Dr. Rachel Sanborn, Providence Thoracic Oncology Program, discusses using adjuvant chemotherapy for elderly and frail patients. What was seen in particular in the trial performed by NCI Canada, using cisplatin with navelbine chemotherapy, was that people who were considered elderly were able to achieve just as much benefit from chemotherapy in terms of survival as younger people did.
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Adjuvant Chemotherapy for Elderly and Frail Patients
Rachel Sanborn, MD, Medical Oncologist and Co-Director,
Providence Thoracic Oncology Program
When we look at the actual data is for the people who are older getting chemotherapy, in the adjuvant clinical trials, those trials that evaluated whether adding chemotherapy after surgery would provide a benefit, they looked at how patients did according to age. What was seen in particular in the trial performed by NCI Canada, using cisplatin with navelbine chemotherapy, was that people who were considered elderly were able to achieve just as much benefit from chemotherapy in terms of survival as people who were younger did. People who were older did require more dose reductions of chemotherapy in order to minimize toxicity. In general, that would be lowering the dose of the chemo based on kidney function or based on other side effects. However, even with that little less chemotherapy that those people got, they were able to achieve the same survival benefit. So what’s shown as more important in thinking about age is considering how healthy a person is overall.
We have to be careful about what is defined as “elderly” in clinical trials, because in most studies, and even in this study that I’m talking about, people were defined as elderly when they were age 65 or greater. I hardly consider a person at the age of 65 to be elderly. When we look at the average age of diagnosis of lung cancer in the United States, that average age is 72. So is the evidence different in much older populations? That part is difficult to understand at this time because not as many people were enrolled in studies. However, even in those elderly populations there were older patients evaluated in that group as well.
When I am talking to a person about chemotherapy, age doesn’t factor in as much as we look at a person’s overall health. We have to look at how much they’re able to be up and active through the day. In all of these trials that showed a benefit with chemotherapy a person needed to be up and active through the majority of their day, able to carry out all of their own daily needs and to be able to do different activities without severe physical limitations. For a person who is up and active and moving, we then also look at their overall health status in terms of risks, including kidney function and heart function and lung function. Also it’s important to consider any type of cognitive deficits as well as those physical deficits and in addition the support that a person may have at home. But for a person who is older who is otherwise healthy, who still has many years of expected life outside of the possibility of the lung cancer coming back, adding chemotherapy after surgery is still an important thing to discuss, although it is important for us to monitor those people closely for toxicities and have a low threshold for decreasing the dose as needed in order to help keep a person safe.
On a separate side of consideration, is thinking about a person who has a lung cancer removed with surgery who may not have that same recovery, who may not have the same level of what’s called functional status after their lung cancer has been removed. In the clinical trials again, a person is required, to be eligible, to be able to be up and moving and active through the majority of their day without any significant physical limitations. What happens when a person has been less active at baseline? What happens when a person may be still having a difficult time to recover after surgery, where they’re active for less than half of their day, when they don’t have the ability to be up and moving around? They still have a risk of a cancer coming back. At the same time, we have to be very careful in those situations because chemotherapy when given has significant risk as well. The risks of the complications increase the less active that a person is, particularly risks of getting infections, like pneumonias, bladder infections, things that can be life-threatening when a person has more physical limitations than in a person who is able to be up and active without restriction in their day. It’s important to think about the fact that although we’re trying to cure a patient, we also don’t want to kill them with that cure.
In some situations, when a person may have a higher risk tumor, but their functional status, that ability to be active through the day, may be more marginal, we may consider an adaption of the chemotherapy. Instead of using cisplatin-based chemotherapy, for example, one may consider carboplatin-based chemotherapy. But those situations need to be very carefully evaluated, with lots of discussions with the oncologist and the patient, working through what the risks may be, both with the lung cancer itself as well as from the chemotherapy and its possible toxicities.
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