Lung cancer in the elderly: current and future chemotherapeutic options

Lung cancer is a prevalent malignancy disproportionately affecting the elderly, and in our aging societies will only increase in magnitude. Physicians typically assume that elderly lung cancer patients will have poorer prognoses. This belief is in part based on certain physiological changes of aging affecting the kidneys, liver, and bone marrow. However, there are no data to clearly support or refute increased toxicity from chemotherapy or a lessened therapeutic effect in the elderly based on these changes, although it is a field worthy of further study. Retrospective studies of treatment of elderly non-small cell and small cell lung cancer patients do not suggest a worse prognosis based on advanced age alone. Clinicians are hampered by the lack of clinical trials focusing on or even including the elderly, despite the increased incidence of lung cancer in the elderly. Phase II studies in elderly non-small cell lung cancer patients concentrate on newer agents (vinorelbine and gemcitabine) alone or combined with platinum compounds in hopes of more favourable toxicity profiles. Phase III trials have demonstrated survival benefits, quality of life improvements, and acceptable toxicity profiles for vinorelbine compared to best supportive care alone and the combination of vinorelbine and gemcitabine compared to vinorelbine alone. Data are also sparse for elderly small cell lung cancer patients. Phase II studies focused on single agent oral etoposide also in hopes of lessening toxicity. However, phase III trials have shown improvement in survival and quality of life for multiagent intravenous chemotherapy compared to oral etoposide. Given the existing data, altering therapy for lung cancer patients based on age alone would not be warranted. Given the prevalence of the disease, future studies need to include an appropriate number of elderly patients with continued emphasis on quality of life in addition to survival.