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September - December 2003: 
Volume 16, Issue 3

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Management of elderly patients with lung cancer
Abstract
ABSTRACT. The majority of patients with lung cancer (LC) are elderly patients, since 60% of the newly diagnosed patients with LC are >65 years old and 30% are >70 years old. It is common for elderly patients to suffer from a variety of chronic diseases and hence receive multiple drug treatments, which combined with their particular psychosocial and financial situation makes the process of diagnosis, staging and treatment of the disease difficult; therefore, it is necessary to employ an individualized approach. We thoroughly reviewed the differences between elderly and younger patients with lung cancer and pinpoint the need for an individualized approach to the management of elderly patients with lung cancer. Pneumon 2003, 16(3):337-341.
Full text

Introduction

A significant increase in life expectancy was achieved in the second half of the 20th century, which inevitably led to a rise in the number of people aged over 65 years. In fact, people aged >85 years comprise 8.5% of the general population, whereas it has been predicted that this rapidly growing group will amount to some 15% of the general population by the year 2010. It is estimated that the number of people aged >80 years will have increased by 135% in the countries of the European Union and North America by the year 2020, as people at the age of 70 have an average life expectancy of 14 years, people at the age of 80 are expected to live 8 years more and people at the age of 85 another 6 years. Realizing the aging process of the global population, health care systems as well as medical and academic communities are bound to revise health care policies and services so as to meet increased needs and respond to the particular situation of elderly patients.

Lung cancer (LC) is the most common cause of cancer death in both sexes. The overwhelming majority of lung cancer patients are elderly patients, since 60% of the newly diagnosed patients with LC are over 65 and 30% are over 70 years old. In fact, both incidence and mortality of lung cancer are increasing with increasing age; diagnosis of lung cancer has the higher incidence at ages between 75-80 years. Therefore, a further increase in life expectancy is expected to result in a corresponding increase in the incidence of the disease. These patients commonly suffer from chronic medical conditions and receive multiple drug treatments, which combined with their particular psychosocial and financial situation makes the diagnostic and staging process as well as the management of the disease difficult and calls for an individualized approach.1 

The aim of the present review is to pinpoint the differences between elderly and non-eldelry patients with lung cancer and the need for an individualized approach to the management of elderly patients with lung cancer.

Screening for lung cancer in the elderly

The rational selection of a screening program for a specific disease in a certain population group is based on life expectancy, among other factors of the target population. Since evidence supporting the usefulness of implementing a screening program in individuals older than 70 years is scarce even in the case of malignancies for which systematic screening programs have already been established for younger age groups, the situation appears to be more confused as regards lung cancer, for the implementation of a screening program for this malignancy in younger ages is still controversial.

Lung cancer screening studies in the elderly using lung imaging methods (i.e. chest radiographs) and sputum cytology testing were fruitless. This means that randomized studies failed to demonstrate a reduction in mortality rates in the screening group compared to the control group. Nevertheless, further studies are required aiming to assess the yield of more sophisticated imaging methods (computer tomography [CT], spiral CT, magnetic resonance imaging [NMR]) in the elderly. Up to now, there is not enough evidence supporting the implementation of lung cancer screening programs in persons >65 years old.

Smoking and lung cancer in the elderly

Since the yield of secondary prevention is poor, the value of primary prevention, which is mainly comprised of smoking cessation, should be stressed once more. Actually, although the incidence of lung cancer increases with age, the risk of the disease is proportional to exposure to smoke rather than to advancing age; the risk of lung cancer in smokers who have given up this harmful habit does not increase with age, but in the years that follow it remains at the level it had reached at the age of smoking cessation. Furthermore, clinical studies have shown that a greater reduction in lung cancer mortality rates is achieved in males who give up smoking at a comparably early age.

Another study that compared lung cancer patients aged >65 years with their counterparts of <65 years showed that the number of smoking years was less significant than the number of cigarettes smoked daily as a determinant of lung cancer risk.

Diagnosis and staging of lung cancer patients

The clinical presentation of lung cancer may be atypical in patients of any age, but most commonly in elderly patients. In addition, due to reduced physical and psychological reserves as well as increased incidence of comorbid conditions, the diagnostic work-up of elderly patients with lung cancer is often inadequate. The disease may manifest itself with atypical symptoms or symptoms that the patient or the family doctor attribute to preexisting chronic medical conditions. Cough, anorexia and fatigue are some of the symptoms that the patient and/or those who are close to the patient evaluate as compatible with advanced age; in consequence, there is a delay in seeking medical advice. Furthermore, the elderly have difficulty in using public means of transport, which combined with the complexities associated with health insurance coverage, makes health care services less accessible to elderly. All these reason contribute to a significant delay in the diagnosis of the disease in the elderly.1,2 

If lung cancer is suspected, a detailed medical history should be obtained taking special note of the duration and intensity of the symptoms the patient complains about. A comprehensive clinical examination is also essential in order to evaluate all organ systems and record co-existing morbidities and drug treatments the patient receives for these conditions. It is recommended to have the patient evaluated by specialist doctors such as a cardiologist, a nephrologist, a rheumatologist and an orthopaedist; respiratory and cardiac function should also be examined by performing haematological and biochemical tests, imaging studies and pulmonary function tests.

Histological or cytological confirmation of lung cancer requires bronchoscopy, biopsy or thoracentesis, procedures contraindicated in many elderly patients due to poor general health status and concomitant cardiopulmonary disease, e.g. chronic obstructive disease and heart failure. Comprehensive staging involves axial computer tomography imaging and bone scintigram, both of which fail to yield meaningful images if the patient does not cooperate due to either his/hers inability to remain still or the presence of skeletal changes or rheumatic disease.1,2 

Certainly, not all aspects of lung cancer are unfavorable for elderly patients. Clinical studies have shown that, in contrast to what is widely believed, elderly patients accept the diagnosis of cancer more easily and are more likely to give their consent for the indicated treatment being determined to suffer its associated side effects. Contrary to the predominant view, elderly are more familiar with the use of health care services and are better prepared to accept a state of illness, or even the possibility of death. However, those patients who are unable to cooperate with health care professionals due to preexisting mental disorders (e.g. depression) are an exception as regards the general attitude of elderly patients towards the reality of cancer.

Management of elderly patients with lung cancer

Surgical resection is the treatment of choice for stage I, stage II and selected cases of stage III non-small cell lung cancer (NSCLC). Although age alone should not preclude elderly patients from undergoing surgery, postoperative mortality is actually higher in patients >70 years old compared to their younger counterparts, even though these mortality rates are now significantly lower than they were in the period from 1960 to 1980. This reduction in postoperative mortality rates is attributed to advances in surgical methods, but also to more rational patient selection. Appropriate preoperative conditioning, which includes smoking cessation, intensive respiratory physiotherapy, treatment with bronchodilators, as well as antibiotics in case of a co-existing bronchitis, is vital. Those patients with a history of chronic obstructive pulmonary disease (COPD) benefit the most from intensive preoperative conditioning; this is hardly the case for patients with atelectasis or pleural effusion due to underlying malignancy. In the postoperative period, early mobilization of the patient has been shown to be associated with lower complication rates and lower postoperative mortality.3,4 

As regards surgical procedures, it is suggested that pneumonectomy be avoided in elderly patients, if possible, since compared to lobectomy and segmental resection of lung parenchyma it has been found to be related to twofold and threefold mortality rates, respectively.3 

In conclusion, age itself should not preclude elderly patients with lung cancer from surgical treatment. The process of decision-making should take into account the general performance status and comorbidity. Adequate preoperative conditioning and early postoperative mobilization are essential if postoperative morbidity and mortality are to be minimized.4 

Radiotherapy

Radiotherapy is often chosen by the attending physician as a less toxic treatment modality for the elderly patient. Radiotherapy has also begun to be applied in cases of operable NSCLC who are not willing or are judged unfit to undergo surgery. However, the view that radiotherapy is associated with less toxic effects has not been clinically established. Since patients aged >75 years are systematically excluded from clinical studies, the medical community has only limited knowledge regarding the effect of age on radiobiology issues, in particularly regarding how radiation influences regeneration and oxygenation of normal tissue. Recent studies in experimental animal models that develop malignant tumors showed that tumor oxygenation is reduced with age due to reduced blood perfusion, rendering the tumor more resistant to radiotherapy.5-7 

The compliance of elderly patients with medical instructions during radiotherapy sessions is often extremely difficult to ensure. Concomitant chronic diseases such as Parkinson's disease or senile dementia, inability to use public means of transport, prolonged treatment, which may last up to 45 days, are some of the reasons that render radiotherapy difficult to implement and less effective in elderly patients.

Despite the above-described difficulties, improvements in technical equipment and the use of higher doses of radiation -up to 600 Gy- have yielded a significant increase in overall survival in recent series of patients. The contribution of three-dimensional conformal radiotherapy to the effective delivering of high radiation doses with minimal toxicity in the adjacent healthy tissues has been of pivotal importance. The use of radiation therapy with curative intent may also be beneficial for up to 80% of patients with limited small cell lung cancer (SCLC).6 Furthermore, the role of radiotherapy as palliative treatment for cancer patients is also highly important, since it can help preserve airway patency and reduce the incidence of respiratory infections, whereas it is also used in the management of pain associated with bone metastases and the prevention of imminent fractures.

Chemotherapy

Contrary to the widely held view that patients >65 years old are unable to undergo chemotherapy due to poor tolerance, recent clinical studies have completely reversed the situation in that they showed that elderly patients with lung cancer whose general health status is judged good or moderate (Eastern Co-operative Oncology Group [ECOG] Performance Status <2) can tolerate indicated chemotherapy regimens well and hence benefit from this treatment modality. These studies showed that the kind, incidence and severity of chemotherapy toxicity are not related to age, perhaps with a single exception, that of myelosuppression, which is the most important side effect, but can be successfully treated with the use of hemopoietic growth factors in elderly patients, just as this is done in non-elderly patients.

As regards chemotherapy regimens, a variety of treatment approaches have been formulated and established according to histological type of lung cancer. More aggressive treatment is justified in elderly patients with small cell lung cancer due to the sensitivity of this type of cancer to chemotherapy.8,9 As far as NSCLC is concerned, the prevailing view suggests that the use of platinum-based chemotherapy regimens be avoided and recommends a more mild and rational approach to the treatment of these patients including single-agent or combination chemotherapy that does not contain platinum. Among newer agents, gemcitabine has been shown to be most effective with the least toxicity in phase II/III studies; vinorelbine and taxanes have also demonstrated satisfactory efficacy.10-12 

Conclusions

The ever-increasing number of elderly patients with lung cancer mandates that health care systems and clinicians who treat these patients modify their routine practice. The fact that in the past these patients were systematically excluded from clinical studies accounts for the lack of essential knowledge and has led to their being treated quite empirically and arbitrarily. It is important to understand that age alone cannot be a criterion for decision-making. The single strong criterion should be the general performance status of the patient, as well as comorbidity. Elderly patients with lung cancer require an individualized approach in well-organized oncology centers and should be evaluated by a team of specialist doctors. Lastly, doctors should be encouraged to include their patients in multicentered clinical studies designed specifically for elderly patients with lung cancer. This is the only way to make up for our deficit in knowledge and be able to provide the best possible treatment for these patients.


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