Treating Lung Cancer in Older Adults

Treatment options are available for people in their 80s and 90s

Senior man and doctor talking about treatment of his lung cancer
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Lung cancer in older adults is treatable just as in younger adults, and many people are surprised to hear that many potential treatments are well tolerated by people who are 80 years of age, 90 years of age, or older. With early-stage non-small cell lung cancers, surgery (especially some procedures and surgical methods) is tolerated quite well, though an alternative to surgery that is much less invasive, stereotactic body radiotherapy (SBRT) is an option that likewise offers the chance of a cure. For more advanced cancers, the newer targeted therapies as well as immunotherapy drugs are often much better tolerated than chemotherapy, and in many cases, more effective. Age alone is not a reason to forego treatment, and it's been found that choosing no treatment, in contrast to standard-of-care, lowers survival.

Lung Cancer in Older Adults

One of the myths of lung cancer has been that older adults don’t have the options for lung cancer treatment that young adults with lung cancer have. There seems to be a general thought that older adults are unable to tolerate the side effects of treatment, or that treatment should at least be “toned down.”

It's important, however, to look at what well-designed studies are telling us. After all, we are hearing that 50 is the new 30, and 70 is the new 50. This question is more important than ever to address considering that roughly a third of people diagnosed with lung cancer today are over the age of 75.

Definition of Older Adults

There isn’t a precise definition of what age implies “older adults” or “elderly” patients with lung cancer, but many studies appear to use a cut-off of age 70. If you happen to be in this age group, please read on. We are finding that chronological age is less important than other factors in determining response and ability to tolerate treatment. It is also a very exciting time, as many of the groundbreaking treatments that are being approved for lung cancer treatment, as well as those being tested in clinical trials, are often easier to tolerate than traditional chemotherapy.

Other studies use the term "elderly patients" to describe those over the age of 80. Even in studies that use this age instead of the more common age 70 to describe "older adults," you may be surprised to learn how well many of these people can tolerate treatments for lung cancer.

Lack of Treatment in Older Adults Lowers Survival

The importance of addressing lung cancer treatment in older adults is illustrated in a 2018 study that reviewed a National Cancer Database to look at how lung cancer was treated in adults 80 years and older between 2004 and 2013. The study specifically looked at treatments given for elderly adults who were diagnosed with stage III non-small cell lung cancer.

In this study, almost two-thirds of people (62.7 percent) received no treatment. None at all. Sadly, it was found that people who received no treatment were more likely than those who received standard-of-care treatment to die. People were more likely to receive treatment if they were treated at an academic cancer center, were male, or had fewer other medical conditions. There was less likelihood of treatment in people who were black or in a low-income bracket.

Some of the potential reasons for foregoing treatment included concerns over being too fragile to tolerate treatment, less willingness among the individuals to consider aggressive treatment, and concerns about whether the treatments would have any benefit. Unfortunately, lung cancer has the reputation of having a few good treatment options, a myth that persists despite the approval of many effective and often better-tolerated therapies.

Problems With Using Chronological Age

There are two primary difficulties with using chronological age in considering lung cancer treatment. First off, it’s been found that age alone doesn’t say much about how someone will tolerate these treatments.

Performance status, a measure of “well-being” is also rather poor at predicting how well someone will do. Physicians are looking at other methods for determining how a person will tolerate treatment, such as comprehensive geriatric assessment (CGA). These tools look at patient characteristics in order to predict tolerance to treatment and survival and include:

  • Nutritional status
  • The presence of other medical conditions
  • Activity level
  • Activity of daily living (ADLs)
  • Social support
  • Home environment

Another problem looking at chronological age is that we simply do not know that much. Most drugs and treatments have been studied in clinical trials on younger patients.

How Age Might Affect Lung Cancer Treatment

It's important to first point out that age doesn't decrease the benefits of treatment, but treatments may not be as well tolerated for some older adults.

The overall consensus also seems to be that age alone shouldn’t dictate what treatments can or cannot be used for lung cancer.

That said, there are several reasons why some elderly patients may not tolerate treatments as well as younger patients.

  • Older patients tend to have more co-existing medical conditions (co-morbidities) than younger patients. A history of heart disease, for example, could limit the use of some chemotherapy drugs. Likewise, conditions that limit lung function, such as emphysema, could make lung cancer surgery less optimal.
  • Older patients are more likely to have decreased kidney function or liver function, and many of the drugs used to treat cancer are filtered through the kidneys or liver.
  • Older patients often have less lean body mass, making them less tolerant of weight loss with certain treatments, and more at risk for cachexia.
  • Older patients often have less bone marrow reserve, raising the risk of complications related to bone marrow suppression from chemotherapy.

Predicting How Age Will Affect Treatment

Older patients are at risk for both under-treatment due to fears about age-related tolerance of treatment, and toxicity due to over-treatment. It is important when choosing treatment to keep two things in mind: consider the outcome, and consider your expectations as a patient.

Treatments in Older Adults

To look at treatment options, this article will break down lung cancer stages into early-stage lung cancer (such as stage I non-small cell lung cancer and some stage II cancers), locally advanced lung cancer (some stage II and stage III cancers), and stage 4 (metastatic) lung cancer. While rare, people with small cell lung cancer are candidates for surgery, immunotherapy or chemotherapy are usually the primary treatments.

There has been a general thought among some of the public that people beyond a certain age would not want to pursue aggressive treatment, and would rather have “supportive care” only, but this doesn’t seem to be the case.

When questioned about surgery in one study, 50 percent of elderly patients placed a greater priority on survival than on symptom relief.

Early Stage Lung Cancer in Older Adults

For people of any age with lung cancer, being diagnosed in the early stages offers the chance to cure the disease with surgery and/or stereotactic body radiotherapy.

Surgery Tolerance and Survival

While there seems to be a feeling among the public that surgery for lung cancer would be dangerous for older patients, studies don’t support this. In fact, there is not a consistent survival difference between older patients and younger patients who have surgery for non-small cell lung cancer. On top of this, higher rates of surgery are correlated with higher rates of survival for elderly patients with early-stage lung cancer.

Types of Lung Cancer Surgery

While there seems to be a survival advantage of older patients who have surgery for early-stage lung cancer, not all types of surgery for lung cancer are the same. Studies looking at wedge resection, segmentectomy, or lobectomy as a treatment have found that many older adults are able to tolerate the surgery quite well. A wedge resection involves removing a wedge-shaped section of lung tissue containing the tumor, a segmentectomy involves removal of a somewhat larger piece of tissue but less than a lobectomy, and a lobectomy involves removing a lobe of a lung (the right lung has three lobes and the left lung has two).

Studies have, however, found higher mortality (death rate) for older adults who undergo a pneumonectomy (removal of an entire lung). It's important to note that studies only report statistics, and a surgeon may have a much better idea about who would tolerate the surgery and who would not.

An Experienced Surgeon Is Important

For those who are considering surgery, it's worth finding a surgeon who specializes in lung cancer surgery and has experience with the surgery in older adults. For anyone, it's been found that people who have lung cancer surgery at cancer centers that perform large volumes of lung cancer surgeries have better outcomes. Given the potential risk related to age, it may be even more important to seek treatment at one of these centers (such as a National Cancer Institute designated cancer center), even if it means you will need to travel for treatment.

Minimally Invasive Surgery Should Be Considered

VATS (video-assisted thoracoscopic surgery) is a less invasive method (considered a type of minimally invasive surgery) of removing a lobe or part of a lobe and can be a good choice in selected patients (though this procedure is not always possible due to the location of a tumor). A 2018 study again confirmed that older adults (over the age of 80) tend to tolerate surgery for lung tumors as well as younger adults, but did find that segmentectomies were correlated with better outcomes.

Stereotactic Body Radiotherapy (SBRT)

For people with early-stage lung cancer that is inoperable, or if someone does not want to go through surgery, stereotactic body radiotherapy (SBRT) can be used to try and cure lung cancer, and may be considered in even very elderly people. A 2017 study found that SBRT for stage I lung cancer appeared to be both safe and effective for people aged 90 and older. Some lung cancer specialists now believe that SBRT should be the treatment of choice for early-stage lung cancer in people over the age of 80, and from 2008 to 2016, the number of surgeries performed has declined while the number of elderly people treated with SBRT has significantly increased.

SBRT is usually well tolerated, though radiation pneumonitis (inflammation of the lungs caused by radiation) is common in older patients who have this procedure. This inflammation, however, is very treatable.

Radiofrequency ablation is another method that is being evaluated as an alternative to surgery.

Pulmonary Rehabilitation

Pulmonary rehabilitation before or after lung cancer surgery can be beneficial for people of all ages, but especially for older adults.

Locally Advanced Lung Cancer in Elderly Patients

Age alone is not a contraindication (reason not to do the procedure) for removal of lung cancer (resection) and adjuvant chemotherapy (chemotherapy designed to rid the body of micrometastases—cancer cells that may be present but are too small to be seen on imaging tests). For older patients with stage I, stage II, and stage IIIA non-small cell lung cancer, surgery may be considered (see above under early-stage lung cancer regarding surgery).

With locally advanced lung cancer (stage II and stage IIIA), there is a significant risk that cancer will recur (come back) and adjuvant chemotherapy is often recommended. There is a small amount of evidence that adjuvant chemotherapy for stage II or stage IIIA lung cancer may improve survival in carefully selected older patients. Studies, however, did not find that post-operative radiation had a significant impact on this group. (Again, it’s important to state that these are statistics, and there may be good reasons a physician would recommend radiation therapy.)

For stage III lung cancers that are inoperable, the immunotherapy drug Imfinzi (durvalumab) has been approved for use after chemotherapy.

Advanced or Metastatic Lung Cancer in Older Adults

With stage IIIB and stage IV lung cancer. surgery is not usually recommended. That said, there are many treatment options.

Targeted Therapies

For people with non-small cell lung cancer, it's recommended that everyone have molecular profiling (genetic testing) before treatment is started, if possible. The best option for testing is next-generation sequencing, a test that looks for many possible genetic abnormalities in lung cancer cells, though some oncologists recommend checking a rapid EGFR test, or beginning chemotherapy until the results become available, if symptoms warrant immediate treatment.

Targeted therapies are medications that target specific pathways involved in the growth of cancer, and usually, have much milder side effects than chemotherapy. These drugs do not cure cancer, but can sometimes keep cancer at bay for an extended period of time, and are usually very well tolerated by older patients.

FDA approved therapies are now available for people who have:

Treatment may also be considered (either in a clinical trial, off-label, or expanded access) for MET mutations, RET rearrangements, and HER2 mutations.

Resistance to targeted therapies almost always develops in time, but for some mutations, such as EGFR mutations, there are now second and third generation medications available so that another drug can be used to control the growth of cancer.

Immunotherapy

The first immunotherapy drug was approved for lung cancer in 2015, and there are now four different drugs available (with different indications):

  • Opdivo (nivolumab)
  • Keytruda (pembrolizumab)
  • Tecentriq (atezolizumab)
  • Imfinzi (durvalumab)

These drugs, classified as checkpoint inhibitors, can be thought of simplistically as drugs that restore and activate our own immune system’s ability to fight off cancer. These medications do not work for everyone with lung cancer, take some time to begin working, but when effective, may sometimes result in long-term control of even advanced lung cancers. 

Both Opdivo and Keytruda appear to be fairly well tolerated and effective (increase survival) in older adults.

Chemotherapy

Chemotherapy is still sometimes used for stage 4 lung cancer if a gene mutation is not found or if resistance develops to targeted therapy (though second and third-generation targeted therapy drugs are now available for some mutations). A single chemotherapy drug (plus an angiogenesis inhibitor) may be used along with an immunotherapy drug, or chemotherapy may be used alone. When used alone, a combination of two drugs is usually recommended. Even though the side effects of chemotherapy tend to be more severe than those of targeted therapies or immunotherapy, there is a clear survival benefit in older adults who are able to tolerate the side effects.

It's important to note that the side effects people experience with chemotherapy differ tremendously than those people may have heard of in the past. Hair loss is still common, but medications to control nausea and vomiting have advanced to a point where many people have little or no nausea.

If You're an Older Adult With Lung Cancer

If you're over the age of 70 or 80 with lung cancer, keep in mind that the age you "act" and "feel" is probably much more important than the age you write on your medical records when it comes to tolerating lung cancer treatment. At the same time, medical professionals who don't know you as well as you know yourself may view the age written on your chart as more important. It is all they have to work with.

What this means, especially amidst the common myths that older adults cannot tolerate the side effects of treatment, is that you have to develop a good working relationship with your doctor. Make sure she is aware that you may be 85 years old but feel more like you are 70. If you are willing to tolerate a few side effects to live longer, make sure to speak up. While studies are telling us what older adults want and are willing to tolerate, not everyone has read those studies.

Thankfully we are living in an era when cancer treatments are becoming much more personalized, and differences between patients are being honored. That said, taking the time to learn how to be your own advocate in your cancer care will certainly help you flow with the challenges of living with cancer and cancer treatments better, but may even play a role in your outcome.

A Word From Verywell

Lung cancer in older adults has become more treatable (and often better tolerated) just as with younger adults. Unfortunately, the world hasn't necessarily caught up with these advances and elderly people who are diagnosed with lung cancer may need to speak up and ask to learn about options, or seek out care with oncologists who are experienced in working with older patients.

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