Stage III non small cell lung cancer: what is evidence based for older patients?

Lung cancer is a disease of the elderly. According to the SEER database, the median age at diagnosis in the United States, between 2001 and 2005, was 71 with 36.2% of patients being above the age of 75.1

A third of non small cell lung cancer (NSCLC) patients present with stage III disease and the standard of care in stage III NSCLC is concurrent chemo-radiotherapy. However old age is often associated with co-morbidities precluding chemotherapy treatments. Therefore thoracic radiotherapy plays a major role in the curative and palliative treatment of these patients.

Specific issues regarding radiotherapy treatment of the elderly/co-morbid patients include: risk of under or over-treatment; selection of patients; selection of treatment; impact of age/co-morbidities on side effects, prognosis and quality of life.

Unfortunately there is paucity of prospective data addressing such issues as these patients are generally excluded from clinical trials, particularly in the combined modality setting. There is controversy about the prognosis of elderly patients treated with thoracic radiotherapy alone. Some authors report a similar or better survival in older patients while others concluded that the outcome of elderly patients was poor compared to younger counterparts. These studies did not report an excess of radiotherapy-related complications in elderly patients.

Elderly patients treated with concurrent chemo-radiotherapy generally experience increased haematological toxicity compared to younger patients but have similar outcome. An increase in non haematological toxicity has been inconsistently reported. A Japanese study recently reported improved survival in patients above the age of 70, PS0-2, treated with thoracic radiotherapy with daily low-dose carboplatin compared to radiotherapy alone.

In this talk outstanding questions in the group of patients will be discussed
•How can we better select patients for aggressive treatments such as chemo-radiotherapy?

•Less toxic alternatives to chemo-radiotherapy?

•Shall we adapt RT planning parameters (i.e. V20, MLD) according to age?

•Clinical trials for the elderly/patients with co-morbidities

•Little data for octogenarians

•Little data on the impact of age on biology of the disease

•Relax ‘unnecessary restrictive’ inclusion criteria in clinical trials

•Explore role of a comprehensive geriatric assessment on treatment decision

•Explore targeted therapies + radiotherapy as an alternative to chemo-radiotherapy

•Collect more population-based data? Theragnostics?

In conclusion, arbitrary numerical definitions of age should not be used to make decision regarding RT or CTRT treatment. There may be a role for role of a comprehensive geriatric assessment to determine which patients will benefit from combined chemo-radiotherapy.