Featured Review: Chemotherapy for advanced non-small cell lung cancer in the elderly population
Survival, harm, and quality of life included in comparison of chemotherapy
Worldwide, lung cancer is the commonest cause of cancer-related death among individuals of both sexes. For patients with advanced disease, chemotherapy regimens based on the combination of cisplatin or carboplatin with another agent are considered the standard of care. Approximately 50% of patients with newly diagnosed non-small cell lung cancer (NSCLC) are over 70 years of age at diagnosis. Despite this, few elderly patients have been included in relevant clinical trials of chemotherapy, raising concerns about the safety and effectiveness of the standard regimens in this patient group. As a consequence, older patients are often treated with less ‘intensive’ (i.e. less toxic but perhaps less effective) chemotherapy regimens.
A team of Cochrane authors based in Brazil worked with the Cochrane Lung Cancer Group to investigate the effects of different chemotherapy regimens (non-platinum single-agent, non-platinum combination, and platinum combination) on survival, quality of life, tumor shrinkage, and toxicity in older people with advanced lung cancer.
Non-platinum single-agent versus non-platinum combination therapy
The research team reviewed five randomised trials involving 1294 participants and the use of non-platinum regimens; they found that single agent and combination regimens are equally effective for survival. However, combinations of non-platinum agents are associated with a greater chance of tumour response. These regimens are similar in their risk of major toxicity, such as low levels of haemoglobin, platelets, and white cell counts (neutrophils). Only two trials assessed the impact of treatment on quality of life, and results were not combined because of lack of information
Non-platinum therapy versus platinum combination therapy
In this category, the authors assessed 14 randomised trials involving 1705 elderly participants; they found that platinum therapy is associated with longer survival and a greater chance of decreasing tumor response. However, these regimens are more toxic than those based on non-platinum agents, and have a greater risk of low hemoglobin and platelet levels, fatigue, nausea or vomiting, and numbness or tingling in the hands and feet. Only five trials assessed the impact of treatment on quality of life, and these were not combined because of lack of information.
“Older adults with advanced lung cancer and no co-morbidities have increased survival with platinum combination therapy. However this needs to be balanced against higher risk of major adverse events when compared with non-platinum therapy,” said Fábio N Santos, lead author of the Cochrane Review from AC Camargo Cancer Center in São Paulo, Brazil. For people who are not suitable candidates for platinum treatment, the review authors found low-quality evidence suggesting that non-platinum combination and single-agent therapy regimens have similar effects on survival. Additional evidence on quality of life gathered from additional studies is needed to help inform decision making.
The group also highlighted one of the major challenges for future research in geriatric oncology. “Even in the absence of major co-morbidities, elderly patients can be very different from one another in terms of health conditions associated with ageing. Thus, predictive tools to identify either patients at higher risk of toxicity, or those who might not benefit for treatment, need to be developed and validated to guide clinical practice.” said Fabio N Santos.