[Management and outcome of French elderly patients with lung cancer: an IFCT survey]

Risk factors for early mortality of lung cancer patients in France: A nationwide analysis

BACKGROUND

Despite therapeutic advances, lung cancer remains the first cause of death from cancer. The main objective of this study was to identify risk factors associated with death within 3-months of the first hospitalization for lung cancer in France.

METHODS

This analysis included patients with a first hospitalization for lung cancer (between January 1, 2016 and December 31, 2018) according to diagnosis-related groups entered into the French national medical-administrative database. Clinical and socioeconomic parameters and characteristics of that first hospitalization were analyzed. A model predictive of early mortality was developed based on those variables.

RESULTS

The 144,087 included patients were 67% men; median age of 68 [interquartile range 60-76] years; 47% had metastatic disease at diagnosis; and 34% and 23%, respectively, had received systemic treatment or undergone curative surgery. The 3-month mortality was 19%, and significantly higher for those ≥70 versus <70 years old (OR 1.33, 1.22-1.45), men versus. women (OR 1.50, 1.44-1.55), those with metastatic disease at diagnosis (OR, 3.30, 3.18-3.43), first hospitalization via the emergency room (OR 1.65 1.59-1.71) and first hospitalization lasting >30 days (OR, 1.58 1.49-1.68). In contrast, no socioeconomic characteristic was associated with early mortality.

CONCLUSION

Almost 1 in 5 patients diagnosed with lung cancer in France died within 3 months post-diagnosis. Improving survival requires diagnosis at an earlier stage and better organization of diagnosis and specific care pathways.

Factors associated with early lung cancer mortality: a systematic review

Introduction: Despite recent therapeutic advances, lung cancer remains the primary cause of cancer deaths worldwide, and early lung mortality was poorly studied.Area covered: Early lung-cancer mortality reflects local therapy (surgery or radiotherapy) impact (localized forms), and metastatic disease evolution, comorbidities and healthcare-system accessibility. The definition of early lung cancer mortality is not consensual; thresholds range from 1 to 12 months post-diagnosis. This systematic review was undertaken to identify and analyze factors significantly associated with early lung cancer mortality. Age, male sex, non-adenocarcinoma histology, advanced stage at diagnosis and ECOG performance status are the main clinical factors of early lung cancer mortality. Active/ex-smoking also seems to favor early mortality, despite heterogeneous definitions of smoker status. For radio-chemotherapy treated locally advance disease, the early mortality rate increases according to tumor volume. Less well studied, socioeconomic characteristics (rurality and social deprivation index) yielded contradictory results, partially because definitions vary over studies. However, early lung cancer mortality is significantly higher for lower socioeconomic class patients.Expert opinion: Prospective, observational, general population studies are needed to better evaluate early lung-cancer mortality. International consensus concerning the patient-, disease- or healthcare system-linked factors of interest to be collected would facilitate comparisons among countries.

Lung cancer in never smokers: The role of different risk factors other than tobacco smoking

Lung cancer (LC), the leading cause of cancer-related deaths worldwide, is a complex and highly heterogeneous disease. Additional to its biological complexity, LC patients are often confronted with a high degree of stigma, mostly from the association of the disease with tobacco. Nonetheless, a proportion of LC patients are never-smokers, a population which we are beginning to comprehensively explore. Several risk factors have been linked to LC in never-smokers. Studies have consistently shown that radon exposure and domestic fuel smoke increase LC risk. Additionally, infections such as Mycobacterium tuberculosis, and Human Papilloma Virus are also risk factors. Other less conclusive associations include inflammatory diseases such as asthma and sarcoidosis. Moreover, we are now aware that molecular characteristics of LC vary widely according to smoking history, with important therapeutic implications. This review comprehensively assesses the current knowledge in terms of risk factors and disease characteristics in the never-smoker lung cancer population.

Osimertinib in Elderly Patients with Epidermal Growth Factor Receptor T790M-Positive Non-Small-Cell Lung Cancer Who Progressed During Prior Treatment: A Phase II Trial

LESSONS LEARNED

Non-small-cell lung cancer (NSCLC) represents 85% of lung cancer in elderly patients.In the present study performed in the 36 elderly subjects with epidermal growth factor receptor (EGFR) T790M mutation-positive NSCLC, osimertinib 80 mg demonstrated statistically significant improvement in the objective response rate, which was comparable to those in the nonelderly population.Osimertinib appears to be an effective and safe treatment option in elderly patients with advanced NSCLC with EGFR mutation; further research in larger scale is warranted.

BACKGROUND

Previous findings suggest the possibility of relatively safe use of osimertinib for patients with T790M-positive non-small-cell lung cancer (NSCLC), with few serious adverse events for the elderly in comparison with conventional endothelial growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs), and with an antitumor effect.

METHODS

This phase II study was performed to prospectively investigate the efficacy and safety of osimertinib for elderly patients aged ≥75 years with ineffective prior EGFR TKI treatment or with recurrence in T790M EGFR TKI resistance mutation-positive NSCLC.

RESULTS

A total of 36 patients were included in the analyses. Among the 36 subjects, 63.9% were female, with mean age of 79.9 years. The objective response rate (ORR) was 58.3% (95% confidence interval [CI], 42.2%-72.9%), demonstrating statistically significant efficacy of osimertinib (p = .0017). The median duration of response (DOR) was 27.9 weeks (95% CI, 21.1-82.0). Complete response (CR) and partial response (PR) were 2.8% and 55.6%, respectively. Disease control rate (DCR) was 97.2%. A waterfall plot revealed that 33 (91.6%) subjects exhibited tumor shrinkage during treatment, including 12 of 14 subjects who had stable disease (SD). All adverse events were not reason for discontinuation of the study drug.

CONCLUSION

Osimertinib may be an effective and safe treatment option in elderly patients with advanced NSCLC with EGFR mutation.

Comorbidities in the management of patients with lung cancer

Lung cancer represents a major public health issue worldwide. Unfortunately, more than half of them are diagnosed at an advanced stage. Moreover, even if diagnosed early, diagnosis procedures and treatment can be difficult due to the frequent comorbidities observed in these patients. Some of these comorbidities have a common major risk factor, i.e. smoking, whereas others are unrelated to smoking but frequently observed in the general population. These comorbidities must be carefully assessed before any diagnostic and/or therapeutic decisions are made regarding the lung cancer. For example, in a patient with severe emphysema or with diffuse lung fibrosis, transthoracic needle biopsy can be contraindicated, meaning that in some instances a precise diagnosis cannot be obtained; in a patient with chronic obstructive pulmonary disease, surgery may be impossible or should be preceded by intensive rehabilitation; patients with interstitial lung disease are at risk of radiation pneumonitis and should not receive drugs which can worsen the respiratory insufficiency. Patients who belong to what are called "special populations", e.g. elderly or HIV infected, should be treated specifically, especially regarding systemic treatment. Last but not least, psychosocial factors are of great importance and can vary from one country to another according to health insurance coverage.

Epidemiology of Lung Cancer in Korea: Recent Trends

Lung cancer causes the most cancer deaths in Korea. Although the smoking rate has begun to decrease, the prevalence of lung cancer is still increasing. We reviewed the national lung cancer registry data and the data published about lung cancer in Korea. In 2012, the crude incidence rate of lung cancer was 43.9 per 100,000. The age-standardized mortality rate of lung cancer was 19.8 per 100,000. The 5-year relative survival rate for lung cancer was 11.3% from 1993 to 1995 and increased to 21.9% in the period from 2008 to 2012. Lung cancer occurring in never-smokers was estimated to increase in Korea. Adenocarcinoma is steadily increasing in both women and men and has replaced squamous cell carcinoma as the most common type of lung cancer in Korea. In patients with adenocarcinoma, the frequency of EGFR mutations was 43% (range, 20%–56%), while that of the EMK4-ALK gene was less than 5%.

Chemotherapy Treatment of Elderly Patients (≥70 Years) with Non-Small Cell Lung Cancer: A Seven-Year Retrospective Study of Real-Life Clinical Practice at Karolinska University Hospital, Sweden

An increasing proportion of cancer patients are aged >65 years and many are aged >70 years. Treatment of the elderly with lung cancer has, therefore, become an important issue; so we performed a retrospective study of our patients to demonstrate how elderly patients with NSCLC are treated in real-life, clinical practice. All patients aged ≥70 years with NSCLC at our department were reviewed retrospectively. In total, 1059 patients (50.8% of all NSCLC patients). Of these patients, 243 (22.9%) received chemotherapy, 164 (70.4%) of whom were treated with a platinum doublet using carboplatin. Second- and third-line chemotherapy were given to 31.4% and 13.9% of patients, respectively. Median overall survival was 289 and 320 days for male and female patients, respectively. Patients with performance status (PS) 0 experienced significantly better survival than patients with PS1 or PS 2: 410, 314, and 204 days, respectively. Age was of less importance, with patients aged 70-79 years versus those aged ≥80 years. Treatment of elderly NSCLC patients with chemotherapy is feasible if they have a good PS and appears to prolong survival. In this study, we found no significant differences in survival either between age groups or genders.

Modern Treatments in Advanced Non-Small-Cell Lung Cancer: Temporal Trends and Effect on Survival. A French Population-Based Study

Extrapolation of clinical trials results to the general population is always challenging. We analysed 1047 patients diagnosed with an advanced stage disease between 1998 and 2005 in a french administrative department and found a good spread of modern chemotherapy since 1998 and targeted therapy since 2002. Moreover, the outcomes in patients treated according to guidelines are very proximal from those obtained in clinical trials.

BACKGROUND

Management of metastatic non-small-cell lung cancer has considerably evolved during the past 2 decades. In this study we aimed to assess how treatments have spread at a population-based level and their effect on survival.

PATIENTS AND METHODS

Medical records of patients diagnosed from 1998 to 2005 in the French department of Bas-Rhin were checked to collect data on patient characteristics and treatments received. Multivariate analysis of survival was performed using pretherapeutic and therapeutic factors including targeted therapies received as third-line treatment.

RESULTS

We included 1047 patients with stage IIIB to IV non-small-cell lung cancer. The proportion of patients who underwent chemotherapy increased from 373/471 (79.2%) to 491/576 (85.2%) over the 1998 to 2001 and 2002 to 2005 periods, and there was an increased use of third-generation drugs associated with platin. Third-line treatment was gefitinib or erlotinib in 73/155 (47.1%) of the cases among patients diagnosed from 2002 to 2005. Compared with older agents, targeted therapy administered as third-line treatment was associated with a longer survival but there was no significant difference in survival with recent chemotherapy agents in multivariate analyses (hazard ratio, 0.773; 95% confidence interval, 0.445-1.343).

CONCLUSION

Results of our study showed a good spread of modern chemotherapy and targeted therapy use at a population-based level. However, even if the general outcomes were improved along the years, the results observed in real clinical practice were slightly different from those reported in clinical trials.

Management of elderly patients

SUMMARY

Elderly patients are often excluded from clinical trials, yet more than two-thirds of patients diagnosed with lung cancer are over 65 years old. It is therefore important to develop specific tools and trials for this specific patient population.

METHODS

This chapter first examines the management specificities of elderly patients. Randomized trials specifically involving elderly patients are then described, and likely future developments are considered.

RESULTS

Older people have several specificities. In addition to traditional criteria such as age and performance status, other important factors include the number of comorbidities and age-related changes such as cognitive deficits and depression. Specific indices taking these factors into account have been published and validated. Single-agent therapy has been widely used to treat metastatic lung cancer in the elderly, following publication of negative results from randomized phase III trials of combination chemotherapy. Recently, however, a trial of doublet therapy gave positive results, in a subgroup of independent older patients. The benefit of patient selection based on a combination of these indices has been demonstrated in open-label and randomized trials. These results must now be confirmed in phase III trials including the use of tyrosine kinase inhibitors combined with chemotherapy.

CONCLUSIONS

Indices based on a combination of age-related factors, together with judicious use of biological markers, will further improve the prognosis of elderly lung cancer patients.

[Lung cancer in the elderly: what about surgery?]

Geriatric oncology is a rapidly expanding domain because of the deep epidemiological changes of the last decades related to the ageing of the population. Lung cancer treatment in patients 75 years and over is a major issue of thoracic oncology. Curative surgery remains the treatment offering the best survival rates to the patient whatever his age. The important variability observed within the elderly forces us to take into account their specificities, in particular for ageing physiology and associated comorbidities. Thus, preoperative workup permitting to assess the resectability of the tumor but also the operability of the patient is all the more essential in the advanced age that it must be adapted to the particular characteristics of the elderly. Thanks to recent data of the literature, morbidity and mortality associated to surgical treatment are now better characterized and considered as acceptable in accordance with long-term survival. Clinical investigation remains essential to acquire a better knowledge of potential benefit of multimodal treatments in the elderly, for which very few data are available.

Platinum doublets as first-line treatment for elderly patients with advanced non-small cell lung cancer

Aims and background

More than 50% of patients with advanced non-small cell lung cancer are diagnosed in the elderly. Few prospective clinical data with cisplatin-based chemotherapy are available, and some authors have suggested that a non-platinum single agent should be the preferred form of cure in these patients. The aim of the study was to evaluate the efficacy and safety of first-line chemotherapy based on platinums (carboplatin or cisplatin) plus a third generation compound (vinorelbine or gemcitabine) in elderly patients with advanced non-small cell lung cancer in daily clinical practice.

Methods

A retrospective analysis of consecutive elderly (≥70 years of age) patients with advanced non-small cell lung cancer treated at our Medical Oncology Unit from February 2005 to September 2011 was performed.

Results

A total of 249 cycles of chemotherapy was administered to 62 patients (median age, 72 years; range, 70–81) presenting a median Charlson comorbidity index of 1 and a good ECOG PS (0–1, 52 patients; 2, 10 patients). The median number of cycles/patient was 4, and all 62 patients received a platinum-based doublet as first-line chemotherapy: 57 with carboplatin (92%) and 5 with cisplatin (8%). As best response to the treatment, 19 (31%) partial responses and 20 (32%) stable diseases were observed. Median overall survival was 9.8 months. Toxicity was mild; grade III-IV neutropenia was the most frequently observed side effect in 19 administered cycles (8%).

Conclusions

Advanced non-small cell lung cancer in elderly patients can be safely treated with a platinum-based doublet. Observed toxicity is manageable, and overall survival is in keeping with data from the literature.

Carboplatin-containing regimens as front-line treatment for advanced non-small-cell lung cancer in two groups of elderly

OBJECTIVES

We evaluated the impact of a carboplatin-based doublet in two groups of elderly patients with advanced non-small cell lung cancers (NSCLC).

MATERIALS AND METHODS

A retrospective analysis of all consecutive elderly patients (≧70 year old) with advanced NSCLC who received a carboplatin-based doublet as front-line therapy at our medical oncology unit was performed.

RESULTS

In the study, 57 consecutive elderly patients with advanced NSCLC were included. Carboplatin was combined with vinorelbine in 41 patients (71·9%) and with gemcitabine in 16 patients (28·1%). Overall, a total of 227 cycles were administered to 57 patients - 142 cycles were administered to patients in group 1 and 85 cycles were given to patients in group 2 - median number of administered cycles per patient was 4 (range 1-6). Of the patients, 35 (62%, group 1) were 'young-old' (70-74-year old) and 20 (38%, group 2) were 'old-old' (75-82-year old). Toxicity was mild in both subgroups (grade 3-4 neutropenia in 17·1% of group 1 and in 9·1% of group 2). At the univariate analysis, the median overall survival (OS) was 10·07 months (P = 0·789, 95% CI: 8·49-11·64), 10·1 months in group 1 and 9·8 months in group 2.

CONCLUSIONS

This evaluation shows the safety and efficacy of a carboplatin-based doublet given as first-line chemotherapy in elderly advanced NSCLC patients. The combination with vinorelbine or gemcitabine is associated with a very good toxicity profile that does not seem to have a detrimental effect on efficacy.

Therapeutic options in older patients with metastatic non-small cell lung cancer

The increase in life expectancy, with its concomitant increase in the risk of cancer, has led to an increased incidence of lung cancer in older people. The median age at diagnosis of lung cancer is between 63 and 70 years. For a long time, there has been a pessimistic attitude by doctors, patients and their relatives and thus an undertreatment of older patients. Older patients have some specific differences compared with younger patients: more comorbidities with concomitant medications that may interfere with chemotherapy, geriatric syndromes, frailty and so on. The first trial devoted to older patients with advanced non-small cell lung cancer (NSCLC) was a comparison between vinorelbine and best supportive care. There was a significant benefit of survival in the chemotherapy arm. Doublet therapy with gemcitabine plus vinorelbine did not give better results than either of these drugs alone. Thus, the recommendations for the treatment of older patients with advanced NSCLC were to give monotherapy. In some clinical trials not dedicated to older patients it appeared that patients might benefit from platinum-based doublet therapy like their younger counterparts. A randomized trial conducted by the French intergroup, IFCT, in patients aged at least 70 years comparing vinorelbine or gemcitabine alone with monthly carboplatin combined with weekly paclitaxel demonstrated that there was a highly significant benefit of survival in the doublet arm. This study resulted in a modification of the recommendations on the treatment of older patients with advanced NSCLC.

Optimal pharmacotherapeutic strategies for elderly patients with advanced non-small cell lung cancer

Increases in both life expectancy and cancer incidence with age result in a significant rise in lung cancer rates among elderly patients, with a median age at diagnosis of between 63 and 70 years. However, elderly patients are under-represented in clinical trials and generally receive suboptimal treatment, mainly because of fears about increased toxicity of chemotherapy. Indeed, physiological modification of renal and haematopoietic functions with age together with co-morbidity and associated polypharmacy may alter the metabolism of chemotherapy drugs, resulting in greater toxicity. Moreover, performance status (PS), the main prognostic factor in younger patients, does not correlate well with geriatric indexes such as activities of daily living, cognition and physical performance, and comprehensive geriatric assessment is important in elderly patients. Until 2010, based on the small number of clinical trials designed for elderly patients, monotherapy was the recommended treatment for those with advanced non-small cell lung cancer (NSCLC), whereas for fit younger patients, a platinum-based doublet was and continues to be the recommended first-line therapy. However, at the plenary session of the 2010 Annual Meeting of the American Society of Clinical Oncology, results were presented from a randomized controlled trial conducted by the French Intergroup of Thoracic Oncology that demonstrated that in PS 0-2 patients aged≥70 years with advanced NSCLC, monthly carboplatin with weekly paclitaxel resulted in significantly longer survival than single-agent therapy (vinorelbine or gemcitabine). It should be noted that even in a priori unfavourable prognostic subgroups (patients with a PS score of 2, those aged>80 years or those with an activities of daily living scale score of <6), doublet therapy was associated with a survival advantage over monotherapy. Thus, the new paradigm of treatment of elderly patients with advanced NSCLC and a PS score of 0-2 should now be monthly carboplatin with weekly paclitaxel. While there have been no trials of second-line therapy for NSCLC specifically in elderly patients, exploratory subgroup analyses indicate that docetaxel, pemetrexed and erlotinib may provide outcomes in elderly patients similar to those reported in younger patients. However, specific second-line therapy trials in elderly patients are required as the elderly patients in trials conducted to date were probably highly selected to fit the inclusion criteria. There is no more room for nihilism in the treatment of elderly patients with advanced NSCLC. Such patients should be evaluated carefully by geriatric indexes and, if they have a PS score of 0-2, may be treated with platinum-based (mostly carboplatin) doublet therapy in the same manner as their younger counterparts. The optimal second line treatment remains to be determined.

Lung cancer in never smokers--a review

An estimated 10-25% of lung cancers worldwide occur in never smokers, i.e. individuals having smoked less than 100 cigarettes in their lifetime. Lung cancer in never smokers (LCINS) is more frequent in women, although large geographic variations are found. Histologically, adenocarcinomas predominate. The mere existence of LCINS suggests that risk factors other than smoking must be present. Exposure to environmental tobacco smoke (particularly in women) and exposure to workplace carcinogens (particularly in men) are the two most important alternative risk factors. However, a history of either is absent in more than a third of LCINS. The large proportion of women in LCINS suggest a hormonal element that may interact with other identified factors such as hereditary risks, a history of respiratory infections or disease, exposure to air pollution, cooking and heating fumes, or exposure to ionising radiation. The study of genomic polymorphisms finds constitutive DNA variations across subjects according to their smoking status, particularly in genes coding for enzymes that participate in the metabolism of certain carcinogens, in those coding for DNA repair enzymes, or in genes associated with tobacco addiction, or inflammatory processes. The type of molecular mutation in p53 or KRAS varies with smoking status. EGFR mutations are more frequent in never smokers, as are EML4-ALK fusions. The mutually exclusive nature of certain mutations is a strong argument in favour of separate genetic paths to cancer for ever smokers and never smokers. In the present paper we review current clinical and molecular aspects of LCINS.

Chemotherapy in elderly patients with advanced non-small cell lung cancer

Because of increasing life expectancy and of higher risk of cancer with ageing, lung cancer in elderly is a frequent disease. For a long time nihilism influenced treatment decisions in elderly patients with advanced non-small cell lung cancer. Since the beginning of the last decade single agent chemotherapy has been accepted as standard of care, vinorelbine and gemcitabine being the most frequently used drugs in Europe and US, docetaxel in Japan. Platinum-based doublets have been shown to be superior to monotherapy in young and fit patients with advanced non-small cell lung cancer. Although there were some indications from subgroup analyses of clinical trials not specifically dedicated to elderly patients that a platinum-based doublet might also benefit to older patients, there was no definitive proof of concept until ASCO meeting 2010. At this meeting results of a phase 3 trial showed that PS 0-2 patients, aged 70-89 years drove a significant benefit from a treatment with carboplatin associated to weekly paclitaxel compared to a monotherapy. Thus, the paradigm of treatment in elderly patients should perhaps be modified from a single agent to doublet chemotherapy. Whether other platinum-based doublets would provide the same benefit as the specific one studied remains to be evaluated.

[The status and prospects of treatment protocols for elderly patients with non-small cell lung cancer]

近年来，老年晚期肺癌发病率和死亡率呈明显上升趋势，但老年患者总体接受积极治疗的人数却明显少于非老年患者，同时因受到社会、经济、家庭等医疗以外诸多因素的影响，老年晚期肺癌患者治疗现状不容乐观。现就当前国内外老年非小细胞肺癌患者的治疗现状和趋势作一综述。