Many patients aged 90 years or older who have non–small cell lung cancer (NSCLC) are not offered any treatment at all, even though treatment improves survival odds substantially, especially surgery for earlier-stage disease, say researchers reporting a nationwide retrospective analysis.

"It is unclear why patients are not receiving therapy, but we speculate that ageism may be a factor," lead author Chi-Fu Jeffrey Yang, MD, Stanford University Medical Center, California, said in a statement.

"But our study suggests that elderly patients with lung cancer who receive curative-intent, standard-of-care treatment in a multidisciplinary setting can have better outcomes than what you might have initially expected," he added.

"Surgery in carefully selected patients may not only be reasonable but also an optimal therapy," Yang emphasized.

The study was published online November 19 in the Annals of Thoracic Surgery.

"Treatment should not be withheld from these 'oldest old' patients based on their age alone," the investigators conclude.

Reinforcing this sentiment, Brendon Stiles, MD, Weill Cornell Medicine, New York City, who was not directly involved with the study, said many patients who are 90 years or older can easily tolerate treatment for lung cancer without a significant decrease in their physical or mental quality of life.

"Obviously the authors aren't suggesting that we operate on every nonagenarian, but in that same light, we shouldn't refuse every nonagenarian a chance at curative therapy," Stiles said in a statement.

Analysis of More than 7000 Patients

The team analyzed data from the National Cancer Data Base from 2004 to 2014 to determine how treatment might benefit patients aged 90 years or older who have NSCLC.

From the database, the investigators identified 7205 patients who were 90 years of age or older and who had been diagnosed with NSCLC.

Approximately 20% of the group had stage I NSCLC; 7.6% had stage II disease; about 21% had stage III disease; and 52% had stage IV disease.

More than half (57.6%) of all these patients did not receive any therapy, Yang and colleagues report.

Approximately one quarter received radiotherapy alone; some 4% were treated with chemoradiotherapy; and about 5% received stereotactic body radiotherapy (SBRT).

Only 3.7% were treated surgically; some 6% were treated with chemotherapy.

Five-Year Survival Rates

"The overall 5-year survival of the entire cohort was 4.9%," the investigators report.

However, 9.3% of patients who received some form of therapy were alive at 5 years, compared to 1.7% of those who received no treatment, they note.

For those with stage I disease, 15.7% were still alive at 5 years, as were 6.4% with stage II disease.

For those with stage III or IV disease, 5-year survival rates were 2.9% and 1.2%, respectively.

The most noticeable improvement in survival was seen for patients with stage I NSCLC.

In this group of patients, median survival was 63% better among those who received curative-intent treatment compared with patients who received no treatment, the investigators indicate.

Indeed, for patients who underwent curative-intent treatment — whether it was surgery or any type of radiotherapy — survival was about 17 months longer than it was for those who received no treatment at all.

No Treatment at All

A third of patients with stage I disease received no treatment at all, despite the fact that as a group, many patients with stage I disease were relatively healthy and had a low Charlson comorbidity index score, the authors point out.

For stage II patients, the survival benefit was associated with a 68% improvement in survival among those who received curative-intent therapy compared with those who received no treatment (P < .001).

For those with stage III disease, curative-intent treatment was associated with a 45% improvement in survival compared with no treatment (P = .002), as was palliative-intent treatment, which was associated with a 41% improvement in survival compared with no treatment (P < .001).

Even among patients with stage IV disease, treatment improved survival odds by 40% compared with no treatment (P < .001), the investigators note.

Table. Median Survival for the Oldest Old NSCLC Patients

Stage I Stage II Stage III Stage IV No treatment 10 months 4.5 months 2.3 months 1.5 months Palliative-intent Tx 16.6 months 9.5 months 7.7 months NA Curative-intent Tx 27.4 months 12.8 months 11.6 months 4.4 months

Best Outcomes

Perhaps not surprisingly, the best outcomes were for stage I patients whose lung cancer was amenable to surgery.

In this group of patients, 33.7% were alive at 5 years, compared to 17.1% of patients whose cancer was not amenable to surgery and 6.2% of stage I patients who were not treated.

Compared to SBRT, surgery was significantly associated with a 33% improvement in survival (P = .05), the study authors point out.

"More research needs to be done, but preliminarily, our study suggests that people in their 90s with early-stage lung cancer who undergo surgery live longer than patients who are healthy enough to undergo surgery but do not," Yang pointed out.

Should Be the Patient's Choice

Asked by Medscape Medical News for his thoughts on the study, Arthur Caplan, PhD, director, Division of Medical Ethics, New York University Langone Medical Center, New York City, noted that some of these patients may not want to be treated, but that should be their choice, not that of the healthcare provider.

"Treatment or surgery is not something that we should expect these patients to do, but we should be making an informed choice and not presume that patients don't want to be treated," Caplan observed. "There will be some healthy 90-year-olds with early-stage lung cancer who might say yes [to treatment]," he added.

He also suggested that with new approaches to treatment for lung cancer, such as immunotherapy, "it's important to keep in mind that therapies that are more drug based and not like radiation or chemotherapy are emerging and that we should not make any blind assumptions about treatment based solely on age," he said.

"Ninety may not be the new 60, but being 90 should not exclude you completely from consideration for treatment," Caplan emphasized.

Yang has disclosed no relevant financial relationships. A coauthor has a financial relationship with Scanlan International. Caplan has served as a director, officer, partner, employee, advisor, consultant, or trustee for Johnson & Johnson's panel for compassionate drug use and as a contributing author and advisor for Medscape.

Ann Thorac Surg. Published online November 19, 2019. Abstract

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