Clinical investigation: lung
Do age and comorbidity impact treatment allocation and outcomes in limited stage small-cell lung cancer? a community-based population analysis

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Abstract

Purpose

The effects of age and comorbidity on treatment and outcomes for patients with limited stage small-cell lung cancer (L-SCLC) are unclear. This study analyzes relapse and survival in a community-based population with L-SCLC according to age and comorbidity.

Methods

A retrospective review was performed on 174 patients with L-SCLC referred to the British Columbia Cancer Agency, Vancouver Island Centre, between January 1991 and December 1999. Patient and treatment characteristics, disease response, relapse, and survival were compared among three age cohorts: <65 years (n = 55, 32%), 65–74 years (n = 76, 44%), and ≥75 years (n = 43, 25%); and according to Charlson comorbidity scores 0, 1, and ≥2. Multivariate analysis was performed to identify independent prognostic factors associated with treatment response and survival.

Results

Patient factors that significantly differed with age were functional status classified by Eastern Cooperative Oncology Group performance status and number of comorbidities. Increasing age was significantly associated with fewer diagnostic scans. Combined modality chemoradiotherapy (CRT) was given in 86%, 66%, and 40% of patients ages <65, 65–74, and ≥75 years, respectively, (p <0.0001). Thoracic irradiation use was comparable among the age cohorts (p >0.05), but chemotherapy use varied significantly with less intensive regimens, fewer cycles, and lower total doses with advancing age (p <0.05). Prophylactic cranial irradiation (PCI) was used in 41 patients, only 3 of whom were age >70 years. Overall response rates to primary treatment significantly decreased with advancing age: 91%, 79%, and 74% in patients ages <65, 65–74, and ≥75 years, respectively (p = 0.014). Treatment toxicity and relapse patterns were similar across the age cohorts. Overall 2-year survival rates were significantly lower with advancing age: 37%, 22%, and 19% (p = 0.003), with corresponding median survivals of 17, 12, and 7 months among patients ages <65, 65–74, and ≥75 years, respectively. On multivariate analysis, age and Charlson comorbidity scores were not significantly associated with treatment response and survival. Independent prognostic factors favorably associated with survival were good performance status, normal lactate dehydrogenase, absence of pleural effusion, and ≥four cycles of chemotherapy.

Conclusion

Increasing age was associated with decreased performance status and increased comorbidity. Older patients with L-SCLC were less likely to be treated with CRT, intensive chemotherapy, and PCI. Treatment response and survival rates were lower with advancing age, but this may be attributed to poor performance status and suboptimal treatment rather than age.

Introduction

Management of limited stage small-cell lung cancer (L-SCLC) has become more defined in the last decade, with randomized controlled trials (RCTs) demonstrating improved local control and survival with combined modality chemoradiotherapy (CRT) with multiagent chemotherapy (1), thoracic irradiation (TI) 2, 3, and prophylactic cranial irradiation (PCI) for complete responders (4). Despite initial response rates to CRT of approximately 80%, median survival remains modest at 12–24 months 1, 2, 3, 4, 5, 6, 7, 8. Incidence and mortality of SCLC increase with age (9, but the prognostic significance of age in L-SCLC is unclear. Results from clinical trials, which have accrued few subjects 65 years and older (10), cannot be readily extrapolated to the elderly patients with intercurrent medical problems frequently encountered in community practice. This study analyzed the effects of age and comorbidity on treatment delivery and outcomes in a population-based cohort of L-SCLC patients referred to a regional cancer center.

Section snippets

Methods and materials

The British Columbia (BC) Cancer Agency database was used to identify patients referred to the BC Cancer Agency, Vancouver Island Centre, between January 1, 1991 and December 31, 1999, with L-SCLC. Patient records were retrospectively reviewed to obtain data on patient characteristics, treatment, and clinical outcomes. Among 189 patients identified, 15 patients were excluded because they did not have L-SCLC (n = 13) or their case records could not be located (n = 2). The remaining 174 patients

Results

In this study cohort of 174 patients with L-SCLC, the median age was 68 years (range 35–86 years). Thirty-two percent (n = 55), 43% (n = 76), and 25% (n = 43) of these patients were ages <65, 65–74, and ≥75 years at diagnosis, respectively. At the time of analysis, 152 (87%) were deceased. Median follow-up time for patients alive was 52 months (range 10–92 months). Three patients were lost to follow-up at 10 months, 20 months, and 39 months, respectively.

Because of this study’s long accrual

Discussion

This analysis of a community-based cohort with L-SCLC has identified significant variations in patient and treatment characteristics according to age. Response and survival rates were lower with increased age and comorbidity; however, age and comorbidity were not independent factors affecting these unfavorable outcomes.

The caveat in extrapolating results from L-SCLC RCTs to the general population is underscored by the observations that, although most RCTs do not specifically exclude older

Conclusion

This study has confirmed that patient characteristics of a community-based cohort of L-SCLC patients differed from those typically enrolled in RCTs. Performance status declined and comorbidity increased significantly with advancing age. Elderly patients had less complete staging and received less intensive chemoradiation and PCI. With increasing age, response rates and overall survival significantly declined. Age and comorbidity, however, did not emerge as independent prognostic factors

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