Non-Small Cell Lung Cancer in the Elderly: a Practical Approach to Screening, Diagnosis, and Treatment
- 39 Downloads
Purpose of Review
Lung cancer is primarily a disease of the elderly. We summarize the literature on screening, diagnosis, and treatment of early non-small cell lung cancer in the elderly population.
Lung cancer screening has resulted in a reduction in lung cancer mortality and is recommended in some patients up to 80 years old. Minimally invasive techniques, such as endobronchial ultrasound guided biopsy, have allowed for low diagnostic complications rates in elderly patients. Surgical treatment remains the standard of care; however, stereotactic body radiation therapy in non-operative candidates has similar outcomes with less morbidity. Decision to treat and choice of treatment should not be based on age alone, but should incorporate functional status, comorbid disease, and patient preference.
Advances in screening, diagnostic techniques, and radiation therapies have transformed the management of early non-small cell lung cancer in the elderly. Further studies are needed incorporating larger numbers of geriatric patients in a disease that primarily affects the elderly.
KeywordsNon-small cell lung cancer Stereotactic body radiation therapy Elderly patients Lung cancer
The views reflected in this manuscript are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or US Government.
Compliance with Ethical Standards
Conflict of Interest
Michal Sobieszczyk, Whittney Warren, Andrew Polito, and Sy Sarkar declare no conflict of interest.
William Krimsky is a part-time employee for the Medtronic corporation. He is also a consultant/CSO for Gala Therapeutics, consultant for Innovital Systems, and consultant for Peytant Solutions.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 1.In: American Cancer Society: Facts & Figures 2017. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf. Accessed February 2018.
- 2.In: SEER Cancer Statistics Review, 1975-2014. Bethesda, MD. https://seer.cancer.gov/csr/1975_2014/. Accessed February 2018.
- 4.Giroux Leprieur E, Labrune S, Giraud V, Gendry T, Cobarzan D, Chinet T. Delay between the initial symptoms, the diagnosis and the onset of specific treatment in elderly patients with lung cancer. Clin Lung Cancer. 2012;13(5):363–8. https://doi.org/10.1016/j.cllc.2011.11.010.CrossRefPubMedGoogle Scholar
- 7.Goodgame B, Viswanathan A, Zoole J, Gao F, Miller CR, Subramanian J, et al. Risk of recurrence of resected stage I non-small cell lung cancer in elderly patients as compared with younger patients. J Thorac Oncol. 2009;4(11):1370–4. https://doi.org/10.1097/JTO.0b013e3181b6bc1b.CrossRefPubMedGoogle Scholar
- 8.Humphrey LL, Johnson M, Teutsch S. U.S. Preventive Services Task Force evidence syntheses, formerly systematic evidence reviews. Lung Cancer Screening: An Update for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004.Google Scholar
- 9.Humphrey L, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, et al. U.S. Preventive Services Task Force evidence syntheses, formerly systematic evidence reviews. Screening for Lung Cancer: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.Google Scholar
- 12.•• Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395–409. https://doi.org/10.1056/NEJMoa1102873. Sentinel study that randomized 53,454 persons at high risk for lung cancer to screening with single posteroanterior chest radiography versus low-dose computed tomography. The study demonstrated significantly reduced lung cancer mortality in the group screened with low-dose computed tomography. CrossRefPubMedGoogle Scholar
- 16.Gohagan J, Marcus P, Fagerstrom R, Pinsky P, Kramer B, Prorok P. Baseline findings of a randomized feasibility trial of lung cancer screening with spiral CT scan vs chest radiograph: the Lung Screening Study of the National Cancer Institute. Chest. 2004;126(1):114–21. https://doi.org/10.1378/chest.126.1.114.CrossRefPubMedGoogle Scholar
- 19.Mahajan AK, Patel S, Hogarth DK, Wightman R. Electromagnetic navigational bronchoscopy: an effective and safe approach to diagnose peripheral lung lesions unreachable by conventional bronchoscopy in high-risk patients. J Bronchol Interv Pulmonol. 2011;18(2):133–7. https://doi.org/10.1097/LBR.0b013e318216cee6.CrossRefGoogle Scholar
- 21.Khandhar SJ, Bowling MR, Flandes J, Gildea TR, Hood KL, Krimsky WS, et al. Electromagnetic navigation bronchoscopy to access lung lesions in 1,000 subjects: first results of the prospective, multicenter NAVIGATE study. BMC Pulm Med. 2017;17(1):59. https://doi.org/10.1186/s12890-017-0403-9.CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S–e50S. https://doi.org/10.1378/chest.12-2355.CrossRefPubMedGoogle Scholar
- 25.Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155(3):137–44. https://doi.org/10.7326/0003-4819-155-3-201108020-00003.CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Takeshita J, Masago K, Kato R, Hata A, Kaji R, Fujita S, et al. CT-guided fine-needle aspiration and core needle biopsies of pulmonary lesions: a single-center experience with 750 biopsies in Japan. AJR Am J Roentgenol. 2015;204(1):29–34. https://doi.org/10.2214/ajr.14.13151.CrossRefPubMedGoogle Scholar
- 28.Boskovic T, Stanic J, Pena-Karan S, Zarogoulidis P, Drevelegas K, Katsikogiannis N, et al. Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance. J Thorac Dis. 2014;6(Suppl 1):S99–S107. https://doi.org/10.3978/j.issn.2072-1439.2013.12.08.PubMedPubMedCentralCrossRefGoogle Scholar
- 32.Walters S, Maringe C, Coleman MP, Peake MD, Butler J, Young N, et al. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007. Thorax. 2013;68(6):551–64. https://doi.org/10.1136/thoraxjnl-2012-202297.CrossRefPubMedGoogle Scholar
- 35.Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393–400.e1. https://doi.org/10.1016/j.jtcvs.2011.08.037.CrossRefPubMedGoogle Scholar
- 37.Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77–137. https://doi.org/10.1016/j.jacc.2014.07.944.CrossRefPubMedGoogle Scholar
- 38.Mason DP, Subramanian S, Nowicki ER, Grab JD, Murthy SC, Rice TW, et al. Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database study. Ann Thorac Surg. 2009;88(2):362–70; discussion 70-1. https://doi.org/10.1016/j.athoracsur.2009.04.035.CrossRefPubMedGoogle Scholar
- 39.Network NCC. Non-Small Cell Lung Cancer (Version 2.2018). https://www.nccn.org/professionals/physician_gls/pdf/nscl_blocks.pdf. Accessed February 10, 2018.
- 40.Speicher PJ, Ganapathi AM, Englum BR, Onaitis MW, D'Amico TA, Berry MF. Survival in the elderly after pneumonectomy for early-stage non-small cell lung cancer: a comparison with nonoperative management. J Am Coll Surg. 2014;218(3):439–49. https://doi.org/10.1016/j.jamcollsurg.2013.12.005.CrossRefPubMedGoogle Scholar
- 41.•• Bravo Iniguez CE, Armstrong KW, Cooper Z, Weissman JS, Ducko CT, Wee JO, et al. Thirty-day mortality after lobectomy in elderly patients eligible for lung cancer screening. Ann Thorac Surg. 2016;101(2):541–6. https://doi.org/10.1016/j.athoracsur.2015.08.067. In this study of 2,690 patients undergoing lobectomy for early stage non-small cell lung cancer, the older subgroup of patients, aged 75-80, had comparable mortality when VATs was used to perform lobectomy compared to those aged 65-69 (1.56 vs 1.27%) suggesting that in appropriately selected elders, curative lobectomy should be offered as a treatment modality with relatively low postoperative mortality. CrossRefPubMedGoogle Scholar
- 43.Mery CM, Pappas AN, Bueno R, Colson YL, Linden P, Sugarbaker DJ, et al. Similar long-term survival of elderly patients with non-small cell lung cancer treated with lobectomy or wedge resection within the surveillance, epidemiology, and end results database. CHEST. 2005;128(1):237–45. https://doi.org/10.1378/chest.128.1.237.CrossRefPubMedGoogle Scholar
- 44.•• Tsutani Y, Tsubokawa N, Ito M, Misumi K, Hanaki H, Miyata Y, et al. Postoperative complications and prognosis after lobar resection versus sublobar resection in elderly patients with clinical stage I non-small-cell lung cancer. Eur j cardiothorac surg. 2017; https://doi.org/10.1093/ejcts/ezx296. Overall survival and postoperative complications were compared in patients ≥ 75 receiving lobectomy vs sublobar resection for treatment of early non-small cell lung cancer with similar results.
- 47.Kataria S, Malik R, Jamis C, Chen L, Suy S, Collins S, et al. Stereotactic Body Radiation Therapy (SBRT) With Fiducial Tracking for Peripheral Stage I NSCLC: Electromagnetic Navigational Bronchoscopy Fiducial Placement Reduces the Risk of Pneumothorax. Chest. 2014;145(3):345A. https://doi.org/10.1378/chest.1818983.CrossRefGoogle Scholar
- 48.•• Hobbs CJ, Ko SJ, Paryani NN, Accurso JM, Olivier KR, Garces YI, et al. Stereotactic body radiotherapy for medically inoperable stage I-II non–small cell lung cancer: the mayo clinic experience. Mayo Clin Proc. 2017; https://doi.org/10.1016/j.mayocpiqo.2017.11.001. The largest single institution series examining outcomes for early stage NSCLC treated with stereotactic body radiation therapy demonstrating excellent disease control for medically inoperable patients.
- 49.Chang JY, Senan S, Paul MA, Mehran RJ, Louie AV, Balter P, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015;16(6):630–7. https://doi.org/10.1016/s1470-2045(15)70168-3.CrossRefPubMedPubMedCentralGoogle Scholar
- 56.Fruh M, Rolland E, Pignon JP, Seymour L, Ding K, Tribodet H, et al. Pooled analysis of the effect of age on adjuvant cisplatin-based chemotherapy for completely resected non-small-cell lung cancer. J Clin Oncol. 2008;26(21):3573–81. https://doi.org/10.1200/jco.2008.16.2727.CrossRefPubMedGoogle Scholar
- 58.Zhong WZ, Wang Q, Mao WM, Xu ST, Wu L, Shen Y, et al. Gefitinib versus vinorelbine plus cisplatin as adjuvant treatment for stage II-IIIA (N1-N2) EGFR-mutant NSCLC (ADJUVANT/CTONG1104): a randomised, open-label, phase 3 study. Lancet Oncol. 2018;19(1):139–48. https://doi.org/10.1016/s1470-2045(17)30729-5.CrossRefPubMedGoogle Scholar
- 63.Maestu I, Munoz J, Gomez-Aldaravi L, Esquerdo G, Yubero A, Torregrosa MD, et al. Assessment of functional status, symptoms and comorbidity in elderly patients with advanced non-small-cell lung cancer (NSCLC) treated with gemcitabine and vinorelbine. Clin Transl Oncol. 2007;9(2):99–105.CrossRefPubMedGoogle Scholar
- 65.Repetto L, Fratino L, Audisio RA, Venturino A, Gianni W, Vercelli M, et al. Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. J Clin Oncol. 2002;20(2):494–502. https://doi.org/10.1200/jco.2002.20.2.494.CrossRefPubMedGoogle Scholar
- 67.Asmis TR, Ding K, Seymour L, Shepherd FA, Leighl NB, Winton TL, et al. Age and comorbidity as independent prognostic factors in the treatment of non small-cell lung cancer: a review of National Cancer Institute of Canada Clinical Trials Group trials. J Clin Oncol. 2008;26(1):54–9. https://doi.org/10.1200/jco.2007.12.8322.CrossRefPubMedGoogle Scholar