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Doc, Am I Too Old for Chemo?
dr dubey

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".

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