Skip to main content

Advertisement

SpringerLink
Log in

Medical Treatment in Elderly Patients with Non-Small Cell Lung Cancer

  • Lung Cancer (HA Wakelee, Section Editor)
  • Published:
Current Treatment Options in Oncology Aims and scope Submit manuscript

Opinion statement

Lung cancer is the leading cause of cancer-related deaths worldwide. In the USA, ≈60 % of lung cancer cases are diagnosed in elderly patients (≥65 years of age). However, elderly patients are underrepresented in clinical studies, leading to a paucity of evidence to guide treatment decisions. Several treatment barriers exist in elderly patients, including comorbidities and poor performance status. In addition, lack of reliable geriatric assessment tools and physician reluctance to treat may contribute to undertreatment in this population. For decades, systemic chemotherapy for elderly patients with advanced non-small cell lung cancer (NSCLC) was either omitted or given as monotherapy, frequently with significant dose reductions, potentially compromising the efficacy of these therapies. Recent analyses of elderly subgroups from multiple clinical trials provide evidence for improved outcomes associated with platinum-based doublet chemotherapies vs monotherapy. Moreover, in the new era of precision medicine, molecularly targeted therapies and more recently immune-targeting therapies (anti-PD-1 and anti-PD-L1 agents) exhibit relatively milder toxicities but superior clinical outcomes in subgroups of patients compared with conventional cytotoxic chemotherapies. Further clinical trials will be needed to confirm similar safety and efficacy profiles of these therapeutic approaches in the elderly compared with their younger counterparts. In this article, we review available evidence from clinical studies and also present expert consensus on the management of NSCLC in the elderly, including treatment in the adjuvant setting and treatment of advanced disease. Screening tools, such as the Comprehensive Geriatric Assessment, that help to identify the right population of elderly patients suitable for systemic treatment are also discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as •• Of major importance

  1. Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, et al (eds). SEER cancer statistics review, 1975-2012, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2012/, based on November 2014 SEER data submission, posted to the SEER web site, April 2015.

  2. Lewis JH, Kilgore ML, Goldman DP, et al. Participation of patients 65 years of age or older in cancer clinical trials. J Clin Oncol. 2003;21(7):1383–9.

    Article  PubMed  Google Scholar 

  3. Hoffe S, Balducci L. Cancer and age: general considerations. Clin Geriatr Med. 2012;28(1):1–18.

    Article  PubMed  Google Scholar 

  4. ClinicalTrials.gov. NCT02360761. Accessed 24 Jun 2015.

  5. Edwards BK, Noone AM, Mariotto AB, et al. Annual report to the nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer. Cancer. 2014;120(9):1290–314.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Arias E. United States life tables, 2010. Natl Vital Stat Rep. 2014;63(7):1–63.

    PubMed  Google Scholar 

  7. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750–6.

    Article  CAS  PubMed  Google Scholar 

  8. Rubenstein LZ, Stuck AE, Siu AL, Wieland D. Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Soc. 1991;39(9 pt 2):8S–18.

    Article  CAS  PubMed  Google Scholar 

  9. Caillet P, Laurent M, Bastuji-Garin S, et al. Optimal management of elderly cancer patients: usefulness of the Comprehensive Geriatric Assessment. Clin Interv Aging. 2014;9:1645–60. This report provides an in-depth background on use of the Comprehensive Geriatric Assessment tool in elderly patients and demonstrated the importance of its use on treatment decisions in oncology.

    PubMed  PubMed Central  Google Scholar 

  10. McCorkle R, Strumpf NE, Nuamah IF, et al. A specialized home care intervention improves survival among older post-surgical cancer patients. J Am Geriatr Soc. 2000;48(12):1707–13.

    Article  CAS  PubMed  Google Scholar 

  11. Kalsi T, Babic-Illman G, Ross PJ, et al. The impact of comprehensive geriatric assessment interventions on tolerance to chemotherapy in older people. Br J Cancer. 2015;112(9):1435–44.

    Article  CAS  PubMed  Google Scholar 

  12. Corre R, Chouaid C, Grellier L, et al. Quality of life analysis of ESOGIA-GFPC-GECP trial—a phase III, randomized, multicenter study comparing in elderly patients (≥70 years) with stage IV NSCLC a standard strategy of treatment allocation based on PS and age with an experimental strategy according to a comprehensive geriatric assessment (CGA). Ann Oncol. 2014;25 suppl 4:iv426–70.

    Google Scholar 

  13. Horgan AM, Leighl NB, Coate L, et al. Impact and feasibility of a comprehensive geriatric assessment in the oncology setting: a pilot study. Am J Clin Oncol. 2012;35(4):322–8.

    Article  PubMed  Google Scholar 

  14. Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations. Ann Oncol. 2015;26(2):288–300. In these recent International Society of Geriatric Oncology recommendations, use of screening tools to identify patients in need of further geriatric assessment is supported.

    Article  CAS  PubMed  Google Scholar 

  15. Foster JA, Salinas GD, Mansell D, Williamson JC, Casebeer LL. How does older age influence oncologists' cancer management? Oncologist. 2010;15(6):584–92.

    Article  PubMed  PubMed Central  Google Scholar 

  16. NCCN Clinical Practice Guidelines in Oncology. Non-small cell lung cancer. V7.2015. http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed 5 Oct 2015.

  17. NSCLC Meta-analyses Collaborative Group, Arriagada R, Auperin A, Burdett S, et al. Adjuvant chemotherapy, with or without postoperative radiotherapy, in operable non-small-cell lung cancer: two meta-analyses of individual patient data. Lancet. 2010;375(9722):1267–77.

    Article  Google Scholar 

  18. Pepe C, Hasan B, Winton TL, et al. Adjuvant vinorelbine and cisplatin in elderly patients: National Cancer Institute of Canada and Intergroup Study JBR.10. J Clin Oncol. 2007;25(12):1553–61.

    Article  CAS  PubMed  Google Scholar 

  19. Cuffe S, Booth CM, Peng Y, et al. Adjuvant chemotherapy for non-small-cell lung cancer in the elderly: a population-based study in Ontario, Canada. J Clin Oncol. 2012;30(15):1813–21.

    Article  PubMed  Google Scholar 

  20. Wisnivesky JP, Smith CB, Packer S, et al. Survival and risk of adverse events in older patients receiving postoperative adjuvant chemotherapy for resected stages II-IIIA lung cancer: observational cohort study. BMJ. 2011;343:d4013.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Ganti AK, Williams CD, Gajra A, Kelley MJ. Effect of age on the efficacy of adjuvant chemotherapy for resected non-small cell lung cancer. Cancer. 2015;121(15):2578–85.

    Article  PubMed  Google Scholar 

  22. Sigel K, Mhango G, Cohen J, et al. Outcomes after adjuvant platinum-based chemotherapy in elderly NSCLC patients with T4 disease. Ann Surg Oncol. 2013;20(3):1013–9.

    Article  PubMed  Google Scholar 

  23. Malhotra J, Mhango G, Gomez JE, et al. Adjuvant chemotherapy for elderly patients with stage I non-small cell lung cancer (NSCLC) with tumors ≥ 4 cm: a SEER-Medicare analysis. J Clin Oncol. 2014;32(suppl):e18508.

    Google Scholar 

  24. Fruh M, Rolland E, Pignon JP, et al. Pooled analysis of the effect of age on adjuvant cisplatin-based chemotherapy for completely resected non-small-cell lung cancer. J Clin Oncol. 2008;26(21):3573–81.

    Article  CAS  PubMed  Google Scholar 

  25. Park S, Kim IR, Baek KK, et al. Prospective analysis of quality of life in elderly patients treated with adjuvant chemotherapy for non-small-cell lung cancer. Ann Oncol. 2013;24(6):1630–9.

    Article  CAS  PubMed  Google Scholar 

  26. Quoix E, Zalcman G, Oster JP, et al. Carboplatin and weekly paclitaxel doublet chemotherapy compared with monotherapy in elderly patients with advanced non-small-cell lung cancer: IFCT-0501 randomised, phase 3 trial. Lancet. 2011;378(9796):1079–88.

    Article  CAS  PubMed  Google Scholar 

  27. Quoix E. Optimal pharmacotherapeutic strategies for elderly patients with advanced non-small cell lung cancer. Drugs Aging. 2011;28(11):885–94.

    Article  PubMed  Google Scholar 

  28. Biesma B, Wymenga AN, Vincent A, et al. Quality of life, geriatric assessment and survival in elderly patients with non-small-cell lung cancer treated with carboplatin-gemcitabine or carboplatin-paclitaxel: NVALT-3 a phase III study. Ann Oncol. 2011;22(7):1520–7.

    Article  CAS  PubMed  Google Scholar 

  29. Depierre A, Lemarie E, Dabouis G, Garnier G, Jacoulet P, Dalphin JC. A phase II study of Navelbine (vinorelbine) in the treatment of non-small-cell lung cancer. Am J Clin Oncol. 1991;14(2):115–9.

    Article  CAS  PubMed  Google Scholar 

  30. Gridelli C. The ELVIS trial: a phase III study of single-agent vinorelbine as first-line treatment in elderly patients with advanced non-small cell lung cancer. Elderly Lung Cancer Vinorelbine Italian Study. Oncologist. 2001;6 suppl 1:4–7.

    Article  CAS  PubMed  Google Scholar 

  31. Kudoh S, Takeda K, Nakagawa K, et al. Phase III study of docetaxel compared with vinorelbine in elderly patients with advanced non-small-cell lung cancer: results of the West Japan Thoracic Oncology Group Trial (WJTOG 9904). J Clin Oncol. 2006;24(22):3657–63.

    Article  CAS  PubMed  Google Scholar 

  32. Fidias P, Supko JG, Martins R, et al. A phase II study of weekly paclitaxel in elderly patients with advanced non-small cell lung cancer. Clin Cancer Res. 2001;7(12):3942–9.

    CAS  PubMed  Google Scholar 

  33. Bianco V, Rozzi A, Tonini G, et al. Gemcitabine as single agent chemotherapy in elderly patients with stages III-IV non-small cell lung cancer (NSCLC): a phase II study. Anticancer Res. 2002;22(5):3053–6.

    CAS  PubMed  Google Scholar 

  34. Leong SS, Toh CK, Lim WT, et al. A randomized phase II trial of single-agent gemcitabine, vinorelbine, or docetaxel in patients with advanced non-small cell lung cancer who have poor performance status and/or are elderly. J Thorac Oncol. 2007;2(3):230–6.

    Article  PubMed  Google Scholar 

  35. Gridelli C, Perrone F, Gallo C, et al. Chemotherapy for elderly patients with advanced non-small-cell lung cancer: the Multicenter Italian Lung Cancer in the Elderly Study (MILES) phase III randomized trial. J Natl Cancer Inst. 2003;95(5):362–72.

    Article  CAS  PubMed  Google Scholar 

  36. Karampeazis A, Vamvakas L, Agelidou A, et al. Docetaxel vs. vinorelbine in elderly patients with advanced non–small-cell lung cancer: a Hellenic Oncology Research Group randomized phase III study. Clin Lung Cancer. 2011;12(3):155–60.

    Article  CAS  PubMed  Google Scholar 

  37. Kim YH, Hirabayashi M, Kosaka S, et al. Phase II study of pemetrexed as first-line treatment in elderly (≥75) non-squamous non-small-cell lung cancer: Kyoto Thoracic Oncology Research Group Trial 0901. Cancer Chemother Pharmacol. 2013;71(6):1445–51.

    Article  CAS  PubMed  Google Scholar 

  38. Hattori Y, Iwasaku M, Satouchi M, et al. A phase II study of pemetrexed in chemotherapy-naive elderly patients aged ≥ 75 years with advanced non-squamous non-small-cell lung cancer (HANSHIN Oncology Group 003). Jpn J Clin Oncol. 2013;43(12):1184–9.

    Article  PubMed  Google Scholar 

  39. Gridelli C, de Marinis F, Thomas M, et al. Final efficacy and safety results of pemetrexed continuation maintenance therapy in the elderly from the PARAMOUNT phase III study. J Thorac Oncol. 2014;9(7):991–7.

    Article  CAS  PubMed  Google Scholar 

  40. Socinski MA, Bondarenko I, Karaseva NA, et al. Weekly nab-paclitaxel in combination with carboplatin versus solvent-based paclitaxel plus carboplatin as first-line therapy in patients with advanced non-small-cell lung cancer: final results of a phase III trial. J Clin Oncol. 2012;30(17):2055–62.

    Article  CAS  PubMed  Google Scholar 

  41. Socinski MA, Langer CJ, Okamoto I, et al. Safety and efficacy of weekly nab®-paclitaxel in combination with carboplatin as first-line therapy in elderly patients with advanced non-small-cell lung cancer. Ann Oncol. 2013;24(2):314–21.

    Article  CAS  PubMed  Google Scholar 

  42. Gervais R, Robinet G, Clement-Duchene C, et al. Pemetrexed and carboplatin, an active option in first-line treatment of elderly patients with advanced non-small cell lung cancer (NSCLC): a phase II trial. Lung Cancer. 2013;80(2):185–90.

    Article  PubMed  Google Scholar 

  43. Pereira JR, Cheng R, Orlando M, Kim JH, Barraclough H. Elderly subset analysis of randomized phase III study comparing pemetrexed plus carboplatin with docetaxel plus carboplatin as first-line treatment for patients with locally advanced or metastatic non-small cell lung cancer. Drugs R D. 2013;13(4):289–96.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Zukin M, Barrios CH, Pereira JR, et al. Randomized phase III trial of single-agent pemetrexed versus carboplatin and pemetrexed in patients with advanced non-small-cell lung cancer and Eastern Cooperative Oncology Group performance status of 2. J Clin Oncol. 2013;31(23):2849–53.

    Article  CAS  PubMed  Google Scholar 

  45. Abe T, Takeda K, Ohe Y, et al. Randomized phase III trial comparing weekly docetaxel plus cisplatin versus docetaxel monotherapy every 3 weeks in elderly patients with advanced non-small-cell lung cancer: the intergroup trial JCOG0803/WJOG4307L. J Clin Oncol. 2015;33(6):575–81.

    Article  CAS  PubMed  Google Scholar 

  46. Des Guetz G, Uzzan B, Nicolas P, Valeyre D, Sebbane G, Morere JF. Comparison of the efficacy and safety of single-agent and doublet chemotherapy in advanced non-small cell lung cancer in the elderly: a meta-analysis. Crit Rev Oncol Hematol. 2012;84(3):340–9.

    Article  PubMed  Google Scholar 

  47. Crino L, Cappuzzo F, Zatloukal P, et al. Gefitinib versus vinorelbine in chemotherapy-naive elderly patients with advanced non-small-cell lung cancer (INVITE): a randomized, phase II study. J Clin Oncol. 2008;26(26):4253–60.

    Article  CAS  PubMed  Google Scholar 

  48. Jackman DM, Yeap BY, Lindeman NI, et al. Phase II clinical trial of chemotherapy-naive patients > or = 70 years of age treated with erlotinib for advanced non-small-cell lung cancer. J Clin Oncol. 2007;25(7):760–6.

    Article  CAS  PubMed  Google Scholar 

  49. Lee SM, Khan I, Upadhyay S, et al. First-line erlotinib in patients with advanced non-small-cell lung cancer unsuitable for chemotherapy (TOPICAL): a double-blind, placebo-controlled, phase 3 trial. Lancet Oncol. 2012;13(11):1161–70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Dy GK, Molina JR, Qi Y, et al. NCCTG N0821 (Alliance): a phase II first-line study of pemetrexed, carboplatin, and bevacizumab in elderly patients with advanced nonsquamous non-small-cell lung cancer with good performance status. J Thorac Oncol. 2014;9(8):1146–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Spigel DR, Hainsworth JD, Shipley DL, et al. A randomized phase II trial of pemetrexed/gemcitabine/bevacizumab or pemetrexed/carboplatin/bevacizumab in the first-line treatment of elderly patients with advanced non-small cell lung cancer. J Thorac Oncol. 2012;7(1):196–202.

    Article  CAS  PubMed  Google Scholar 

  52. Langer CJ, Socinski MA, Patel JD, et al. Isolating the role of bevacizumab in elderly patients with previously untreated nonsquamous non-small cell lung cancer: secondary analyses of the ECOG 4599 and PointBreak trials. Am J Clin Oncol. 2015 Jan 24. [Epub ahead of print].

  53. Lilenbaum R, Hainsworth J, Joseph M, et al. Randomized phase II study of pemetrexed v. pemetrexed/bevacizumab v. carboplatin/metrexed/bevacizumab in patients with previously untreated advanced non-squamous non-small-cell lung cancer and poor performance status. J Thorac Oncol. 2013;8 suppl 2:P2.11–005.

    Google Scholar 

  54. Ciardiello F, De Vita F, Orditura M, Tortora G. The role of EGFR inhibitors in nonsmall cell lung cancer. Curr Opin Oncol. 2004;16(2):130–5.

    Article  CAS  PubMed  Google Scholar 

  55. Omachi K, Tamiya M, Tamiya A, et al. Preliminary analysis of the phase II study of pemetrexed plus carboplatin as first-line chemotherapy for elderly patients with advanced nonsquamous, non-small cell lung cancer. J Clin Oncol. 2014;32(suppl):e19162.

    Google Scholar 

  56. Kozuki T, Nogami N, Kitajima H, et al. Feasibility study of pemetrexed (PEM) plus bevacizumab (BV) as the first-line treatment for elderly advanced or recurrent non-squamous (non-sq) non-small cell lung cancer (NSCLC): TORG1015. J Clin Oncol. 2013;31(suppl):e19054.

    Google Scholar 

  57. ClinicalTrials.gov. NCT02151149. Accessed 24 Jun 2015.

  58. ClinicalTrials.gov. NCT00137800. Accessed 24 Jun 2015.

  59. ClinicalTrials.gov. NCT00678964. Accessed 24 Jun 2015.

  60. ClinicalTrials.gov. NCT01850303. Accessed 24 Jun 2015.

  61. ClinicalTrials.gov. NCT01405586. Accessed 24 Jun 2015.

  62. ClinicalTrials.gov. NCT01593293. Accessed 24 Jun 2015.

Download references

Acknowledgments

The authors received editorial support from Min Yu, MD, CMPP, MediTech Media, funded by Celgene Corporation. The authors were fully responsible for the content and editorial decisions for this report.

Author information

Authors and Affiliations

  1. Department of Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA

    Kamila Bakirhan M.D., Janaki Sharma M.D., Roman Perez-Soler M.D. & Haiying Cheng M.D., Ph.D.

Authors
  1. Kamila Bakirhan M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Janaki Sharma M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Roman Perez-Soler M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Haiying Cheng M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Haiying Cheng M.D., Ph.D..

Ethics declarations

Conflict of Interest

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Lung Cancer

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bakirhan, K., Sharma, J., Perez-Soler, R. et al. Medical Treatment in Elderly Patients with Non-Small Cell Lung Cancer. Curr. Treat. Options in Oncol. 17, 13 (2016). https://doi.org/10.1007/s11864-016-0388-2

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11864-016-0388-2

Keywords

Search

Navigation