Prescribing adjuvant chemotherapy in elderly patients
Dr Ajeet Gajra - Upstate Medical University, Syracuse, USA
In terms of adjuvant chemotherapy for the older patient there are multiple challenges. First of all, we need to recognise that not all older patients receive surgical therapy which is a standard of care. For the patients that do receive surgical therapy and have either stage 2 or stage 3 disease the standard of care is that they should receive cisplatin based adjuvant chemotherapy. However, we all recognise that cisplatin is hard to administer to older patients and that’s where all the challenge and the controversy comes in. So we reviewed significant literature, most of it retrospective because there aren’t prospective studies in this patient population, and what we discovered is that a very small minority of old adults actually gets offered adjuvant chemotherapy.
Could you be treating many more patients?
I think some of the hesitation on the part of the treating medical oncologist stems from the fact that they fear the toxicity of cisplatin. So in the review that we conducted it appears that two important things come up and, again, I recognise that this is all retrospective and from large databases – the SEER database in the United States, also the Veterans Administration provides a huge information source in the United States. What we found was that it appears that carboplatin based therapy might be as effective as cisplatin based therapy, which is the standard, so it may not be wrong because what we recognised was that patients received a survival advantage very similar to cisplatin based therapy in these retrospective analyses. Carboplatin is easy to give so there is no major concern regarding that. The other thought is that perhaps we recognise, even in large prospective trials, there’s the IALT trial, the ANITA trial and the JBR.10 trials and we looked at the subset of patients in those trials who were older, mainly over age 65. They do receive, they’re able to withstand, lower dose intensity but they still get the survival benefit so it may be OK, it may be alright to lower the dose and still try to treat them.
What would you say to doctors concerned about frailty?
For the most part, if an older individual is able to sustain a lobectomy, which is quite a major operation, then I think they’re mostly in reasonable health. However, having said that, a post-operative state can itself render an older adult somewhat frail. So ideally we should be utilising geriatric assessment, or at least an abridged version of that, more frequently. I did allude to some of the studies that have been conducted as the so-called CARG tool or Cancer and Aging Research Group has developed such an index which has now been validated in a subsequent study. But that just helps to risk stratify patients to recognise who are at the highest risk for toxicity.
How much additional time and quality of life could this provide a patient?
A very, very valid question. Based on what we have in terms of various meta-analyses for adjuvant therapy in lung cancer if people receive four cycles of cisplatin based therapy on an average we gain about 5% absolute improvement in survival. However, this is very similar to various other manoeuvers, especially in adjuvant therapy, that are popularly practised in the cancer field. But, having said that, we need to understand and really find out the patient’s preference first. An older individual might not have the same attitude towards going through additional chemotherapy for a finite amount of life gain. So to present it to the older person first is crucial and sometimes we don’t do a good job, we either assume that they wouldn’t want it and don’t even present it to them, or else we try to be very data driven and say that everybody should get it and then inflict a load of toxicity on them. So I think an honest open discussion for the patient preference is vital.
What is the take-home message for clinicians?
A few things: number one, again as is the theme, chronologic age has really no relevance. If the patient, even if they are older but they are fit, then they should essentially be treated like a younger individual and get the same sort of therapy, or at least be offered the same sort of therapy. If they are vulnerable, although hopefully not frail, we should consider a carboplatin based therapy if we feel that there are contraindications to cisplatin. Alternatively, it may be reasonable to just start out with a lower dose of cisplatin to assess their tolerance. One other thing that we did come across, which is quite crucial, is that there is really no justification to offer this sort of treatment to patients over the age of 80 years. What was seen was that there was probably more harm than good and so perhaps, even though we said chronologic age has no relevance, but for octogenarians we do have to bear that in mind.