Two clinical studies highlight the importance of evaluating overall health instead of age in the management of lung cancer. In fact, younger patients with non-small cell lung cancer (NSCLC) are more likely to receive treatment than older patients, regardless of overall health and prognosis according to the results of a study published in the Journal of Clinical Oncology.
About Lung Cancer
Lung cancer is the most common cancer in the world and is the leading cause of cancer death, with 160,000 deaths in the U.S. annually. While there are more than a dozen different kinds of lung cancer there are two main types; non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), which together account for over 90% of all lung cancers. Malignant mesothelioma is a rare cancer that develops in the tissues that comprise the lining of the lung. Non-small cell lung cancer accounts for approximately 75% of these cancers and consists of squamous cell, adenocarcinoma and large cell types. Small cell lung cancer represents 20-25% of all lung cancers and is also referred to as “oat cell cancer”
Many individuals with NSCLC are over the age of 65, but there is limited information about how best to treat older patients coupled with concern that older patients will not be able to tolerate aggressive treatment. As a result, older patients sometimes do not receive treatment that might be of benefit; for example, older patients may be treated with single-agent chemotherapy rather than the combination chemotherapy that is commonly used in younger patients.
Previous research has indicated that older patients with NSCLC who are otherwise healthy can benefit from treatment, while those with comorbidities—or other severe illnesses—are more vulnerable to the toxicity of cancer treatments and therefore less likely to tolerate and complete a course of treatment.
To examine the effects of comorbidity and age on treatment outcomes, researchers used data from the Veterans Affairs (VA) Central Cancer Registry to analyze treatment and outcomes from more than 20,000 veterans over age 65 with NSCLC. They found that regardless of stage of cancer, treatment rates decreased more in association with older age than with comorbidity.
Younger patients—those between the ages of 65 to 74—were more likely to receive treatment, regardless of comorbidity status. In other words, those who were severely ill—and thus less likely to benefit and more likely to be harmed—received treatment at approximately the same rate as patients in the same age range who were not severely ill. In contrast, older patients—those between the ages of 75 and 84—were less likely to receive treatment, even if they had no comorbidities and a better prognosis.
The researchers concluded that physicians appear to base treatment strictly on age, while overlooking other factors. A patient’s overall state of health is an important factor when determining treatment. An otherwise healthy 75-year-old may tolerate treatment well, whereas a severely ill 65-year-old may not. In short, treatment decisions must be individualized rather than based strictly on age in order to target NSCLC treatment to older patients who may benefit.
Chemotherapy for Older Patients: What You Should Know About the Risk of Infection
Although patients with lung cancer are increasingly treated with precision cancer medicines, many patients still receive chemotherapy alone or in combination with these newer targeted therapies. Chemotherapy works by attacking the rapidly dividing cells it finds in the body, particularly cancer cells because they multiply quickly. However, chemotherapy can’t differentiate between cancer cells and other rapidly dividing healthy cells, such as bone marrow cells. As a consequence, many chemotherapy patients, especially older patients, experience a drop in the levels of their blood cells, including their infection-fighting white blood cells.2,4,5 This may lead to the patient’s chemotherapy being stopped or reduced until the white blood cell count recovers enough to resume treatment, which can give cancer cells a chance to grow. A low white blood cell count, a condition called neutropenia, may also increase a patient’s risk of infection, which can lead to delays in treatment, or hospitalization.1,5-7
Chemotherapy-related infections may:
- Delay chemotherapy treatment
- Require changing the patient’s chemotherapy dose
- Require hospitalization, most commonly in the first and second chemotherapy cycles5,7
Older patients, due to normal body changes, are at greater risk than younger patients for a low white blood cell count and its complications.1,4 For example, the risk of infection is measurably greater in patients receiving chemotherapy with non-Hodgkin’s lymphoma aged 65 and older than in younger patients. Not only are these complications more common in older patients, but when older patients are hospitalized to treat an infection, they tend to have longer hospital stays than younger patients.1,4,6
To help minimize the risk of such complications, older patients are more likely than younger patients to be given reduced doses of chemotherapy. However, studies indicate that full-dose, on-schedule treatments may improve outcomes, especially in the case of potentially curable tumors. This is important to know because older patients with cancer can respond as well to treatment as younger patients if they are given similar levels of chemotherapy.1,3
Fortunately, there are drugs called white blood cell boosters that can stimulate white blood cell production and help protect against infection caused by strong chemotherapy, and may help allow full-dose chemotherapy on schedule.1,4,6-9
- Wang S, Wong ML, Hamilton N, et al: Impact of age and comorbidity on non-small-cell lung cancer treatment in older veterans. Journal of Clinical Oncology. 2012; 30(13): 1447-1455.
- Repetto L. Greater risks of chemotherapy toxicity in elderly patients with cancer. J Supportive Oncol. 2003;1(2):18-24.
- Chemotherapy and you: A Guide to self-help during cancer treatment: Understanding chemotherapy. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/chemot herapy-and-you/page2. Accessed December 8, 2004.
- Older patients with colon cancer benefit from chemotherapy. National Cancer Institute Web site. Available at: http://www.cancer.gov/clinicaltrials/results/older-patients-and-chemo1001. Accessed December 8, 2004.
- Osby E, Hagberg H, Kvaloy S, et al. CHOP is superior to CNOP in elderly patients with aggressive lymphoma while outcome is unaffected by Filgrastim treatment: results of a Nordic Lymphoma Group randomized trial. Blood. 2003 May 15;101(10):3840-8.
- Lyman GH, Delgado DJ. Risk and timing of hospitalization for febrile neutropenia in patients receiving CHOP, CHOP-R, or CNOP chemotherapy for intermediate-grade non-Hodgkin lymphoma. Cancer. 2003 Dec 1;98(11):2402-9.
- Rivera E, Erder MH, Fridman M, Frye D, Hortobagyi GN. First-cycle absolute neutrophil count can be used to improve chemotherapy-dose delivery and reduce the risk of febrile neutropenia in patients receiving adjuvant therapy: a validation study. Breast Cancer Res. 2003;5(5):R114-R120.
- Lyman GH, Morrison VA, Dale DC, Crawford J, Delgado DJ, Fridman M; OPPS Working Group; ANC Study Group. Risk of febrile neutropenia among patients with intermediate-grade non-Hodgkin’s lymphoma receiving CHOP chemotherapy. Leuk Lymphoma. 2003 Dec;44(12):2069-76.
- Neulasta® (pegfilgrastim) prescribing information, Amgen.