery for early stage NSCLC, at least for stage II and IIIA resected disease (stage IB has had more mixed results and remains quite debatable). The chemo regimens that have been most clearly shown to confer improved survival are cisplatin-based and can have very challenging toxicity in anybody, especially after a major lung surgery. In fact, the rates of administering chemo as planned after surgery are generally about 65-75%, and this is in clinically trials that tend to enroll disproportionately younger, fitter, and more aggressively-minded patients than are seen in a broader “real world” experience. So the question of how feasible it is to administer post-operative chemo in older and potentially less robust patients is an important issue. Do such patients receive a benefit similar to that seen in younger patients, or does adjuvant chemo potentially represent treatment beyond the point of benefit that may do more harm than good? We don’t have much information, but one study presented last year provides some useful information that indicates that adjuvant chemotherapy appears to be at least of equal benefit in older compared to younger patients. Continue reading
Targeted Therapy in Older and Sicker Patients: A Replacement for Chemo?
The emergence of targeted therapies provides a goal of treating the cancer more selectively, thereby minimizing side effects, while hopefully achieving results as good as or better than standard chemotherapy. Although this is important in the entire population of cancer patients, this is a particularly welcome benefit in patients who may be reluctant to or not healthy enough to receive standard chemotherapy. As I mentioned in my last post on the association of age and benefits of chemotherapy, chronological age is not nearly as important as performance status, at least up until around age 80, where we have very few patients on clinical trials to help tell us what to expect. Regardless, there have been several studies of tarceva/erlotinib in older patients, and other trials specifically looking at patients with marginal performance status regardless of age, asking whether we can do as well or better with tarceva as with conventional chemotherapy in these patients. Continue reading
Does Age Matter? Treating Older Patients with Advanced NSCLC
We know far too little about the best way to treat older patients with NSCLC, that lung cancer, like many other cancers, is a disease highly related to advanced age. First, how do we define an older, or elderly, population in cancer treatment terms? Beyond the joke that it increases as the person answering gets older, in the US it’s usually around 70, occasionally defined as 65, generally outside of the US. Despite the fact that the average age for patients newly diagnosed with lung cancer is in the late 60s, trials done in lung cancer far disproportionately enroll younger patients. It’s only been in the last few years that trials have been done specifically looking at older patients, or including them in large enough numbers in broader trials to ask meaningful questions about whether they should be treated identically or differently than younger patients. Continue reading
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