The management of elderly patients with lung cancer: a single center retrospective study

Introduction

Lung cancer is ranked as the leading cause of cancer mortality among malignant tumors (1). In China, lung cancer was the third leading cause of years of life lost in 2017, exceeding chronic obstructive pulmonary disease, another common respiratory disease (2). However, the focus on the treatment and prognosis of lung cancer patients in people over 80 years of age is still poorly investigated, resulting in limited treatment options for this subpopulation. Our study collected the clinical data of lung cancer patients who expired in our hospital from 1998 to 2020, to evaluate the therapeutic significance and influencing factors of these patients. The study was intended to provide recommendations for clinicians regarding the treatment options available for lung cancer patients aged 80 years and older.

We present the following article in accordance with the STROBE reporting checklist (available at http://dx.doi.org/10.21037/apm-20-2125).

Methods

Subjects

The study was approved by the PLA General Hospital Medical Ethics Committee (S2020-447-01). All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). Individual consent for this retrospective analysis was waived. Demographic and treatment information from 1998 to 2020 of deceased patients aged 80 years and older diagnosed with lung cancer were retrospectively collected in our hospital. Pathology was confirmed by histopathology and cytopathology. Patients without pathological confirmation were excluded. All patients were re-staged according to the International Association for the Study of Lung Cancer’s (IASLC) TNM classification of lung cancer (8th edition) (3).

We first evaluated the overall cohort of patients aged 80 years and older with clinical stages I to IV lung cancer [non-small cell lung cancer (NSCLC) + small cell lung cancer (SCLC)], including staging and histology. Predictors of survival were determined using a multivariable logistic regression model. The variables in this adjusted model were age, sex, smoking, comorbidity condition, and history of previous malignancy.

Overall survival of the different subgroups (stages I–IV) stratified by treatment types (i.e., chemotherapy, or tyrosine kinase inhibitor (TKI), radiation, chemoradiation, surgery, and no treatment) was assessed using the Kaplan-Meier analysis and multivariable Cox models adjusting for clinical stage, tumor location, and histology.

Statistical analysis

For all comparisons, a P value =0.05 was used to define statistical significance. Statistical analysis was performed using SPSS software, version 25.0 (IBM).

Results

Patient cohort

From 1998 to 2020, 56 patients with lung cancer were enrolled into our study. These patients had died past 80 years of age, and had complete, clinically relevant data. Lung cancer was confirmed by pathology (histopathology and cytopathology), 7 patients exhibited SCLC, and 49 had NSCLC. Adenocarcinoma was the most common pathological type. Table 1 provides additional patient characteristics. In our patient cohort, most patients displayed concurrent diseases of other systems. The most common comorbidities were hypertension and coronary heart disease. Seven patients were identified to concurrently exhibit tumors in other systems. Approximately 40% of patients had an Eastern Cooperative Oncology Group (ECOG) score of 2 points and above at the time of diagnosis.

Table 1 Baseline patient characteristics
Full table

Clinical characteristics and survival

The overall median survival time in the subject population was 9.067±1.2477 months. The median survival time of SCLC patients was 7.167±3.797 months, whereas NSCLC cancer patients displayed an overall survival of 9.500±1.493 months. The intergroup differences were not found to be significant (Figure 1 and Table 2). The effects of age and gender on the overall survival of patients were also not significant. However, smoking was shown to be a risk factor affecting the overall survival of patients (P<0.05) (Table 3). The effect of complications on patient survival was not significant.

Figure 1 Histology and survival.

Table 2 Pathology and survival
Full table

Table 3 Clinical characteristics and survival
Full table

Primary tumor characteristics and survival

In the study population, the left upper lung was the most affected site of lung cancer. Furthermore, the primary site of lung cancer significantly affected overall survival. Patients with the primary site at the left upper lung displayed the longest median survival time (Figure 2). Within our cohort, 76.8% of patients were not tested for driver gene mutations, only 2 patients exhibited epidermal growth factor receptor (EGFR) mutations, 1 displayed the v-raf murine sarcoma viral oncogene homologue B1 (BRAF) mutations, while another had receptor tyrosine kinase rearranged during transfection (RET) mutations. Furthermore, 9 had no mutations detected (Table 1).

Figure 2 Primary tumor characteristics and survival.

Treatment and survival

In the overall study population, 16 patients did not receive any treatment after diagnosis confirmation. The most common treatment was chemotherapy. Four patients underwent surgical treatment, while 9 received radiation and chemoradiation. Meanwhile, 16 of the 56 patients aged 80 years or older with stage I–IV NSCLC did not receive any therapy. Survival analysis revealed a significantly worse survival rate for patients who did not receive any treatment, compared to their treated counterparts. The patients who underwent surgery displayed the longest survival duration (Figure 3).

Figure 3 Treatment and survival.

Staging and survival

The effects of staging on patient survival are illustrated in Figure 4. In the overall population, 53.6% of patients were at stage IV at the time of diagnosis. Additionally, 33.9% of the total analysed population refused any examination to assess their condition (Table 1 and Figure 4). There was a significant correlation between progression-free survival (PFS) and overall survival. Both PFS1 obtained after the first treatment and PFS2 obtained after progression were significantly associated with survival time. However, no correlation was noted between the diagnosis-and-treatment interval and overall survival (Figure 5).

Figure 4 Stage and survival.

Figure 5 PFS1, PFS2, therapy-diagnosis time, and survival.

Conclusions

In the present study, the clinical data, treatment and survival time of 56 deceased patients with lung cancer diagnosed at our center were analyzed. Approximately one-third of patients refused tumor assessment and one-third refused treatment. An increased ECOG score, increased TNM stage, and concern for treatment side effects were the main factors for their refusal for treatment and examination. However, our study still included more treated patients compared to other investigations (4). After rigorous review, we concluded that this difference may be attributed to the development of targeted drugs with lower toxicity, which was more easily accepted by vulnerable, elderly patients. EGFR gene mutations were detected in only 2 patients, and were treated with EGFR-TKI therapy. Another 15 patients received the same treatment without gaining clear benefit. One of the limitations of the present is the small sample size, which affected the conclusion.

Our findings indicate that overall survival of treated patients exceeded that of their treatment-naïve counterparts. However, patients who received surgical removal at stage I predominantly benefited most, which was consistent with other studies (5,6). Since economic evaluation was not performed, benefit from treatment in patients with high ECOG scores and advanced TNM stages remains to be determined for future investigations.

The gradual increase in the average age of lung cancer patients, along with the growing proportion of people aged over 80 years in this population highlights the need for further evaluations into the treatment options of this group. At present, an increasing number of studies have analyzed the therapeutic effect of these patients; however, the majority of these studies were retrospective (7-9). Reports of prospective clinical drug trials, solely targeting this population are still limited (10). Furthermore, the number of clinical studies that included this population is low (11,12). Further studies are expected to evaluate the treatment and prognosis of octogenarians.

The present study retrospectively evaluated the current status of treatment in lung cancer patients, aged 80 years and older. To minimize bias, we selected data from deceased patients. Due to the retrospective nature of the study, the absence of some indicators might have affected the results. In the present study, the left upper lung was the most common site of primary lesions in these patients, with surgery observed as the best treatment for stage I patients. However, over half of the patients were at stage IV, and chemotherapy can benefit such patients. Our findings indicate that the treatment of lung cancer in patients aged 80 years and above requires re-evaluation, with multiple factors, in addition to age, needing to be considered for the most effective treatment.

Acknowledgments

Funding: This work was supported by the Tanslational Medicine Programme of Chinese PLA General Hospital (2017TM-011).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at http://dx.doi.org/10.21037/apm-20-2125

Data Sharing Statement: Available at http://dx.doi.org/10.21037/apm-20-2125

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/apm-20-2125). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the PLA General Hospital Medical Ethics Committee (S2020-447-01). All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki (as revised in 2013). Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editors: E. Tan and J. Gray)