Small cell lung carcinoma in the elderly

A combination chemotherapy of carboplatin and irinotecan with granulocyte colony-stimulating factor (G-CSF) support in elderly patients with small cell lung cancer

BACKGROUND

We have previously reported that carboplatin plus etoposide is an effective and relatively non-toxic regimen in elderly patients with small cell lung cancer (SCLC). Recently, the Japan Clinical Oncology Group reported that irinotecan plus cisplatin was more effective than etoposide plus cisplatin in the treatment of non-elderly patients with extensive disease (ED)-SCLC. Therefore, we conducted a prospective feasibility study designed specifically to evaluate the efficacy of carboplatin (day 1) and irinotecan (days 1, 8, 15) with granulocyte colony-stimulating factor (G-CSF) support in elderly SCLC patients.

METHODS

Three carboplatin AUC and irinotecan dose levels were used: 4 mg/ml x min and 50 mg/m2, respectively (level 1); 5 mg/ml x min and 50 mg/m2, respectively (level 2), and 5 mg/ml x min and 60 mg/m2, respectively (level 3). Although a phase I trial using this drug combination against non-SCLC performed at our institution found that the recommended dose was level 3, as the current trial included only elderly patients, the starting dose used was level 2. However, if a patient had history of prior chemotherapy, performance status (PS) of 2, or was aged 75 years or more, the dose administered was reduced by 1 level. If a patient had a PS of 0, the dose was increased by 1 level. Cycles were repeated every 4 weeks, and patients aged 70 years or more with a PS of 0-2 were eligible.

RESULTS

Eighteen patients were enrolled, of which nine were given the level 1 dose, seven the level 2 dose, and two the level 3 dose. The patient group had a median age of 75 years, 8 patients had limited disease (LD) versus 10 with ED, 9 had received previous treatment for SCLC versus 9 previously untreated, and 13 had a PS of 0-1 versus 5 with a PS of 2. Seventeen (94%) patients received two or more cycles of chemotherapy, and the median actual delivery of irinotecan was 84% of the projected dose. Grade 3/4 neutropenia, anemia, and diarrhea occurred in 50%, 33% and 6% of patients, respectively. Other toxicities were mild and no treatment-related deaths occurred. The response rate was 89%, with two complete responses and 14 partial responses. The median survival time was 13.3 months and the 1-year survival rate was 62%.

CONCLUSIONS

The combination of carboplatin and irinotecan with G-CSF support was an effective and non-toxic regimen in elderly SCLC patients and should be further evaluated in phase III trials.

Platinum-Etoposide Chemotherapy in Elderly Patients With Small-Cell Lung Cancer: Results of a Randomized Multicenter Phase II Study Assessing Attenuated-Dose or Full-Dose With Lenograstim Prophylaxis—A Forza Operativa Nazionale Italiana Carcinoma Polmonare and Gruppo Studio Tumori Polmonari Veneto (FONICAP-GSTPV) Study

Purpose

Small-cell lung cancer (SCLC) is increasingly diagnosed in elderly patients, who are at higher risk of treatment-related morbidity and mortality. We conducted a randomized two-stage phase II study to assess the therapeutic index of two different platinum/etoposide regimens, attenuated-dose (AD) and full-dose (FD) plus prophylactic lenograstim.

Patients and Methods

SCLC patients older than 70 years were randomized to receive four courses of cisplatin 25 mg/m2 on days 1 and 2, and etoposide 60 mg/m2 on days 1, 2, and 3 every 3 weeks (AD); or cisplatin 40 mg/m2 on days 1 and 2, and etoposide 100 mg/m2 on days 1, 2, and 3 every 3 weeks, plus lenograstim 5 mg/kg days 5 through 12, every 3 weeks (FD). A combined primary end point named therapeutic success (TS), which took into account activity, toxicity, and compliance, was used.

Results

Ninety-five patients were enrolled. Seventy-five percent and 72% of the patients in the AD and FD arms, respectively, completed the treatment as per protocol. Response rate was 39% and 69% in the AD and FD arms, respectively, and 1-year survival probability was 18% and 39%, respectively. Treatment was well tolerated in both groups, with no grade 3 to 4 myelotoxicity in the AD arm, and 12% myelotoxicity in the FD arm. Overall, the observed TSs were 10 (36%) of 28 patients and 42 (63%) of 67 patients for AD and FD treatments, respectively.

Conclusion

In elderly patients with SCLC a full-dose cisplatin/etoposide regimen combined with prophylactic lenograstim is active and feasible, while attenuated doses of the same regimen are associated with a poor therapeutic outcome.

Trends in incidence and prognosis of the histological subtypes of lung cancer in North America, Australia, New Zealand and Europe

BACKGROUND

Since the incidence of the histological subtypes of lung cancer in industrialised countries has changed dramatically over the last two decades, we reviewed trends in the incidence and prognosis in North America, Australia, New Zealand and Europe, according to period of diagnosis and birth cohort and summarized explanations for changes in mortality.

METHODS

Review of the literature based on a computerised search (Medline database 1966-2000).

RESULTS

Although the incidence of lung cancer has been decreasing since the 1970s/1980s among men in North America, Australia, New Zealand and north-western Europe, the age-adjusted rate continues to increase among women in these countries, and among both men and women in southern and eastern Europe. These trends followed changes in smoking behaviour. The proportion of adenocarcinoma has been increasing over time; the most likely explanation is the shift to low-tar filter cigarettes during the 1960s and 1970s. Despite improvement in both the diagnosis and treatment, the overall prognosis for patients with non-small-cell lung cancer hardly improved over time. In contrast, the introduction and improvement of chemotherapy since the 1970s gave rise to an improvement in - only short-term (<2 years) - survival for patients with small-cell lung cancer.

CONCLUSIONS

The epidemic of lung cancer is not over yet, especially in southern and eastern Europe. Except for short-term survival of small cell tumours, the prognosis for patients with lung cancer has not improved significantly.

Treatment and outcomes for elderly patients with small cell lung cancer

It is estimated that approximately half of the 500 000 people diagnosed with lung cancer worldwide every year are aged >70 years. Thus, this disease represents a major problem in the elderly and one that will indeed increase as the median age of the population increases. For small cell lung cancer (SCLC), which accounts for approximately 20% of cases of lung cancer, the primary treatment is chemotherapy and in the majority of cases the primary aim is to control the disease which generally would have spread beyond the lungs at the time of presentation. A small number of 'standard' chemotherapy regimens (combined with radiotherapy for patients with limited disease) have been shown to improve survival and quality of life and are widely used. Much of the work investigating the relationship between age and treatment outcomes has been based on clinical trial data and may itself be inherently biased due to trial eligibility criteria excluding elderly patients. However, there is no good evidence that elderly patients fare worse with treatment than their younger counterparts in terms of response rates and survival. Nevertheless with increasing age comes increasing concomitant illnesses which may account for the widely observed increases in drug toxicity, and this may be the primary consideration in selecting the treatment option. Thus for many elderly patients, carboplatin/ etoposide may be the treatment of choice because it is perhaps the least toxic of the standard regimens. Whatever regimen is chosen, the key to treatment effectiveness seems to be to deliver the first 3 or 4 cycles without delay or dosage reduction. Although palliation of symptoms remains a major goal in the treatment of all patients with SCLC there is a dearth of data on whether elderly patients are equally well palliated as their younger counterparts. There is no good evidence that age per se should be a factor in deciding whether patients should receive standard treatment rather than a more gentle approach, and more elderly patients should be included in clinical trials. The key areas where more information is required regarding the treatment and outcomes of elderly patients with SCLC are the assessment of palliation, and comprehensive reviews of all patients diagnosed with the disease, not just those included in trials.

Improvement and plateau in survival of small-cell lung cancer since 1975: a population-based study

BACKGROUND

Cytotoxic therapy appears to have improved short-term survival for patients with small-cell lung cancer, but little is known about the results for unselected patients and trends in long-term survival.

PATIENTS AND METHODS

One thousand seven hundred ninety-six patients with small-cell lung cancer diagnosed between 1975 and 1994 in southeastern Netherlands. We studied treatment policy for and survival of unselected patients since 1975, when cytotoxic therapy emerged.

RESULTS

The proportion patients receiving chemotherapy, with or without irradiation, almost tripled from 30% to 82% for patients younger than 70 years of age and from 15% to 56% for those over 70, whereas the proportion receiving only radiotherapy decreased from 36% to 5% in both age groups. The short-term (< 2 year) survival rate improved markedly between 1975 and 1989, especially for patients younger than 70 (median survival increased from five to 10 months). Two-year survival remained poor (8%). Two percent of all patients younger than 70 years at diagnosis survived for at least eight years, but these patients still represent an excess five-year mortality of 39%.

CONCLUSIONS

In southeastern Netherlands short-term survival of patients with small-cell lung cancer improved markedly up to the end of the 1980s, but a major impact on cure rates has not been achieved.

Treatment of small cell lung cancer in the elderly

OBJECTIVE

Since both the incidence of lung cancer and the proportion of the population over age 65 are increasing rapidly in North America, we undertook a retrospective review of elderly patients with small cell lung cancer (SCLC) in an attempt to assess the effect of age on treatment decisions, response, survival, and toxicity.

DESIGN

Retrospective chart view.

SETTING

Oncology Unit of a university-affiliated teaching hospital.

PATIENTS

There were 123 patients age > 70 years treated from 1976-88. Chemotherapy consisted of either cyclophosphamide, doxorubicin, and vincristine, or etoposide and cisplatin.

RESULTS

There were 74 patients aged 70-74, 35 aged 75-80, and 14 aged 80 years or older. No significant differences existed between the groups in sex, stage, performance status, or presence of co-morbid disease. Median survivals for patients with limited and extensive disease were 11.9 and 5.2 months, respectively (P = < 0.0001), with no significant difference for patients in any age group (P = 0.4). For both limited and extensive disease, survival correlated strongly with the treatment received. Twenty-five patients received no treatment (median survival 1.1 months), 20 had radiation only (median 7.8 months), and 27 patients had < 3 cycles of chemotherapy (median 3.9 months). Median survival for the 50 patients who had 4-6 cycles was 10.7 months (limited disease 15.0 months, extensive disease 8.61 months). In the Cox Model, survival correlated strongly with stage of disease and chemotherapy treatment (P < 0.0001), but only marginally with performance status (P < 0.077). Of the 77 patients who had chemotherapy, less than 50% in all age groups completed six cycles. Only two patients completed chemotherapy without a single dose reduction, and 76.7% required more than two reductions.

CONCLUSIONS

Chemotherapy should not be withheld from elderly patients with SCLC on the basis of age. The survival of patients who receive chemotherapy is significantly longer than that of untreated patients even though frequent dose reductions for toxicity may be required. The survival benefit is due to treatment effect and is not due to a selection bias in the cohort of patients chosen for therapy.

Retrospective review of chemotherapy for small cell lung cancer in the elderly: does the end justify the means?

Between 1978 and 1983, 72 patients aged 70 years or older (median 72, range 70-80) were treated for biopsy-proven, small cell lung cancer (SCLC). Intercurrent disorders were common, including ischaemic heart disease, peripheral vascular disease, chronic airflow limitation and second malignancies. 26 patients (36%) had limited extent of disease, and 46 (64%) had extensive disease. "Intensive" chemotherapy incorporating vincristine, cyclophosphamide and doxorubicin (OCA regimen) was administered to 32 patients [complete response (CR) + partial response (PR) = 84%]; less rigorous regimens (e.g. single agent chemotherapy, planned dose reductions, radiotherapy only) were used in 34 cases (CR + PR = 52%); and 6 received no active treatment. In the intensively treated group, there were 3 treatment-related deaths and 26 episodes of WHO grade 3-4 toxicity. In the less intensively treated group, there were no treatment-induced deaths and only 1 episode of severe toxicity. The overall median survival was 25 weeks (36 weeks for intensive treatment, 16 weeks with less intense treatment). For patients with limited disease only, the median survival in each group was 43 and 26 weeks, respectively. Intensive treatment for elderly patients with small cell lung cancer is associated with substantially increased toxicity and higher response rates than for gentle treatment, but without a major survival benefit.

Systemic treatment of cancer in the elderly

The goal of this review is to provide a readable and exhaustive reference in three major areas of geriatric oncology: complications of chemotherapy and radiotherapy, responsiveness of cancer to systemic treatment, social issues in the care of elderly patients with terminal illnesses. The conclusions of this study are: 1. Progressive deterioration of renal function is the most consistent change of aging. Adjustment of doses of renally excreted drugs to individual creatinine clearance may prevent life-threatening myelotoxicity in the elderly. 2. Intensive chemotherapy regimens (acute leukemia, non Hodgkin's lymphoma) cause more serious and prolonged myelotoxicity in the elderly. Elderly are more susceptible than younger patients to cardiotoxicity and central and peripheral neurotoxicity. Age is a poor predictor of complications in other organs or systems. 3. The prognosis of patients with Hodgkin's disease worsens with aging, possibly due to increased prevalence of mixed cellularity histology. It is controversial whether the prognosis of other neoplasias is poorer. Prognosis is not age-related in multiple myeloma. In general, elderly in good performance status may benefit from systemic cancer treatment to the same extent as younger patients, except for Hodgkin's disease. 4. The Informal Support Network, epitomized by the family, appears the most suitable environment to care for the elderly with cancer.