Chemotherapy — or not? For older patients with advanced lung cancer, the answer is not simple

Non small cell lung cancer is a leading cause of cancer-related death in the United States. Almost half (47 percent) of patients with lung cancer are age 70 or older. While the incidence of and death rate from lung cancer have improved in people age 50 and younger, that is not the case for those age 70 and older, says Ajeet Gajra, MD, above, who reviewed treatment options for the Journal of Clinical Oncology.

Non small cell lung cancer is a leading cause of cancer-related death in the United States. Almost half (47 percent) of patients with lung cancer are age 70 or older. While the incidence of and death rate from lung cancer have improved in people age 50 and younger, that is not the case for those age 70 and older, says Ajeet Gajra, MD, above, who reviewed treatment options for the Journal of Clinical Oncology. Photo by Susan Kahn.

Treatment for lung cancer can include surgery, radiation and/or chemotherapy, and what works for one patient may not be so successful in another. That’s particularly true among older patients.

“Care for older patients is much more complex,” says Ajeet Gajra, MD, a medical oncologist and cancer researcher at Upstate.

People age 70 and older are likely to have additional medical problems and may be taking medication. They may have cognitive deficits, undiagnosed psychological issues and/or inadequate social support.

“Most important perhaps, they have limitations in physical function. They experience more side effects from treatments. We cannot treat them in the same way that we treat younger patients.”

Gajra was asked by the Journal of Clinical Oncology to outline the treatment options for lung cancer in older patients to keep physicians informed. His work was published last year.

Is chemotherapy worthwhile? Gajra cited studies that show chemotherapy can add several weeks to the lives of patients over age 70 with advanced lung cancer. However, side effects of many of the medications used to treat cancer may be more severe in older patients.

Some older patients may prefer to preserve quality of life over prolonging life, he points out.

One drug or two? Doctors may prescribe chemotherapy that includes a single medication or a combination. Gajra found research showing the benefits of both treatments. He opposes a blanket recommendation for all older patients. “The elderly are heterogeneous: some are functional, some are not; some have excellent organ function, others do not,” he writes.

Which drugs?

A monoclonal antibody called bevacizumab is commonly prescribed because doctors believe it can add a couple of months to the lifespan of patients with metastatic lung cancer. But after focusing on patients age 70 and older in four unrelated studies, Gajra says the drug’s benefits are not so clear and may not add to survival.

Erlotinib – which slows the growth of cancer cells — can lengthen survival in older patients, but with more severe side effects. Patients over age 65 reported more rashes, fatigue and dehydration than younger patients. “A prescription for erlotinib should be preceded by a realistic discussion of adverse effects,” Gajra advises.

What about after surgery? Patients who have surgery may receive chemotherapy afterward. Which drug, how much and for how long have to be considered for each individual patient.

Chemotherapy containing the drug, cisplatin works for relatively healthy older adults, but its benefit has not been shown in patients age 80 and older “and should be undertaken with extra caution,” Gajra writes. He also notes that chemotherapy containing the drug, carboplatin may provide modest benefit to some patients.

What about during radiation? Some doctors prescribe chemotherapy to be taken while a patient undergoes radiation therapy for cancer that is still confined to the chest. While some studies have shown no improvement in survival or quality of life by adding chemotherapy to radiation, others have shown improved outcomes, but with significant side effects.

Gajra says some older patients may benefit from chemotherapy with radiation, but he urges doctors use caution with this type of therapy – and consider the patient’s overall health and nutritional state.

See Gajra’s journal article

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