NSCLC treatment provides significant survival benefit in the oldest old

Treatment of non-small-cell lung cancer (NSCLC) provides significant overall survival (OS) benefit in patients aged ≥90 years and should not be withheld based on old age alone, according to an analysis of data from the US National Cancer Database.

The analysis included 7,205 patients aged ≥90 years who were diagnosed with stage I–IV NSCLC between 2004 and 2014 (stage I, 19.9 percent; stage II, 7.6 percent; stage III, 20.7 percent; stage IV, 51.8 percent). Most patients did not have a significant number of major comorbidities – a Charlson/Deyo comorbidity score (CDCS) of ≥2 was noted in only 13.3 percent of the patients. [Ann Thorac Surg 2019, doi: 10.1016/j.athoracsur.2019.09.027]

In the entire cohort, the 5-year OS rate was 4.9 percent. Those who received treatment for NSCLC had a significantly higher 5-year OS rate than those who received no treatment (9.3 percent vs 1.7 percent; adjusted hazard ratio [HR], 0.53; p<0.001).

Patients with stage I NSCLC were found to have the most pronounced OS benefit from curative-intent treatment, with a median OS of 27.4 months compared with 10.0 months among those who received no treatment and a 5-year OS rate of 20.9 percent vs 6.2 percent (HR, 0.37; 95 percent confidence interval [CI], 0.29 to 0.47; p<0.001).

Among patients with stage I disease, surgery was associated with a significantly higher 5-year OS rate (33.7 percent) compared with nonsurgical therapy (17.1 percent) or no treatment (6.2 percent). The adjusted HR for surgery and nonsurgical therapy vs no treatment was 0.30 (95 percent CI, 0.22 to 0.41) and 0.41 (both p<0.001), respectively.

In patients with stage II or III disease, curative-intent treatment was also associated with significant improvements in OS compared with no treatment. Median OS was 12.8 months vs 4.5 months, with 5-year OS rates of 9.2 percent vs 2.2 percent (HR, 0.32; 95 percent CI, 0.21 to 0.49; p<0.001), for those with stage II disease. In those with stage III disease, median OS was 11.6 months vs 2.3 months, while 5-year OS rates were 9.5 percent vs 1.7 percent (HR, 0.55; 95 percent CI, 0.38 to 0.80; p=0.002).

Improved OS was also seen in patients with stage IV disease who received treatment compared with those who received no treatment (median, 4.4 months vs 1.5 months; 5-year OS rate, 2.2 percent vs 0.5 percent; HR, 0.60; 95 percent CI, 0.49 to 0.73; p<0.001).

Despite the OS benefit, 57.6 percent of patients in the overall cohort did not receive any treatment for NSCLC. “Of note, patients managed at an academic centre were more likely to receive treatment compared with those managed at community cancer hospitals,” noted the authors.

Among patients who received treatment, radiation therapy (RT) was the most commonly used strategy, with 23.4 percent of patients receiving RT alone, 4 percent receiving chemoradiation therapy, and 5.3 percent receiving stereotactic body RT. Only 3.6 percent of patients were treated with surgery, and 6 percent of patients were treated with chemotherapy.  

According to the authors, results of this analysis suggest that NSCLC treatment should not be withheld for the oldest old patients based on their age alone. “Rather, treatment should be considered based on disease stage and the patients’ preferences in a multidisciplinary setting,” they concluded. “For appropriately selected nonagenarians with earlier-stage NSCLC, surgery may potentially be the optimal treatment strategy.”