LUNG CANCER TREATMENT DECISIONS SHOULD BE BASED ON COMORBIDITIES AND NOT AGE

May 9, 2012 — Clinicians continue to focus more on age than on comorbidity when deciding whether to pursue treatment for elderly lung cancer patients, new research hints.

In a study of more than 20,000 patients 65 years and older with newly diagnosed nonsmall-cell lung cancer (NSCLC), researchers found that younger patients were more likely to receive treatment than older patients, regardless of overall health and prognosis.

Treatment rates decreased more in association with advancing age than in association with worsening comorbid illness, say the authors, led by Sunny Wang, MD, from the San Francisco VA Medical Center and the University of California, San Francisco.

The study was published in the May 1 issue of the Journal of Clinical Oncology.

"It's clear that as human beings and physicians, we fixate on age in deciding whether to pursue cancer treatments, including lung cancer treatments. Instead, we should be looking at our patients' overall state of health," Dr. Wang explained in a press statement.

Suresh S. Ramalingam, MD, director of medical oncology at the Winship Cancer Institute of Emory University in Atlanta, Georgia, who was not involved in the study, told Medscape Medical News that "this issue relates to physician (and perhaps patient) perception of age as a more relevant issue than comorbid illness when it comes to making decisions for lung cancer patients — despite the available evidence to the contrary."

Guideline-Recommended Treatment

In their analysis, the authors used the current National Comprehensive Cancer Network guidelines, which advise consideration of comorbidity when recommending cancer treatment to older patients.

Dr. Wang's team analyzed receipt of guideline-recommended cancer treatment among 20,511 veterans, 65 years and older, diagnosed with NSCLC from 2003 to 2008. They stratified patients by age, Charlson Comorbidity Index score, and American Joint Committee on Cancer stage.

The researchers say guideline-recommended treatment was received by 51% of patients with local disease (3549 of 6986), 35% with regional disease (1599 of 4635), and 28% with metastatic disease (2464 of 8890).

"Age was the strongest predictor of receipt of guideline-recommended treatment, regardless of stage," they report. The percentage of patients with local disease who had surgery fell from 61% for those 65 to 74 years of age, to 44% for those 75 to 84 years of age, to 18% for those 85 years and older (P < .001).

In metastatic disease, rates of chemotherapy declined from 34% for patients 65 to 74 years of age, to 23% for patients 75 to 84 years of age, to 10% for those older than 85 years (P < .001).

In contrast, worsening comorbidity was associated with only a small decrease in the rate of guideline-recommended treatment for all stages.

In patients with local disease, the rate of surgery ranged from 59% for patients with no comorbidity to 46% for patients with severe comorbidity (P < .001). In metastatic disease, patients with no comorbidity had chemotherapy rates of 30%, compared with 23% for those with severe comorbidity (P < .001).

For all stages, treatment rates decreased more with advancing age than with worsening comorbidity, "such that older patients with no comorbidity had lower rates than younger patients with severe comorbidity," they note. For example, 50% of patients with local disease 75 to 84 years of age with no comorbidity had surgery, compared with 57% of patients 65 to 74 years of age with severe comorbidity (P < .001).

On multivariate analysis, age and histology "remained strong negative predictors of treatment for all stages, whereas comorbidity and nonclinical factors had a minor effect," the authors report.

They note that the last decade has brought an "influx" of both retrospective and prospective data in support of providing NSCLC treatment to "fit elders." However, despite data showing survival benefit and acceptable toxicity, treatment rates in the elderly have not increased much in the past 10 years, they point out.

"The message here," Dr. Wang said in a statement, "is don't base cancer treatment strictly on age. Don't write off an otherwise healthy 75 year old, and don't automatically decide to treat a really ill 65 year old without carefully assessing the risks and benefits for that patient."

Dr. Wang and her colleagues are now doing a follow-up study looking at survival outcomes in the same cohort of patients.

This study was supported by funds from the Department of Veterans Affairs, University of California, San Francisco; the National Cancer Institute; and the National Institutes of Health. Some of the funds were administered by the Northern California Institute for Research and Education. Dr. Wang reports receiving research funding from Eli Lilly, Genentech/OSI Pharmaceuticals, ImClone Systems, Morphotek, and Pfizer. A complete list of author disclosures is provided in the paper. Dr. Ramalingam has disclosed no relevant financial relationships.

J Clin Oncol. 2012;30:1447-1455. Abstract