Comparison of Stage I Non-Small-Cell Lung Cancer Treatments for Patients Living With HIV: A Simulation Study

INTRODUCTION

Non-small-cell lung cancer (NSCLC) is a leading cause of death for people living with HIV (PWH). Nevertheless, there are no clinical trial data regarding the management of early-stage lung cancer in PWH. Using data from large HIV and cancer cohorts we parameterized a simulation model to compare treatments for stage I NSCLC according to patient characteristics.

MATERIALS AND METHODS

To parameterize the model we analyzed PWH and NSCLC patient outcomes and quality of life data from several large cohort studies. Comparative effectiveness of 4 stage I NSCLC treatments (lobectomy, segmentectomy, wedge resection, and stereotactic body radiotherapy) was estimated using evidence synthesis methods. We then simulated trials comparing treatments according to quality adjusted life year (QALY) gains by age, tumor size and histology, HIV disease characteristics and major comorbidities.

RESULTS

Lobectomy and segmentectomy yielded the greatest QALY gains among all simulated age, tumor size and comorbidity groups. Optimal treatment strategies differed by patient sex, age, and HIV disease status; wedge resection was among the optimal strategies for women aged 80 to 84 years with tumors 0 to 2 cm in size. Stereotactic body radiotherapy was included in some optimal strategies for patients aged 80 to 84 years with multimorbidity and in sensitivity analyses was a non-inferior option for many older patients or those with poor HIV disease control.

CONCLUSION

In simulated comparative trials of treatments for stage I NSCLC in PWH, extensive surgical resection was often associated with the greatest projected QALY gains although less aggressive strategies were predicted to be non-inferior in some older, comorbid patient groups.

A combined preoperative red cell distribution width and carcinoembryonic antigen score contribute to prognosis prediction in stage I lung adenocarcinoma

AIMS

Hematological markers that can be used for prognosis prediction for stage I lung adenocarcinoma (LUAD) are still lacking. Here, we examined the prognostic value of a combination of the red cell distribution width (RDW) and carcinoembryonic antigen (CEA), namely, the RDW-CEA score (RCS), in stage I LUAD.

MATERIALS AND METHODS

A retrospective study with 154 patients with stage I LUAD was conducted. Patients were divided into RCS 1 (decreased RDW and CEA), RCS 2 (decreased RDW and increased CEA, increased RDW and decreased CEA), and RCS 3 (increased RDW and CEA) subgroups based on the best optimal cutoff points of RDW and CEA for overall survival (OS). The differences in other clinicopathological parameters among RCS subgroups were calculated. Disease-free survival (DFS) and OS among these groups were determined by Kaplan-Meier analysis, and risk factors for outcome were calculated by a Cox proportional hazards model.

RESULTS

Seventy, 65, and 19 patients were assigned to the RCS 1, 2, and 3 subgroups, respectively. Patients ≥ 60 years (P < 0.001), male sex (P = 0.004), T2 stage (P = 0.004), and IB stage (P = 0.006) were more significant in the RCS 2 or 3 subgroups. The RCS had a good area under the curve (AUC) for predicting DFS (AUC = 0.81, P < 0.001) and OS (AUC = 0.93, P < 0.001). The DFS (log-rank = 33.26, P < 0.001) and OS (log-rank = 42.05, P < 0.001) were significantly different among RCS subgroups, with RCS 3 patients displaying the worst survival compared to RCS 1 or 2 patients. RCS 3 was also an independent risk factor for both DFS and OS.

CONCLUSIONS

RCS is a useful prognostic indicator in stage I LUAD patients, and RCS 3 patients have poorer survival. However, randomized controlled trials are needed to validate our findings in the future.

Surgery offers survival advantage over radiotherapy in patients who are 80 years and older with Stage I and II NSCLC: A retrospective cohort study of 7,045 patients

Objective

Elderly people are less likely than younger patients to undergo curative surgery for early-stage lung cancer because of the greater risk of surgery and postoperative complications. We investigated the relationship between treatment modality and the risk of all-cause and lung cancer-specific mortality to compare the efficacy of surgical treatment with radiotherapy in patients with stage I and II non-small cell lung cancer (NSCLC) who were ≥80 years old.

Methods

We extracted data from the most recent Surveillance, Epidemiology, and End Results 9 registry study database (2010-2017). We mainly selected patients with stage I and II NSCLC who were ≥80 years old, and after screening, 7,045 cases were selected for our study. We used univariate analysis, stratified analysis, and multiple regression equation analysis to examine all-cause mortality and lung cancer-specific mortality in different treatment modalities. The overall and stratified populations' survival curves were plotted using the Kaplan-Meier method. The competing risk regression method of Fine and Gray was used to estimate mortality specific to lung cancer.

Results

In the fully adjusted model, all-cause mortality was 1.97 times higher in the radiotherapy-only group (hazard ration (HR) = 1.97, 95% confidence interval (CI) = 1.81-2.14, p < 0.0001) than in the surgery-only group. The lung cancer-specific mortality rate was 1.22 times higher in the radiotherapy-only group (HR = 1.22, 95% CI = 1.13-1.32, p < 0.0001) than in the surgery-only group. The median overall survival (OS) in the surgery-only, radiation therapy-only, surgery plus radiation therapy, and no-treatment groups were 58 months, 31 months, 36 months, and 10 months, respectively. Median lung cancer-specific survival was 61 months, 32 months, 38 months, and 11 months, respectively. The surgery-only group had the highest 1-year OS (0.8679,95% CI = 0.8537-0.8824) and 5-year OS (0.4873, 95% CI = 0.4632-0.5126).

Conclusions

Surgery had a higher overall and lung cancer-specific survival rate than radiotherapy and no treatment in the elderly early-stage NSCLC population. For patients with stage I and stage II NSCLC at advanced ages, surgical treatment might have a greater potential survival benefit.

Assessment of Treatment Strategies for Stage I Non-small Cell Lung Cancer in Patients with Comorbidities

INTRODUCTION

Non-small cell lung cancer (NSCLC) patients frequently have major comorbidities but there is scarce data regarding the impact of these conditions on management strategies. We used simulation modeling to compare different treatments for stage I NSCLC for patients with common major comorbidities.

METHODS

We used data on NSCLC patinet outcomes and quality of life from: (1) the Surveillance Epidemiology and End Results (SEER) database linked to Medicare claims; (2) Kaiser Permanente Southern California electronic health records; and (3) SEER-Medical Health Outcomes Survey to parameterize a novel simulation model of management and outcomes for stage I NSCLC. Relative efficacy of treatment modalities (lobectomy, segmentectomy, wedge resection and stereotactic body radiotherapy [SBRT]) was collected from existing literature and combined using evidence synthesis methods. We then simulated multiple randomized trials comparing these treatments in a variety of scenarios, estimating quality adjusted life expectancy (QALE) according to age, tumor size, histologic subtype, and comorbidity status.

RESULTS

Lobectomy and segmentectomy yielded the greatest QALE gains among all simulated age, tumor size and comorbidity groups. Optimal treatment strategies differed by patient sex and age; wedge resection was among the optimal strategies for women aged 80-84 with tumors 0-2 cm in size. SBRT was included in some optimal strategies for patients aged 80-84 with multimorbidity.

CONCLUSIONS

In simulated comparative trials of four common treatments for stage I NSCLC, aggressive surgical management was typically associated with the greatest projected QALE gains despite the presence of comorbidities, although less aggressive strategies were predicted to be non-inferior in some older comorbid patient groups.

Thoracoscopic Lobectomy Versus Sublobar Resection for pStage I Geriatric Non-Small Cell Lung Cancer

Objectives

The choice of resection method for geriatric patients with early-stage non-small cell lung cancer (NSCLC) remains contentious. This study aimed to evaluate survival and perioperative outcomes after thoracoscopic lobectomy resection (LR) or sublobar resection (SR) in patients aged ≥75 years with pathologic stage (pStage) I NSCLC.

Materials and Methods

We retrospectively examined 258 consecutive patients aged ≥75 years with pStage I NSCLC who underwent thoracoscopic tumor resection at our institute from 2011 to 2018. Propensity score matching (PSM) analysis identified 60 patients in each group for comparison of survival-related parameters, including disease-free survival (DFS), lung cancer-specific overall survival (OS), and non-lung cancer-specific OS, using the Kaplan-Meier analysis.

Results

LR and SR were performed in 84 (32.6%) and 174 (67.4%) patients aged ≥75 years, respectively. The LR group had younger patients, better performance status, larger tumor sizes, and deeper tumor location than the SR group. Multivariate studies showed that the resection method was not a prognostic factor for OS. The two PSM-matched groups were not significantly different with respect to lung cancer-specific OS (p = 0.116), non-lung cancer-specific OS (p = 0.408), and DFS (p = 0.597). SR helped achieve better perioperative outcomes than LR, including fewer postoperative complications (10.0% vs. 28.3%, p = 0.011), shorter operative times (p < 0.001), decreased blood loss (p = 0.026), and shorter chest tube duration (p = 0.010) and hospital stays (p = 0.035).

Conclusions

Thoracoscopic SR may provide similar oncological outcomes to LR, but may be a safer and more feasible surgical method for geriatric patients with pStage I NSCLC.

Patterns of age disparities in colon and lung cancer survival: a systematic narrative literature review

OBJECTIVES

To identify patterns of age disparities in cancer survival, using colon and lung cancer as exemplars.

DESIGN

Systematic review of the literature.

DATA SOURCES

We searched Embase, MEDLINE, Scopus and Web of Science through 18 December 2020.

ELIGIBILITY CRITERIA

We retained all original articles published in English including patients with colon or lung cancer. Eligible studies were required to be population-based, report survival across several age groups (of which at least one was over the age of 65) and at least one other characteristic (eg, sex, treatment).

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed the quality of included studies against selected evaluation domains from the QUIPS tool, and items concerning statistical reporting. We evaluated age disparities using the absolute difference in survival or mortality rates between the middle-aged group and the oldest age group, or by describing survival curves.

RESULTS

Out of 3047 references, we retained 59 studies (20 for colon, 34 for lung and 5 for both sites). Regardless of the cancer site, the included studies were highly heterogeneous and often of poor quality. The magnitude of age disparities in survival varied greatly by sex, ethnicity, socioeconomic status, stage at diagnosis, cancer site, and morphology, the number of nodes examined and treatment strategy. Although results were inconsistent for most characteristics, we consistently observed greater age disparities for women with lung cancer compared with men. Also, age disparities increased with more advanced stages for colon cancer and decreased with more advanced stages for lung cancer.

CONCLUSIONS

Although age is one of the most important prognostic factors in cancer survival, age disparities in colon and lung cancer survival have so far been understudied in population-based research. Further studies are needed to better understand age disparities in colon and lung cancer survival.

PROSPERO REGISTRATION NUMBER

CRD42020151402.

Change in treatment modality and trends in survival among stage I non-small cell lung cancer patients: a population-based study

Background

A number of treatment modalities are available to patients with early non-small cell lung cancer (NSCLC) but there is inconsistency regarding their effects on survival. The associated survival of each treatment modality is crucial for patients in making informed treatment decisions. We aimed to examine the change in treatment modality and trends in survival for patients with stage I NSCLC and assess the association between treatment modality and survival.

Methods

All patients diagnosed with stage I NSCLC in the Canadian province of Ontario between 2007 and 2015 were included in this population-based study. We used a flexible parametric model to estimate the trends in survival rate.

Results

Overall, 11,910 patients were identified of which 7,478 patients (62.8%) received surgical resection and 2,652 (22.3%) radiation only. The proportion of patients who received radiation only increased from 13.2% in 2007 to 28.0% in 2015 (P-for-trend <0.001). Survival increased for all treatment modalities from 2007 to 2015. The increase in 5-year survival was more than 20% for all surgical groups and more than 35% for radiation-only group.

Conclusions

The survival of patients with stage I NSCLC increased for all treatment modalities over the study period, most distinctly in elderly patients, which coincided with a rise in the use of radiation therapy. While surgical resection was associated with the best chance of 5-year survival, radiation therapy is a safe and effective treatment for medically inoperable patients with early disease.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

Anatomical pulmonary resections for primary lung cancer in octogenarians within a dedicated care protocol

Background

The aim of this study was to assess the feasibility of major pulmonary resection for a limited non-small cell lung cancer (NSCLC) in octogenarians within a dedicated care protocol.

Methods

We retrospectively analyzed data of 55 octogenarians operated on in a single institution between January 2005 and December 2016. They were all included in a specific care protocol with systematic geriatric assessment and adaptation of the peri-operative care. We describe the results of post-operative morbidity, mortality, and survival after anatomical resection and radical lymphadenectomy.

Results

Mean age at the time of surgery was 82.1 years (80-86 years). Median Charlson's comorbidity score was 0 (0-3). All patients were classified Balducci 1 or 2. We performed 2 pneumonectomies (3%), 3 bilobectomies (5%), 47 lobectomies (85%) and 3 segmentectomies (5%). The median hospital stay was 11.5 days (7-31 days). The 30-day mortality rate was 3%. The total of relevant clinical complications (Clavien 3 to 5) was 16% (n=9). The Overall Survival at one, three and five years were, respectively: 83% (95% CI: 75-95%); 70% (95% CI: 56-87%); 58% (95% CI: 43-79%).

Conclusions

Major pulmonary resection for primary lung cancer in octogenarians seems to be safe, with an acceptable morbidity, mortality and long-term survival rate, when processing to rigorous selection of the patients, within a dedicated care protocol.

Population-based patterns of treatment and survival for patients with stage I and II non-small cell lung cancer aged 65-74 years and 75 years or older

OBJECTIVES

Insights regarding utilization and survival of surgery and radiotherapy (stereotactic body radiotherapy (SBRT) or conventional radiotherapy (RT)) are lacking for older patients with stage I and II non-small cell lung cancer (NSCLC) in clinical practice.

METHODS

Data from the Netherlands Cancer Registry were retrieved for patients ≥65 years with clinical stage I-II NSCLC in 2010-2015. Descriptive analyses, overall survival (OS), and cox regression were stratified for stage I (n = 8742) and II (n = 3439) and compared age groups (65-74 years vs ≥75 years).

RESULTS

Patients aged 65-74 underwent surgery significantly more often compared to those aged ≥75 (stage I 55% vs 27%; stage II: 65% vs 35%), and received SBRT less often (I: 29% vs 42%; II: 5% vs 11%), conventional RT less often (I: 6% vs 11%; II 10% vs 24%) and best supportive care alone less often (BSC, I: 8% vs 19%; II: 9% vs 25%). One-year OS was significantly higher in patients aged 65-74 compared to those aged ≥75 (I: 87% vs 78%; II: 74% vs 60%); as was five-year OS (I: 49% vs 31%; II: 36% vs 18%). After adjustment for gender, histology, stage, treatment, and comorbidity, hazard ratio (HR) of death was higher for patients aged ≥75 compared to those aged 65-74 (I: HR 1.3, 95% confidence interval (CI) 1.1-1.5; II: HR 1.3 95%CI 1.1-1.7).

CONCLUSION

Patients aged ≥75 with stage I-II NSCLC had poorer OS, underwent surgery less often, and received SBRT, conventional RT, and BSC more often than patients aged 65-74. In both stages, one-year OS within age groups was similar for surgery and SBRT. However, long-term OS adjusted for prognostic factors was superior for surgery compared to SBRT and remained poorer for those aged ≥75. Prospective research should focus on predictive characteristics for treatment selection and patient-centered outcomes.

Prognosis of limited resection versus lobectomy in elderly patients with invasive lung adenocarcinoma with tumor size less than or equal to 2 cm

Background

This study aimed to evaluate the prognostic difference between limited resection and lobectomy among elderly patients with small size lung adenocarcinoma.

Methods

A total of 666 patients >65 years old with stage I lung adenocarcinoma and tumor size ≤2 cm were included. The patient survival was evaluated by disease-free survival (DFS) and overall survival (OS). Results: No DFS or OS advantage was found between the lobectomy and wedge resection groups when tumor sizes were ≤1 cm (DFS, P=0.112; OS, P=0.294). The wedge resection group had a significantly worse OS (P=0.041) than that in the lobectomy group when tumor sizes were >1 cm and ≤2 cm.

Conclusions

We conclude that wedge resection may be a reasonable surgical choice for elderly patients with tumor sizes ≤1 cm.

Benefits and Challenges of Lung Cancer Screening in Older Adults

PURPOSE

Lung cancer screening with low-dose computed tomography has been shown to significantly reduce lung cancer-related mortality in high-risk patients. However, patients diagnosed with lung cancer are typically older and often have multiple age- and smoking-related comorbidities. As a result, cancer screening in older adults remains a complex decision, requiring careful consideration of patients' risk characteristics and life expectancy to ensure that the benefits outweigh the risks of screening. In this review, we evaluate the evidence regarding lung cancer screening, with a focus on older patients.

METHODS

PubMed was searched to identify relevant studies evaluating the clinical outcomes of lung cancer screening. The key words used in our search included non-small cell lung cancer (NSCLC), screening, older, comorbidities, computed tomography, and survival. While we primarily looked for articles specific to older patients, we also focused on subgroup analysis in older patients in larger studies. Finally, we reviewed all relevant guidelines regarding lung cancer screening.

FINDINGS

Guidelines recommend that lung cancer screening be considered in adults aged 55 to 80 years who are at high risk based on smoking history (ie, 30-pack-year smoking history; having smoked within the past 15 years). Patients who fit these criteria have been shown to have a 20% reduction in lung cancer-related mortality with the use of low-dose computed tomography versus chest radiography. High rates of false-positive results and potential overdiagnoses were also observed. Therefore, screening is generally not recommended in adults with severe comorbidities or short life expectancy, who may experience limited benefit and higher risks with screening. However, several studies have shown a benefit with continued lung cancer screening with appropriate selection of older individuals at the highest risk and with the lowest comorbidities.

IMPLICATIONS

Older patients experience the highest risk for lung cancer incidence and mortality, and stand to be the most likely to benefit from lung cancer screening. However, careful consideration must be given to higher rates of false-positives and overdiagnosis in this population, as well as tolerability of surgery and competing risks for death from other causes. The appropriate selection of older individuals for lung cancer screening can be greatly optimized by using validated risk-based targeting.

Decreased expression of FOXF2 as new predictor of poor prognosis in stage I non-small cell lung cancer

Background

Forkhead box F2 (FOXF2) is relatively limited to the adult lung, but its contribution to non-small cell lung cancer (NSCLC) prognosis is unclear.

Results

FOXF2 mRNA levels in NSCLC were lower than that in paired normal lung tissues (P = 0.012). The FOXF2_low patients had shorter survival time than the FOXF2_high patients (P = 0.024) especially in stage I (P = 0.002), chemotherapy (P = 0.018) and < 60 age groups (P = 0.002). Lower FOXF2 mRNA levels could independently predict poorer survival for patients with NSCLC (HR = 2.384, 95% CI = 1.241–4.577; P = 0.009), especially in stage I (HR =4.367, 95% CI =1.599–11.925; P = 0.004). The two independent datasets confirmed our findings.

Methods

We examined FOXF2 mRNA levels in 84 primary NSCLC and 8 normal lung tissues using qRT-PCR. Rank-sum tests and chi-square tests were used to assess the differences among groups with various clinicopathological factors. Kaplan-Meier tests were used to compare survival status in patients with different FOXF2 mRNA levels. Cox proportional hazards regression model was used to evaluate the predictive value of FOXF2 mRNA level in NSCLC patients. Independent validation was performed using an independent dataset (98 samples) and an online survival analysis software Kaplan-Meier plotter (1928 samples).

Conclusions

Our results demonstrated that decreased FOXF2 expression is an independent predictive factor for poor prognosis of patients with NSCLC, especially in stage I NSCLC.

Lung stereotactic body radiation therapy (SBRT) for early-stage non-small cell lung cancer in the very elderly (≥80years old): Extremely safe and effective

OBJECTIVE

Stereotactic body radiotherapy (SBRT) for early-stage non-small-cell lung cancer (NSCLC) is the standard of care in medically inoperable patients. In very elderly patients, previous studies have shown SBRT to offer excellent local control, though with higher toxicities than in younger populations. We report our institutional experience using SBRT in the definitive management of NSCLC in patients ≥80years old.

MATERIALS AND METHODS

Using an IRB-approved registry of 158 patients treated with definitive-intent lung SBRT for early-stage NSCLC at our institution between 2010 and 2016, 31 consecutively treated patients ≥80years of age were identified. CTCAEv4 scales were prospectively recorded during follow-ups and utilized for toxicity assessments. Kaplan-Meier estimates were utilized for survival analyses.

RESULTS

For the 31 patients (with 34 lesions) included, median age was 83 (R: 80-93), median ECOG performance status was 2 (R: 0-3), and median follow-up was 15.8months (R: 3.1-48.3). Median PTV size was 24.0cm³ (R: 5.83-62.1cm³). Median prescription dose was 54Gy in 3 fractions (R: 50-60Gy in 3-8 fractions). Local control was 100% at 1year and 92.3% at 2years. Median survival was 29.1months. There were no grade 2-5 toxicities. Grade 1 toxicities included: fatigue in 5 patients (16.1%), asymptomatic (radiographic) pneumonitis in 12 (38.7%), and dyspnea in 2 (6.5%).

CONCLUSIONS

Lung SBRT with a BED of ≥100Gy10 for very elderly patients with NSCLC is extremely safe and effective, with inordinately low toxicity rates (zero grade 2-5 toxicities). With stringent dosimetric parameters and planning guidelines, patients ≥80years remain excellent candidates for full-dose SBRT.

SUMMARY

SBRT for early-stage NSCLC is the accepted standard of care in medically inoperable patients, though in many very elderly patients, dose is either de-intensified or withheld for concern of toxicity in the setting of advanced age and competing risks. In this study of our very elderly (≥80years old) early-stage NSCLC patients, we highlight both the extremely high efficacy and tolerability (zero grade 2 or above toxicities) associated with definitive intent SBRT.

[Non-small cell lung cancer irradiation in elderly]

People over the age of 65 are often excluded from participation in oncological clinical trials. However, more than half of patients diagnosed with non-small-cell lung cancer are older than 65 years. Any therapeutic strategy must be discussed in multidisciplinary meetings after adapted geriatric assessment. Patients who benefit from the comprehensive geriatric assessment (CGA) of Balducci and Extermann are those whose G8 screening tool score is less than or equal to 14. Age itself does not contraindicate a curative therapeutic approach. Stereotactic radiotherapy is an alternative to surgery for early stages in elderly patients who are medically inoperable or who refuse surgery, because it significantly increases overall survival. Mostly sequential (rarely concomitant) chemoradiotherapy can be proposed to elderly patients with locally advanced stages in good general state of health. For the others, an exclusive palliative radiotherapy, a single or dual agent of chemotherapy, a targeted drug or best supportive care only may be discussed.

A retrospective comparative analysis of elderly and younger patients undergoing pulmonary resection for stage I non-small cell lung cancer

Background

Age has been a critical predictor for immediate postoperative and long-term results after the pulmonary resection for lung cancer. In this study, we evaluated and compared surgical outcome of stage I non-small cell lung cancer and associated predictive factors between elderly and younger groups.

Methods

Short- and long-term outcomes of elderly group (≥70 years) who were surgically treated and pathologically diagnosed as stage I non-small cell lung cancer from 2004 to 2010 were compared to the results of younger group (<70 years).

Results

Total of 1340 patients were included in this study, and the patients were divided into the elderly group (n = 285) and the younger group (n = 1055). The proportions of squamous cell carcinoma (36.8 vs. 20.0 %, p < 0.001) and stage IB cancer (58.3 vs. 40.6 %, p < 0.001) were significantly higher in the elderly group than the younger group. The 30-day and 90-day mortalities were significantly higher in the elderly group (1.8 vs. 0%; p = 0.014, 3.9 vs. 0.5 %; p < 0.001, respectively). The elderly patients also had significantly worse long-term outcomes than the younger group (5-year overall survival rate, 69.0 vs. 91.1 %; p < 0.001, 5-year disease-free survival rate, 53.3 vs. 80.2 %; p < 0.001). Decreased diffusion capacity less than 70 % was an important predictive factor for short- and long-term outcomes in both the younger and the elderly group.

Conclusions

Elderly patients with low diffusion capacity are at risk for significantly worse outcome, indicating that patient selection should include assessment of pulmonary function, including diffusion capacity.

Stereotactic radiotherapy for early lung cancer: Evidence-based approach and future directions

AIM

To review key studies evaluating stereotactic radiotherapy in the setting of early-stage non-small cell lung cancer (NSCLC) for inoperable or high-risk patients, and discuss areas of ongoing research and clinical trials.

BACKGROUND

The use of stereotactic radiotherapy for the treatment of early stage non-small cell lung cancer (NSCLC) has increased rapidly over the past decade. Numerous studies have reported outcomes for patients treated with SBRT who are unfit for surgical resection, or at high risk of surgical complications.

MATERIALS AND METHODS

A narrative review.

RESULTS

The preponderance of evidence suggests that SBRT is associated with excellent local control (∼90% at 3 years) and a favorable toxicity profile. In patients with higher operative risks, such as the elderly and patients with severe COPD, SBRT may provide a less-toxic treatment than surgery with similar oncologic outcomes. Ongoing studies are evaluating the use of SBRT for locally advanced or oligometastatic NSCLC.

CONCLUSIONS

A large body of evidence now exists to support the use of SBRT for early-stage NSCLC. Decisions regarding the optimal choice of treatment should be individualized, and made in the context of a multidisciplinary team.

Limited Resection Versus Lobectomy for Older Patients With Early-Stage Lung Cancer: Impact of Histology

PURPOSE

Limited resection has been increasingly used in older patients with stage IA lung cancer. However, the equivalency of limited resection versus lobectomy according to histology is unknown.

METHODS

We identified patients older than 65 years with stage IA invasive adenocarcinoma or squamous cell carcinoma ≤ 2 cm who were treated with limited resection (wedge or segmentectomy) or lobectomy in the Surveillance, Epidemiology, and End Results-Medicare database. We estimated propensity scores that predicted the use of limited resection and compared survival of patients treated with limited resection versus lobectomy. Treatments were considered equivalent if the upper 95th percentile of the hazard ratio (HR) for limited resection was ≤ 1.25.

RESULTS

Overall, 27% of 2,008 patients with adenocarcinoma and 32% of 1,139 patients with squamous cell carcinoma underwent limited resection. Survival analyses, adjusted for propensity score by using inverse probability weighting, showed that limited resection was not equivalent to lobectomy in patients with adenocarcinoma (HR, 1.21; upper 95% CI,1.34) or squamous cell carcinoma (HR, 1.21; upper 95% CI, 1.39). Although patients with adenocarcinomas treated with segmentectomy had equivalent survival rates to those treated with lobectomy (HR, 0.97; upper 95% CI, 1.07), outcomes of those treated with wedge resection (HR, 1.29; upper 95% CI, 1.42) did not. Among patients with squamous cell carcinoma, neither wedge resection (HR, 1.34; upper 95% CI, 1.53) nor segmentectomy (HR, 1.19; upper 95% CI, 1.36) were equivalent to lobectomy.

CONCLUSION

We found generally that limited resection is not equivalent to lobectomy in older patients with invasive non-small-cell lung cancer ≤ 2 cm in size, although segmentectomy may be equivalent in patients with adenocarcinoma.

Lobar and sub-lobar lung resection in octogenarians with early stage non-small cell lung cancer: factors affecting surgical outcomes and long-term results

OBJECTIVES

Consensus exists as to the concept that surgical therapy should not be denied based on older age alone. Elderly lung cancer patients with multiple morbidities are increasingly referred for surgical care. The aim of this study was to evaluate the surgical outcomes and the long-term survival in octogenarians with early-stage non-small cell lung cancer.

METHODS

Between January 2000 and December 2010, we identified 73 octogenarians who underwent intended curative lung resection for lung cancer in three different thoracic surgery departments. Two surgical groups were defined: patients who underwent lobar resection (group A) and patients who underwent sub-lobar resection (group B).

RESULTS

The in-hospital mortality was 2.7% without difference between groups. Group B had a lower incidence of post-operative complications, in particular respiratory complications. Chronic renal failure, multi pre-operative comorbidities and type of resection were risk factors for post-operative morbidity. After a mean follow-up time of 63.8 months, the overall survival at 1, 3 and 5 years was 96, 83 and 60%, respectively. The low-respiratory reserve was associated with worse long-term survival. The intra-operative and post-operative factors able to influence survival were: the cN status, recurrence of disease and local versus systemic recurrence. The type of operation did not influence survival.

CONCLUSIONS

In our experience, surgery is a safe and justifiable option for octogenarian patients with early stage NSCLC. Sublobar resection provides an equivalent in-hospital mortality and long-term survival in comparison with open lobectomy but with less postoperative morbidity. Further large-scale randomized studies are necessary to confirm our results.

The mortality after surgery in primary lung cancer: results from the Danish Lung Cancer Registry

OBJECTIVES

The study has been performed to investigate the mortality within the first year after resection in patients with primary lung cancer, together with associated prognostic factors including gender, age, tumour stage, comorbidity, alcohol abuse, type of surgery and post-surgical complications.

METHODS

All patients (n = 3363) from the nationwide Danish Lung Cancer Registry with first resection performed between 1 January 2007 and 31 December 2011 were analysed by Kaplan-Meier techniques and Cox-regression analysis concerning death within the first year after resection. Covariates included gender, age, comorbidity (Charlson comorbidity index), perioperative stage, type of resection, registered complications to surgery and alcohol abuse.

RESULTS

The cumulative deaths after 30 days, 90 days, 180 days and 360 days were 72 (2.1%), 154 (4.6%), 239 (7.1%) and 478 (14.2%), respectively. Low stage, female gender, young age, no comorbidity, no postoperative complications, no alcohol abuse and lobectomy as type of resection were favourable for survival.

CONCLUSIONS

Our results demonstrate that resection in primary lung cancer impacts mortality far beyond the initial 30 days after resection, which is conventionally considered a time window of relevance for the adverse outcome of surgery. Increased efforts should be made for optimizing the selection of patients suited for resection and for identifying patients at increased risk of death after resection. Furthermore, patients should be monitored more closely and more frequently, in particular those patients with high risk of death after resection.

Exploring Stage I non-small-cell lung cancer: development of a prognostic model predicting 5-year survival after surgical resection†

OBJECTIVES

Despite impressive results in diagnosis and treatment of non-small-cell lung cancer (NSCLC), more than 30% of patients with Stage I NSCLC die within 5 years after surgical treatment. Identification of prognostic factors to select patients with a poor prognosis and development of tailored treatment strategies are then advisable. The aim of our study was to design a model able to define prognosis in patients with Stage I NSCLC, submitted to surgery with curative intent.

METHODS

A retrospective analysis of two surgical registries was performed. Predictors of survival were investigated using the Cox model with shared frailty (accounting for the within-centre correlation). Candidate predictors were: age, gender, smoking habit, morbidity, previous malignancy, Eastern Cooperative Oncology Group performance status, clinical N stage, maximum standardized uptake value (SUV(max)), forced expiratory volume in 1 s, carbon monoxide lung diffusion capacity (DLCO), extent of surgical resection, systematic lymphadenectomy, vascular invasion, pathological T stage, histology and histological grading. The final model included predictors with P < 0.20, after a backward selection. Missing data in evaluated predictors were multiple-imputed and combined estimates were obtained from 10 imputed data sets.

RESULTS

Analysis was performed on 848 consecutive patients. The median follow-up was 48 months. Two hundred and nine patients died (25%), with a 5-year overall survival (OS) rate of 74%. The final Cox model demonstrated that mortality was significantly associated with age, male sex, presence of cardiac comorbidities, DLCO (%), SUV(max), systematic nodal dissection, presence of microscopic vascular invasion, pTNM stage and histological grading. The final model showed a fair discrimination ability (C-statistic = 0.69): the calibration of the model indicated a good agreement between observed and predicted survival.

CONCLUSIONS

We designed an effective prognostic model based on clinical, pathological and surgical covariates. Our preliminary results need to be refined and validated in a larger patient population, in order to provide an easy-to-use prognostic tool for Stage I NSCLC patients.

A very elderly lung cancer patient: case report of a long disease free survival

Despite the fact that non-small-cell lung cancer (NSCLC) is very common in the older population, these patients are frequently underrepresented in clinical and surgical trials and thus it is difficult to reach evidence-based recommendations for this special population. We present a case of a surgical treatment of asymptomatic lung cancer in a very elderly patient. The patient had no recurrence for 4 years after a complete resection.

Evaluation and management of elderly patients with lung cancer

Most patients diagnosed with lung cancer are older than 65 years. Advancing age is associated with increased medical and psychosocial issues that increase the complexity of care. This article provides a summary and update of work-up and management of elderly patients with lung cancer. Patient-related prognostic factors with attention to assessment of comorbidity in lung cancer patients are reviewed. Recent literature regarding toxicity and advances in locoregional and systemic therapies are reviewed, with recommendations for management.

Adjuvant chemotherapy for non-small-cell lung cancer in the elderly: a population-based study in Ontario, Canada

PURPOSE

Non-small-cell lung cancer (NSCLC) is predominantly a disease of the elderly. Retrospective analyses of the National Cancer Institute of Canada Clinical Trials Group JBR.10 trial and the Lung Adjuvant Cisplatin Evaluation (LACE) meta-analysis suggest that the elderly benefit from adjuvant chemotherapy. However, the elderly were under-represented in these studies, raising concerns regarding the reproducibility of the study results in clinical practice.

PATIENTS AND METHODS

By using the Ontario Cancer Registry, we identified 6,304 patients with NSCLC who were treated with surgical resection from 2001 to 2006. Registry data were linked to electronic treatment records. Uptake of chemotherapy was compared across age groups: younger than 70, 70 to 74, 75 to 79, and ≥ 80 years. As a proxy of survival benefit from chemotherapy, we compared survival of patients diagnosed from 2004 to 2006 with survival of those diagnosed from 2001 to 2003. Hospitalization rates within 6 to 24 weeks of surgery served as a proxy of severe chemotherapy-related toxicity.

RESULTS

In all, 2,763 (43.8%) of 6,304 surgical patients were elderly (age ≥ 70 years). Uptake of adjuvant chemotherapy in the elderly increased from 3.3% (2001 to 2003) to 16.2% (2004 to 2006). Among evaluable elderly patients, 70% received cisplatin and 28% received carboplatin-based regimens. Requirements for dose adjustments or drug substitutions were similar across age groups. Hospitalization rates within 6 to 24 weeks of surgery were similar across age groups (28.0% for patients age < 70 years; 27.8% for patients age ≥ 70 years; P = .54). Four-year survival of elderly patients increased significantly (47.1% for patients diagnosed from 2001 to 2003; 49.9% for patients diagnosed from 2004 to 2006; P = .01). Survival improved in all subgroups except patients age ≥ 80 years.

CONCLUSION

Uptake of adjuvant chemotherapy for NSCLC increased in patients age 70 years or older following reporting of pivotal adjuvant chemotherapy trials, but it remained below that for patients younger than age 70 years. Adoption of adjuvant chemotherapy appears to be associated with significant survival benefit in the elderly (age ≥ 70 years), with tolerability apparently similar to that of patients who are younger than age 70 years.

Radiotherapy and chemotherapy for elderly patients with stage I-II unresected lung cancer

Radiotherapy (RT) is the standard therapy for unresected stage I-II nonsmall cell lung cancer (NSCLC). Using population-based data, we compared survival and toxicity among unresected elderly patients treated with combined chemoradiotherapy (CRT) or RT alone. Using the Surveillance, Epidemiology and End Results (SEER) registry (National Cancer Institute, Bethesda, MD, USA) we identified 3,006 cases of unresected stage I-II NSCLC. We used propensity score methods to compare survival and rates of toxicity of patients treated with RT versus CRT. Overall, 844 (28%) patients received CRT. Adjusted analyses showed that CRT was associated with improved survival (hazard ratio 0.85, 95% CI 0.78-0.94). Combination therapy was also associated with better survival among stage I patients treated with intermediate complexity RT (HR 0.80, 95% CI 0.70-0.90); however, no difference in survival was observed among patients treated with complex RT. In stage II patients, CRT was associated with improved survival regardless of the RT technique (HR 0.61-0.72). CRT was associated with increased odds of toxicity. Despite increased toxicity, CRT may improve survival of elderly unresected patients with stage II disease as well as stage I NSCLC treated with intermediate RT complexity. Randomised trials are needed to clarify the balance of benefits and risk of CRT in unresected patients.

Single nucleotide polymorphisms as susceptibility, prognostic, and therapeutic markers of nonsmall cell lung cancer

Lung cancer is a major public health problem throughout the world. Among the most frequent cancer types (prostate, breast, colorectal, stomach, lung), lung cancer is the leading cause of cancer-related deaths worldwide. Among the two major subtypes of small cell lung cancer and nonsmall cell lung cancer (NSCLC), 85% of tumors belong to the NSCLC histological types. Small cell lung cancer is associated with the shortest survival time. Although tobacco smoking has been recognized as the major risk factor for lung cancer, there is a great interindividual and interethnic difference in risk of developing lung cancer given exposure to similar environmental and lifestyle factors. This may indicate that in addition to chemical and environmental factors, genetic variations in the genome may contribute to risk modification. A common type of genetic variation in the genome, known as single nucleotide polymorphism, has been found to be associated with susceptibility to lung cancer. Interestingly, many of these polymorphisms are found in the genes that regulate major pathways of carcinogen metabolism (cytochrome P450 genes), detoxification (glutathione S-transferases), adduct removal (DNA repair genes), cell growth/apoptosis (TP53/MDM2), the immune system (cytokines/chemokines), and membrane receptors (nicotinic acetylcholine and dopaminergic receptors). Some of these polymorphisms have been shown to alter the level of mRNA, and protein structure and function. In addition to being susceptibility markers, several of these polymorphisms are emerging to be important for response to chemotherapy/radiotherapy and survival of patients. Therefore, it is hypothesized that single nucleotide polymorphisms will be valuable genetic markers in individual-based prognosis and therapy in future. Here we will review some of the most important single nucleotide polymorphisms in the metabolic pathways that may modulate susceptibility, prognosis, and therapy in NSCLC.

Lobectomy in octogenarians with non-small cell lung cancer: ramifications of increasing life expectancy and the benefits of minimally invasive surgery

BACKGROUND

As the population ages, clinicians are increasingly confronted with octogenarians with resectable non-small cell lung cancer (NSCLC). We reviewed the outcomes of octogenarians who underwent lobectomy for NSCLC by video-assisted thoracic surgery (VATS) versus open thoracotomy, to determine if there was a benefit to the VATS approach in this group.

METHODS

We conducted a retrospective single-institution review of patients age 80 years or greater who underwent a lobectomy for NSCLC from 1998 to 2009. Outcomes including complication rates, length of stay, disposition, and long-term survival were analyzed.

RESULTS

One hundred twenty-one octogenarians underwent lobectomy: 40 VATS and 81 through open thoracotomy. Compared with thoracotomy, VATS patients had fewer complications (35.0% vs 63.0%, p = 0.004), shorter length of stay (5 vs 6 days, p = 0.001), and were less likely to require admission to the intensive care unit (2.5% vs 14.8%, p = 0.038) or rehabilitation after discharge (5% vs 22.5%, p = 0.015). In multivariate analysis, VATS was an independent predictor of reduced complications (odds ratio, 0.35; 95% confidence interval, 0.15 to 0.84; p = 0.019). Survival comparisons demonstrated no significant difference between the two techniques, either in univariate analysis of stage I patients (5-year VATS, 76.0%; thoracotomy, 65.3%; p = 0.111) or multivariate analysis of the entire cohort (adjusted hazard ratio, 0.59; 95% confidence interval, 0.27 to 1.28; p = 0.183).

CONCLUSIONS

Octogenarians with NSCLC can undergo resection with low mortality and survival among stage I patients, which is comparable with the general lung cancer population. The VATS approach to resection reduces morbidity in this age demographic, resulting in shorter, less intensive hospitalization, and less frequent need for postoperative rehabilitation.

Are we treating enough elderly patients with early stage non-small cell lung cancer?

Despite the fact that non-small-cell lung cancer (NSCLC) is very common in the older population, these patients are frequently underrepresented in clinical trials evaluating new anti-cancer agents, and thus it is difficult to reach evidence-based recommendations for this special population. The purpose of the present paper is to present the currently available evidence regarding treatment of early-stages of NSCLC in older patients. Although, age is still considered as a negative factor influencing treatment decisions and curative cancer-directed surgery is often omitted in the older population several studies support that surgical resection is feasible in the older patient and that age per se is not a contraindication for various surgical procedures. Pneumonectomy is associated with a higher mortality in the older population and this issue should be taken into account when deciding whether a patient is suitable for pneumonectomy. Older patients should be considered for adjuvant chemotherapy after surgical resection although little information is available regarding the real benefit and tolerability of these regimens for patients over 75 years of age. Given the lack of demonstrated benefit for the use of adjuvant RT it is also not recommended in older population.

A model for morbidity after lung resection in octogenarians

OBJECTIVE

Age is an important risk factor for morbidity after lung resection. This study was performed to identify specific risk factors for complications after lung resection in octogenarians.

METHODS

A prospective database containing patients aged 80 years or older, who underwent lung resection at a single institution between January 2000 and June 2009, was reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed. Morbidity was measured as a patient having any perioperative event as defined by the Society of Thoracic Surgeons General Thoracic Surgery Database. A multivariable risk model for morbidity was developed using a panel of established preoperative and operative variables. Survival was calculated using the Kaplan-Meier method.

RESULTS

During the study period, 193 patients aged 80 years or older (median age 82 years) underwent lung resection: wedge resection in 77, segmentectomy in 13, lobectomy in 96, bilobectomy in four, and pneumonectomy in three. Resection was accomplished via thoracoscopy in 149 patients (77%). Operative mortality was 3.6% (seven patients) and morbidity was 46% (89 patients). A total of 181 (94%) patients were discharged directly home. Postoperative events included atrial arrhythmia in 38 patients (20%), prolonged air leak in 24 patients (12%), postoperative transfusion in 22 patients (11%), delirium in 16 patients (8%), need for bronchoscopy in 14 patients (7%), and pneumonia in 10 patients (5%). Significant predictors of morbidity by multivariable analysis included resection greater than wedge (odds ratio 2.98, p=0.006), thoracotomy as operative approach (odds ratio 2.6, p=0.03), and % predicted forced expiratory volume in 1s (odds ratio 1.28 for each 10% decrement, p=0.01).

CONCLUSIONS

Octogenarians can undergo lung resection with low mortality. Extent of resection, use of a thoracotomy, and impaired lung function increase the risk of complications. Careful evaluation is necessary to select the most appropriate approach in octogenarians being considered for lung resection.

Withholding stereotactic radiotherapy in elderly patients with stage I non-small cell lung cancer and co-existing COPD is not justified: outcomes of a Markov model analysis

BACKGROUND AND PURPOSE

To model outcomes of SBRT versus best supportive care (BSC) in elderly COPD patients with stage I NSCLC.

MATERIAL AND METHODS

A Markov model was constructed to simulate the quality-adjusted and overall survival (OS) in patients ⩾75years undergoing either SBRT or BSC for a five-year timeframe. SBRT rates of local, regional and distant recurrences were obtained from 247 patients treated at the VUMC, Amsterdam. Recurrence rates were converted into transition probabilities and stratified into four groups according to T stage (1, 2) and COPD GOLD score (I-II, III-IV). Data for untreated patients were obtained from the California Cancer Registry. Tumor stage and GOLD score utilities were adapted from the literature.

RESULTS

Our model correlated closely with the source OS data for SBRT treated and untreated patients. After SBRT, our model predicted for 6.8-47.2% five-year OS and 14.9-27.4 quality adjusted life months (QALMs). The model predicted for 9.0% and 2.8% five-year OS, and 10.1 and 6.1 QALMs for untreated T1 and T2 patients, respectively. The benefit of SBRT was the least for T2, GOLD III-IV patients.

CONCLUSION

Our model indicates that SBRT should be considered in elderly stage I NSCLC patients with COPD.

Impact of Introducing Stereotactic Lung Radiotherapy for Elderly Patients With Stage I Non–Small-Cell Lung Cancer: A Population-Based Time-Trend Analysis

Purpose

Stereotactic body radiotherapy (SBRT) for stage I non–small-cell lung cancer (NSCLC) is associated with high local control rates. The impact of introducing SBRT in patients 75 years of age or older was studied using a population-based cancer registry.

Methods

The Amsterdam Cancer Registry was assessed in three eras: 1999 to 2001 (period A, pre-SBRT); 2002 to 2004 (period B, some availability of SBRT), and 2005 to 2007 (period C, full access to SBRT). χ2, Kaplan-Meier, and Cox regression were used to compare treatment patterns and overall survival (OS) in three treatment groups: surgery, radiotherapy (RT), or neither.

Results

A total of 875 elderly patients were diagnosed with stage I NSCLC in the study period. Median follow-up was 54 months. Primary treatment was surgery in 299 patients (34%), RT in 299 patients (34%), and neither in 277 patients (32%). RT use increased between periods A and C (26% v 42%, P < .01), corresponding to a decrease in untreated patients. The percentage of RT patients undergoing SBRT in periods B and C was 23% and 55%, respectively. Median survival for all patients increased from 16 months in period A to 21 months in period C (log-rank P < .01; hazard ratio [HR] = 0.65; 95% CI, 0.54 to 0.80). The improvement in OS was confined to RT patients (HR = 0.70; 95% CI, 0.49 to 0.99), whereas no significant survival improvements were seen in the other groups.

Conclusion

SBRT introduction was associated with a 16% absolute increase in RT use, a decline in the proportion of untreated elderly patients, and an improvement in OS.

Stage I non-small cell lung cancer (NSCLC) in patients aged 75 years and older: does age determine survival after radical treatment?

INTRODUCTION

Curative treatment of stage I non-small cell lung cancer (NSCLC) in elderly patients represents a therapeutic challenge. Data examining outcomes for the elderly after radical radiotherapy (RT) or surgery in the same geographic population are limited.

METHODS

Using prospective databases from British Columbia, patients with stage I NSCLC treated curatively with either surgery or RT between 2000 and 2006 were identified. Kaplan-Meier, Cox regression, and competing risk analyses were used to assess overall survival (OS) and disease-specific survival in the elderly, and the relationship between age and survival outcomes.

RESULTS

Of a total of 558 patients with stage I disease, 310 (56%) received surgery and 248 (44%) received RT. Elderly patients (age > or =75 years) were less likely to undergo resection than their younger counterparts (43% versus 72%, p < 0.0001). Actuarial OS after surgery for elderly patients was 87% at 2 years and 69% at 5 years. On multivariate analysis, OS after surgery was dependent on tumor stage (p = 0.034) and performance status (p = 0.03), but not age (p = 0.87). After RT, actuarial OS for elderly patients was 53% at 2 years and 23% at 5 years. On multivariate analysis, age did not predict for OS after RT (p = 0.43), whereas tumor stage (p = 0.033), sex (p = 0.044), and dose (p = 0.01) were significant predictors.

CONCLUSIONS

Survival after radical treatment for stage I NSCLC is dependent on factors such as tumor stage, performance status, sex, and RT dose, but not age. Elderly patients who are sufficiently fit should not be considered ineligible for radical treatment based on age alone.

EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIOG) experts' opinion for the treatment of non-small-cell lung cancer in an elderly population

Non-small-cell lung cancer (NSCLC) represents a common health issue in the elderly population. Nevertheless, the paucity of large, well-conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The present paper reviews the currently available evidence regarding treatment of all stages of NSCLC in elderly patients. Surgery remains the standard for early-stage disease, though pneumonectomy is associated with higher incidence of postoperative mortality in elderly patients. Given the lack of demonstrated benefit for the use of adjuvant radiotherapy, it is also not recommended in elderly patients. Elderly patients seem to derive the same benefit from adjuvant chemotherapy as younger patients do, with no significant increase in toxicity. For locally advanced NSCLC, concurrent chemoradiotherapy may be offered to selected elderly patients as there is a higher risk for toxicity reported in the elderly population. Third-generation single-agent treatment is considered the standard of care for patients with advanced/metastatic disease. Platinum-based combination chemotherapy needs to be evaluated in prospective trials. Unfortunately, with the exception of advanced/metastatic NSCLC, prospective elderly-specific NSCLC trials are lacking and the majority of recommendations made are based on retrospective data, which might suffer from selection bias. Prospective elderly-specific trials are needed.