Elderly patients with lung cancer: does clinical practice reflect evidence-based medicine? our four-year experience (2013-2016)

Abstract

Background: Treatment for elderly patients (EP) with advanced non-small cell lung cancer (NSCLC) comprises single agent of doublet chemotherapy (CT) or tyrosine kinase inhibitors (TKI) for those harboring mutations of the epidermal growth factor receptor or translocation of anaplastic lymphoma kinase (ALK). Clinical studies show that EP(>70) physically fit to receive CT obtain from platinum-based CT similar benefits than younger patients, but with a higher risk of treatment-related toxicities; overall survival (OS) advantage with doublet CT is controversial: a meta-analysis shows an OS benefit with platinum-based doublets (Des Guetz, 2012), while other data show that OS was not significantly improved by platinum-based therapy (Qi, 2012). Single agent (SA) gemcitabine, vinorelbine, taxane are used in fragile or vulnerable patients. Material and methods, results: We registered in our experience a steady increase in NSCLC cases in EP, who accounted for 47% of all NSCLC cases in 2013, 53% in 2014, 50% in 2015, 54% in 2016. We observed an increase in the percentage of EP diagnosed with advanced stage NSCLC (stage IIIB-IV): 45% of cases in 2013, 48% in 2014, 51% in 2015 and 62% in 2016. Patients' status have been evaluated traditionally only according to the ECOG Performance Status scale, while recently patients have been evaluated more frequently using also the G8 and CGA tool (from only 20% of patients in 2013 to 47% in 2016). The use of G8/CGA evaluation allows oncologists to offer to EP a tailored therapeutic choice, with better results in term of quality of life. Upfront doublet or single agent chemotherapy have been used in 50% and 10% of EP, respectively. SA chemotherapy has been used as second-line treatment in 21% of EP in 2013, with a steady increase up to 60% in 2016. Second-line targeted therapy with TKI, when appropriate, has been given in a progressively higher proportion of NSCLC EP, rising from 3% of patients in 2013 to 11% in 2016. As for the overall NSCLC population, EP benefited from immunotherapy with nivolumab, with 60% of EP receiving the treatment in 2016. Conclusion(s): Our experience confirms the therapeutic evidence reported in medical literature for advanced-stage NSCLC EP, an ever growing population. A better evaluation of such patients with appropriate tools (G8/CGA) will translate in safer and more effective treatments, better preservation of quality of life and reduced financial toxicity, both for patients and their caregivers.