Treating Lung Cancer in Older Adults

Options are available for people in their 80s and 90s

In This Article

Lung cancer is a disease that predominantly affects older adults. In fact, about 50% of those diagnosed with lung cancer are age 70 or older and about 14% are over 80. Lung cancer in older adults is as treatable as it is in younger adults. Surgery, chemotherapy, and other options to cure cancer or halt its spread are well tolerated by people who are in their 80s or 90s.

Unfortunately, many people don’t realize this. In fact, research shows that patients in this age range are less likely to receive treatment. In one study, close to 63% of adults age 80 or older underwent no form of treatment at all after being diagnosed with stage 3 lung cancer.

The truth is age alone is not a reason to forego treatment. Options for early-stage and, potentially, even advanced-stage lung cancer treatments can effectively give you more and fuller years of life.  

Ability to Tolerate Treatment

Cancer treatment options are usually broken down into stages of non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC).

Early-stage treatment options are considered for stage 1 and some stage 2 NSCLC, as well as some limited-stage small cell lung cancer (SCLC).

Locally advanced lung cancer treatment options are used with some stage 2 and stage 3 NSCLC and extensive SCLC.

Treatment for advanced lung cancer is offered for those with metastatic lung cancer, which occurs in stage 4 NSCLC and extensive SCLC.

Treatment is appropriate for older adults at any of these stages. There are some who think that adults in their 80s or 90s are too "fragile" to pursue aggressive treatments for late stages or that lung cancer treatment, in general, offers little benefit. Fortunately, even older adults can see positive results from therapies.

That's not to say that every lung cancer treatment options is equally appropriate or safe for people of all ages or health profiles. But as treatments become more advanced, they're often better tolerated by adults of every age compared to options available in previous decades.

Options for Early Stage Lung Cancer

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

While there may be a concern that surgery could be dangerous for older adults, research shows that survival rates for older patients are comparable to younger patients for various types of surgery for lung cancer.

Surgery

There are four main types of surgery that are performed in an effort to remove lung cancer cells:

  • A wedge resection involves removing a wedge-shaped section of lung tissue containing the tumor.
  • A segmentectomy involves the removal of a somewhat larger piece of tissue than the wedge resection.
  • A lobectomy requires the removal of a complete lobe of a lung (the right lung has three lobes and the left lung has two).
  • pneumonectomy is the removal of an entire lung.

Studies looking at wedge resection, segmentectomy, or lobectomy for lung cancer treatment have found that many older adults are able to tolerate the surgery quite well, and those over age 80 don’t seem to have a higher risk of complications compared to adults 10 or more years younger. 

The same studies, however, found that a pneumonectomy still seems to be highly risky for octogenarians, and older lung cancer patients have significantly lower survival rates after the complete removal of a lung.

Of course, studies only report statistics, and a surgeon may have a much better idea about which type of surgery would offer you the best results based on your overall health and cancer.

It's worth searching for a surgeon who specializes in lung cancer and has experience operating on older adults. It's also recommended that you seek a second opinion. Consider consulting with doctors at one of the larger National Cancer Institute-designated cancer centers. To do so, you need to travel or deal with some inconvenience, but you are more likely to find someone with expertise that matches your specific needs.

VATS: Minimally Invasive Surgery

The removal of lung tissue is usually be done through one of two procedures. The more traditional surgical technique is called an open procedure. An incision is made in the chest, the ribs are spread apart, and the cancerous tissue is removed. 

A newer type of procedure is known as video-assisted thoracoscopic surgery (VATS). This is a less invasive method. The surgeon makes a few small incisions in the chest, and then, with the assistance of a camera, uses small instruments to operate without fully opening up the ribcage.

Depending on where the tumor is located, VATS may not be an option. But when it is, this minimally invasive approach has been recommended by researchers because of the lower risk of complications and the reduction in time needed for surgery, which can help ensure the operation is successful.

Specific studies of lung cancer patients over 65 show that VATS and open chest procedures have better postoperative results and similar long-term survival rates compared to open chest procedures.

Benefits of Pulmonary Rehabilitation

Pulmonary rehabilitation involves using exercises, lifestyle changes, and education to help improve shortness of breath and exercise tolerance, which can improve quality of life. As part of a complete course of treatment, it may be prescribed before or after lung cancer surgery. Pulmonary rehabilitation can be beneficial for people of all ages, but especially for older adults.

Stereotactic Body Radiotherapy (SBRT)

If your early-stage lung cancer is inoperable, or if you prefer not to go through surgery, stereotactic body radiotherapy (SBRT) may be the best mode of treatment.

Research has found that SBRT for stage 1 lung cancer appears to be both safe and effective for people age 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. In fact, the number of surgeries performed on such patients with early-stage lung cancer has steadily declined while the number of those treated with SBRT has significantly increased.

SBRT is usually well tolerated. Radiation pneumonitis, inflammation of the lungs caused by radiation, is common in older patients who have this procedure, but it is very treatable.

Radiofrequency Ablation

Radiofrequency ablation is another alternative to surgery. This minimally invasive procedure has shown promise in eradicating tumors.

Using just a local anesthetic, doctors insert thin probes through the skin to the tumor site and then transmit high-energy waves that heat the tumor and destroy it.

In cases where there are concerns about older adults undergoing surgery, this procedure is being considered as a possible treatment.

Options for Locally Advanced Lung Cancer

In some forms of stage 2 and stage 3 NSCLC, tumors may be large and have spread to nearby lymph nodes or they may be small and have traveled to distant lymph nodes.

Surgery may continue to be an option at this point. However, since there is a greater risk that the cancer will recur, other treatments may be used in conjunction with surgery or in place of it.

Adjuvant Chemotherapy

With chemotherapy, doctors inject a combination of drugs intravenously. These will act on cancer cells throughout the body.

Adjuvant chemotherapy refers to treatments that are administered after surgery to kill any cancer cells that couldn’t be removed during the operation or to rid the body of micrometastases, cancer cells that may be present but are too small to be seen on imaging tests. 

While there are risks of toxicity in older adults, research has shown that adjuvant chemotherapy can improve the prognosis of lung cancer patients over 75 years of age who undergo surgery for locally advanced NSCLC. 

Radiation

By delivering high-energy radiation to any remaining tumors after surgery, radiation therapy also acts as an adjunct therapy to support surgery. This seems to be an effective treatment for all age groups.

Other studies have found that chemoradiation, treating patients with both radiation and chemotherapy, improves the prognosis for older adults. The most effective method for elderly patients seems to be to administer radiation more than 30 days after chemotherapy. 

Options for Advanced or Metastatic Lung Cancer

With stage 3B and stage 4 NSCLC, as well as extensive SCLC, surgery may be used to help manage cancer in older adults. This is not typical, however. Instead, doctors will usually focus on systemic treatments that help relieve symptoms, extend life, and, when appropriate, act as palliative care.

Targeted Therapies

Targeted therapies are medications that target specific pathways involved in the growth of cancer. These may include:

  • Angiogenesis inhibitors: Drugs that stop tumors from growing by targeting blood vessels around the cancer
  • Gene mutation therapy: Drugs that target specific genetic mutations in cancer cells that shrink them or stop them from growing.

These drugs may be used by themselves or with chemotherapy.

Targeted therapies do not cure cancer, but they can sometimes keep cancer at bay for an extended period of time and are usually very well tolerated by older patients.

For people with non-small cell lung cancer, it's recommended that everyone have molecular profiling (genetic testing) before treatment is started, if possible. This will allow your doctors to determine whether using medications that specifically target cells with certain genetic mutations would be useful.

There are now available therapies approved by the U.S. Food and Drug Administration (FDA) 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. However, 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

One of the many difficulties that come with aging is a phenomenon known as immunosenescence, which refers to a decline in the immune system. This affects many older adults and may be a reason for the increased rates of cancer among this age group.

There is a growing interest among researchers to understand how immunotherapy, which boosts the immune system so you can better fight cancer, can offset the effects of immunosenescence. For now, immunotherapy medications, known as immune checkpoint inhibitors, have been shown to improve survival outcomes in mature patients treated for advanced NSCLC.

Four immunotherapy drugs that have been approved by the FDA for lung cancer treatment each of which has different indications:

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

These medications do not work for everyone with lung cancer and may take some time to begin working. But when effective, they can result in long-term control of even advanced lung cancers. 

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

Chemotherapy

When chemotherapy is used for advanced metastatic cancer, it is usually administered as palliative therapy to reduce pain and improve quality of life. It is not intended to cure the disease.

Chemotherapy may be used alone or along with an immunotherapy drug. When used by itself, a combination of two chemo drugs is usually recommended. 

Because older adults are rarely included in clinical trials for chemotherapy, there isn’t strong evidence of how effective these medications are for older adults with lung cancer.

Other health problems that one might have in addition to lung cancer are a concern for chemotherapy. Certain heart conditions that are more common in older adults, for instance, can put a patient at risk for complications from chemotherapy.

These factors should be considered when making a plan for treatment, but they should not automatically disqualify older adults from trying the treatment. Instead, the person’s individual health and goals should be considered when weighing treatment options.

Even though the side effects of chemotherapy tend to be more severe than those of targeted therapies or immunotherapy, it's important to note that the side effects people experience today differ tremendously than those experienced by patients 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.

Factors in Decision Making

Chronological age alone should obviously not be what dictates one's lung cancer treatment plan. Still, there are age-related realities that do need to be considered when you and your doctor are reviewing options.

  • Lack of clinical studies: Most drugs and treatments have been studied in clinical trials on younger patients, so it's not always clear how they will work for adults who are in their 70s, 80s, or 90s.
  • Comorbidities: This refers to other medical conditions you may have in addition to lung cancer. Older patients tend to have more co-existing medical conditions than younger patients. For example, conditions that limit lung function, such as emphysema, could make lung cancer surgery less optimal.
  • Decreased kidney function or liver function: Older patients are more likely to have these problems, which may make some drug treatments problematic if they are filtered through the kidneys or liver.
  • Less lean body mass: A decrease in lean body mass is common among older adults. This can make you less tolerant of weight loss that occurs with certain treatments and make you more at risk for cachexia, unintended weight loss, loss of appetite, and wasting of muscle mass.
  • Less bone marrow reserve: When this occurs among older patients, it can raise the risk of complications related to bone marrow suppression from chemotherapy.

While these conditions may cause some challenges for some mature patients, they should not preclude anyone from seeking treatments that are able to be tolerated.

The Complete Picture

If you're over the age of 70 or 80 with lung cancer, keep in mind that—to an extent—the age you act and feel is probably more important than your actual age when it comes to tolerating lung cancer treatment. This is in large part because that is often reflective of your overall health and lifestyle, which factor into treatment outcomes.

But medical professionals who don't know you as well as you know yourself may view the age written on your chart as more important if it's all the information they have to work with.

Physicians should consider other factors (beyond age) when working to determine how a person will tolerate treatment, such as those covered in the comprehensive geriatric assessment (CGA). This includes:

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

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 doctors.

Make sure they are aware that you may be 85 years old but feel more like you're 70. If you are willing to tolerate a few side effects to live longer, make sure to speak up. With this being considered, also know that certain facts about your health profile may still make some treatment options ill-advised, medically speaking.

Thankfully, we are living in an era when cancer treatments are becoming much more personalized, and differences between patients are being honored. Nevertheless, 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. They 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 older people who are diagnosed with lung cancer may need to advocate for themselves and ask to learn about options. Seeking out care from oncologists who are experienced in working with older patients can help in this regard.

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