Challenges associated with systemic therapy for older patients with inoperable non-small cell lung cancer

ABSTRACT

Introduction

Lung cancer is the most common cancer diagnosed worldwide. Data from several studies fall short to make appropriate conclusions on the management for elderly patients. The discovery of targeted therapy and immunotherapy has allowed these patients access to a wider array of options.

Areas covered

The authors review research for treating older patients with lung cancer focusing on research performed in this patient population. Data are presented relating to chemotherapy, immunotherapy, and targeted therapy in the advanced setting.

Expert opinion

Elderly patients particularly benefit from advances in systemic therapy. Based on the tumor profile, treatment with targeted therapy or immunotherapy should be favored over chemotherapy where possible in the elderly population. Elderly patients benefit from EGFR, ALK, and ROS-1 inhibition in the setting of these tumor alterations. These agents should be utilized early in the treatment course. Across many studies, the benefit from immunotherapy is seen irrespective of age. Favorable outcomes and toxicity profiles from immunotherapy compared to chemotherapy are well described. Chemotherapy should be offered with caution after a detailed assessment. Options include combination or single-agent chemotherapy regimens. Best supportive care alone is a reasonable option in the frailer, highly co-morbid patient.

KEYWORDS:

• Non-small cell lung cancer
• elderly patient
• systemic therapy
• chemotherapy
• immunotherapy
• targeted therapy

Article highlights

• Elderly patients are poorly represented in older drug-based clinical trials

• Age alone should not be the only factor in determining fitness for therapy – performance status, co-morbidities, patient wishes, and appropriate tumor profiling should all inform treatment decisions

• A comprehensive geriatric assessment is a useful tool in determining fitness for therapy

• Targeted therapy and immunotherapy should be favored where relevant as evidence suggests superior outcomes and toxicity profiles in the elderly cohort

• Various chemotherapy strategies can be considered however should be tailored to the clinical scenario

• More focused elderly (≥75 years) clinical trials are required

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One referee declares that his institution receives research support from Bristol-Myers Squibb, Merck & Co, Genentech/Roche, Pfizer and Novartis. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript has not been funded.