Elsevier

Lung Cancer

Volume 33, Supplement 1, October 2001, Pages S115-S120
Lung Cancer

Influence of age and comorbidities on the chemotherapeutic management of lung cancer

https://doi.org/10.1016/S0169-5002(01)00311-7Get rights and content

Abstract

More than 60% of all patients with cancer are currently older than 65 years. Correspondingly, the peak of lung cancer incidence is reached in the age group between 75 and 80 years. As a consequence to this ageing patient population, three factors become of major importance for the chemotherapeutic management of lung cancer, namely functional status, age-specific phenomenon and the presence of comorbidities. While the functional status is dependent on physiological changes in organ function, ageing-specific phenomena include depression, alterations of mental status, reduced nutritional status and missing social support. Comorbidities frequently have a risk profile comparable to that of lung cancer. Clinical studies with a special focus on elderly patients are still rare. In small-cell lung cancer retrospective analyses have demonstrated that age alone is not a major prognostic factor compared to performance status, tumor stage or gender. Nevertheless elderly patients with lung cancer are still frequently excluded from clinical trials, and receive less optimal or even no chemotherapeutic treatment at all. Studies evaluating less aggressive treatment figured out that single agent therapy with etoposide is inferior compared to combination chemotherapy in patients with small cell lung cancer (SCLC). In elderly patients with non-small cell lung cancer (NSCLC), single agent treatment with vinorelbine plus ‘Best Supportive Care’ was significantly superior to ‘Best Supportive Care (BSC)’ alone; with respect to survival and symptom palliation.

Introduction

Cancer is predominantly a disease of the elderly with more than 60% of all cases occurring in people older than 65 years. Demographic analyses predict an increasing percentage of elderly people and thus an increasing number of elderly patients with lung cancer for the upcoming years. These demographic changes are additionally enhanced by the smoking habits dating back to the whole period of the last 50 years [1].

Population-based statistics in Germany reveal that in lung cancer the incidence rate in males reaches a peak between 75 and 80 years with the mean age of first disease manifestation at about 69 years [2]. Among the elderly population a higher degree of heterogeneity compared to the younger age groups can be observed. This heterogeneity is predominantly caused by factors such as changes in functional status, age-specific phenomena; and the presence of major comorbidities (Table 1).

Although these demographic and epidemiological trends are well known, there is a lack of prospective clinical trials dealing with the specific problems of the elderly patient population suffering from lung cancer. The potential benefits from treatment of the elderly patient has to be well balanced against potential physiological alterations, age-specific phenomena, the presence of concomitant diseases, and possible treatment related side effects. This presentation focuses on the specific interactions between age, comorbidities and chemotherapeutic treatment. The importance of these issues for other treatment modalities such as radiotherapy or surgery are discussed elsewhere [3], [4].

Section snippets

Alterations of organ function

Primary alterations of physiological functions affect renal function, liver metabolism, bone marrow reserve, and peripheral neurosensitivity. The elimination of various cytotoxic agents is strongly related to renal function. Renal function as indicated by the glomerular filtration rate or creatinine clearance, is decreased with age and this as a consequence may potentiate the toxicity of cytostatic agents. Another factor that may further influence renal function with ageing is the loss of lean

Age-specific phenomena

Age-specific problems are depression, alterations of mental status, reduced nutritional status; and missing social support. The appearance of depression in elderly cancer patients represents a major problem in the management of chemotherapeutic treatment. However, currently nearly 50% of all cancer patients with depression are misdiagnosed. The reason for this is that symptoms are often subtle and easily missed. A practical tool in screening patients for the occurrence of depression is the

Performance status

The performance status results from changes of organ function, the appearance of ageing-specific phenomena as well as comorbidities. It generally reflects the ability of the patient to perform daily tasks. Well known instruments for assessment are the Karnofsky scale and the Eastern Cooperative Oncology Group (ECOG) score. Performance Status and comorbidities have a low level of correlation and as a consequence should be measured separately [14].

Comorbidities

Ageing is associated with a high prevalence of comorbid diseases. Particularly those patients with a long smoking history are predisposed to concomitant diseases such as chronic obstructive bronchitis, cardiovascular, cerebro-vascular and peripheral vascular diseases, as well as other smoking-related malignancies. In a retrospective review, Findlay and coworkers detected ischemic heart disease in 24%, chronic pulmonary diseases in 18%, and secondary malignancies in 12.5% of patients with SCLC

Elderly patients with SCLC

There are only few data available comparing younger and elder people concerning response and toxicity to chemotherapy. To date, elderly patients are frequently excluded from prospective clinical trials. In the South West Oncology Group only 18% of lung cancer patients above 65 and 7% of lung cancer patients above 70 are enrolled into ongoing clinical trials [18].

Similar results were reported by Dajczman et al. They found that only one out of 81 elderly patients was enrolled in a clinical trials

Conclusions

A number of changes as a consequence to the ageing process can be clinically observed in patients with lung cancer but their overall impact on different clinical outcomes of the patients seems to be rather small. A similar observation can be made for comorbidities, which are occurring more frequently at higher ages. All these parameters should be recorded carefully for our patients. We definitely need more data to give reliable answers to the different issues arising as a consequence to the

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