Dr. Mark Socinski, University of Pittsburgh Medical Center, describes strategies for treatment of the elderly and frail patient with locally advanced NSCLC.

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A substantial portion of our patients are over the age of 70, and this disease is still often associated with smoking, so the older patients tend to have more comorbidities, and often may have a frailness to them at the time of diagnosis. All the paradigms that we’ve been talking about — chemoradiation, surgical excision, certainly have a toxicity associated with them, and surgery has a risk of morbidity and mortality associated with it. So I think special consideration needs to be made to those elderly, frail patients which have been largely underrepresented in many clinical trials because they would have been excluded based on comorbidities or performance status, and therefore you can’t necessarily apply the paradigms defined in published clinical trials to this population.

It is very clear that, for instance, in the chemoradiation world, the standard of care is concurrent use of chemoradiation. This substantially increases the risk of certain toxicities such as esophagitis, myelosuppression, and fatigue, and may be very debilitating in an elderly, frail patient. So one must consider: is this the best treatment for that particular patient? In many patients, we may give a brief course, two to three cycles, of chemotherapy to see how they tolerate it, and then consider following it if they tolerate it well, and if they have a response, particularly with radiotherapy. Often we give that radiotherapy alone, or sometimes we give it with a low dose of chemotherapy during the radiation with a regimen such as carboplatinum and paclitaxel.

So that’s a very common approach at our institution. Alternatively, patients may start with concurrent radiotherapy, or we may start some frail patients who may have very symptomatic disease, who may have impending obstruction of a bronchus or something like that in the medial part of the chest — often we may start them with radiotherapy alone with the intent to palliate their symptoms, to relieve the obstruction as best we can, and then again, if patents do well with initial radiotherapy, follow it up with systemic therapy following this — assuming that the patient’s condition improves as a result of the initial radiotherapy.

So, I don’t know in this population of elderly, frail patients that there’s a one size that fits all. I think one has to review the CT scans, examine the patient, get an idea of how symptomatic the patient is and what the symptoms are. I do think the strategy of chemotherapy alone, followed by radiation, or sequential strategy is something that we do quite often in this population. I think that concurrent chemoradiotherapy can be done with low dose strategies in an eldery, frail population, and actually may be a reasonable strategy if you have local/regional issues that need attention, such as impending bronchial obstruction would be the best example there. We do know that adding chemotherapy to radiation does lead to better regional control in the area, or the field of radiation. So again, I think one has to personalize and customize the treatment for this elderly, frail population.