Fit, older lung cancer patients respond to chemotherapy

[dadstimeon]

http://www.sptimes.com/2005/12/19/Citru ... ance.shtml

By V. UPENDER RAO

Published December 19, 2005

The Geriatric Oncology Consortium, which deals with cancer in the older patients, recently met in Washington, D.C. One issue discussed was chemotherapy in older patients for nonsmall-cell lung cancer.

Rodrigo B. Erlich, co-director of the consortium, said the fit older patients should be treated like younger patients despite increased toxicity. Several other physicians echoed his recommendations.

They mentioned that, although robust phase III clinical trial data is not available, retrospective data on nonsmall-cell lung cancer patients age 70 and older who are enrolled in major clinical trials - as well as meta analytical data from trials that included older patients - indicate that fit older patients have the same response and survival rates as younger patients.

They may experience more short-term toxicity. but good modern supportive care measure can alleviates these. New targeted therapeutic agents such as Iressa and Tarceva (and other similar targeted agents) which could be very effective in selected patients, while being less toxic, may become more prevalent in the nonsmall-cell lung cancer treatment in the future.

Avastin, an antiangiogenesis drug, is one such targeted agent recently approved by the FDA for colon and lung cancers.

Other nonchemotherapeutic targeted agents in the pipeline for nonsmall-cell lung cancer include Velcade (proteosome inhibitor), Thalidomide (antiangiogeogenic), and Telcita (glutathione analogue). Telcita in particular is of interest in that it has produced a response rate of 63 percent in combination with standard chemotherapy for nonsmall-cell lung cancer in phase II clinical trials.

Initial data indicates that this agent has very little toxicity of its own and can be used for prolonged period for maintenance of remission. Telcita is currently available at the Cancer and Blood Disease Center for recurrent ovarian cancer on a prospective randomized clinical trial.

Although cancer is more prevalent in older patients, very few are enrolled in clinical trials. To find the ideal treatments for older patients, it is imperative that they be systematically studied on randomized clinical trials. The oncology community has to do a better job in convincing the referring physicians that this is an important issue.

At the same consortium meeting, Thomas Bilfinger, M.D., ScD chief of thoracic surgery at the State University of New York-Stony Brook, said "lung cancer surgery can be successful in older patients as it is in younger patients, if meticulous attention is paid to certain details."

He also said, "With this careful patient evaluation and selection procedure, age should be a simple scientific fact rather than a source of fear or discrimination in patient management."

Age is of special importance in lung cancer because the majority of patients are older than 65 and as the U.S. population ages, and the absolute numbers of lung cancer patients will rise dramatically. It is therefore better to offer existing, effective and approved treatments and to enroll older patients in clinical trials to develop safer and more effective treatments.

--V. Upender Rao, MD, FACP, practices at the Cancer and Blood Disease Center in Lecanto.

[Last modified December 19, 2005, 01:38:18]

[gail p-m]

Interesting that we don't find many people over 65 with lung cancer posting on this site. I realize that many may not be connected to the NET; however, many caregivers post here and I still don't see many over 65ers written about here. Having an 81 year old dad with lc, I would be interested in having more contact with those caring for elderly or involved with elderly lc people.

Just my ramblings for this AM.

gail p-m

[gpawelski]

The effects of aging on bodily functions and physiology, according to Michael Fisch, M.D., an assistant professor in the Department of Palliative Care and Rehabilitation Medicine at MD Anderson, cannot be ignored when making treatment and referral decisions. Pharmacokinetic processes such as the absorption, metabolism, and excretion of drugs appear to be different in older patients, and in general, a person’s physiologic tolerance or reserve diminishes with increasing age.

The process of aging reduces your organ capacitance. You may have a functioning kidney, functioning lungs, and a functioning brain, but you have less capacitance at 70 years of age than when you were 50. Older people are generally closer to some edge beyond which they would tip into a more clinically important organ dysfunction.

Dr. Fisch added that decisions about the care of older patients with cancer must take into account the stage and type of cancer and the patient’s competing risks. If you are 82 or you have other diseases, and you have cancer, it is not likely to catch up with you, he said. That is not age bias, it is just making appropriate medical decisions in the face of competing risks and the expected course of illness.

Complications of cytotoxic chemotherapy are more common in older patients (65 years of age and older) with cancer than in younger patients, and the occurrence of myelosuppression, mucositis, cardiodepression, peripheral neuropathy, and central neurotoxicity can complicate treatment. Age-related physiologic changes that can increase the toxicity of chemotherapy are decreased stem-cell reserves, decreased ability to repair cell damage, progressive loss of body protein, and accumulation of body fat. A decline in organ function can alter the pharmacokinetics of many of the commonly used chemotherapeutic agents in some elderly patients, making toxicity less predictable. Comorbidities increase the risk of toxicity through their effects on the body. Furthermore, the drugs used to treat comorbidities may interact with chemotherapeutic drugs, potentially increasing toxicity in elderly patients. Prospective trials in older patients with solid tumors have found that age is a risk factor for chemotherapy-induced neutropenia and its complications.

Anemia may be present because of the disease or its treatment, and, if left uncorrected, it can alter drug activity and increase toxicity. Being able to predict which elderly patients are at greater risk of toxicity on the basis of pretreatment factors would be valuable, and there is a need for prospective trials to determine regimen- and patient-specific prognostic factors. Effective management of the toxicity associated with chemotherapy with appropriate supportive care is crucial, especially in the elderly population, to give them the best chance of cure and survival, or to provide palliation.

Lazzaro Repetto, MD, PhD

J Support Oncol 2003;1(Suppl 2):18–24