Dr. Craig H. Reynolds
Dr. Carolyn J. Presley, credit Yale University
Dr. Corey J. Langer, credit DeBalko Photography
Although the care of older patients with NSCLC was a topic of discussion at previous ASCO Annual Meetings, this session will put a special emphasis on the importance of including geriatricians in care teams and providing psychosocial care, said session chair Craig H. Reynolds, MD, of Florida Cancer Specialists & Research Institute.
The session will address the importance of helping patients understand their prognosis, as well as the role of psychosocial support and palliative care. Studies suggest proactive supportive care compared to the more typical reactive model can help patients with advanced cancer avoid unnecessary treatments in the last weeks of life.1 “Interestingly enough, focusing on the prognosis and taking steps such as asking patients if they have a living will are associated with patients living longer,” Dr. Reynolds said.
Talking with patients about death is also a critical part of supportive care, particularly for patients who are terminally ill. Dr. Reynolds will discuss societal attitudes toward death and the reluctance of doctors to broach the subject. “We need to do a better job of thinking [about discussions related to] death not as drudgery but as something that is actually a good thing to discuss,” he said.
Customizing Care for Older Patients
More than half of patients with lung cancer are older than age 65 when they are diagnosed, and 30% are older than 70.2 The comprehensive care for these older patients requires a “three-pronged approach” involving oncology, as well as geriatrics and palliative care, said Carolyn J. Presley, MD, of the Yale Cancer Center.
During the session, Dr. Presley will explain some of the geriatric syndromes that oncologists should be aware of when deciding on a care plan and how to make this plan sensitive to each individual’s goals, which for older patients may include factors such as maintaining their independence. Geriatric syndromes include frailty, falls, cognitive impairment, incontinence, chronic conditions such as heart and kidney impairments, and polypharmacy, which can introduce the risk of drug–drug interactions.
“Because of an aging cancer population, geriatric syndromes and treatment burden are key concepts that will need to be addressed and incorporated when designing and delivering comprehensive cancer care for older adults,” Dr. Presley said.
She will present an overview of several risk-stratification tools for older patients that help predict chemotherapy toxicity based on a comprehensive geriatric assessment of factors, such as functional status. Studies suggest that these tools are more accurate than physicians at predicting chemotherapy toxicity and can reduce overtreatment in frail patients.3 There are currently no risk-stratification tools to guide the use of immunotherapy and novel oral agents in older patients, an area of much needed research.
Another challenge in caring for older patients with NSCLC is their underrepresentation in clinical trials. “The lack of clinical data for this population means there are knowledge gaps, particularly regarding survival outcomes and toxicity associated with treatment. Lack of evidence results in either undertreatment or overtreatment,” Dr. Presley said.
Gleaning Clinical Guidance From Trials
In his presentation, Corey J. Langer, MD, of the University of Pennsylvania Abramson Cancer Center, will highlight about a dozen clinical trials that have focused on the treatment of NSCLC in elderly patients, and subanalyses of elderly participants in trials that were not specific to this age group.
Dr. Langer will begin by describing the 1999 ELVIS trial, which showed that patients age 70 and older who received vinorelbine chemotherapy had a survival advantage compared with those who received supportive care alone.4 Although no longer relevant for clinical practice in 2017, the trial “really set the stage for doing research in the elderly population,” Dr. Langer said.
More relevant for current practice is a 2011 phase III clinical trial of patients between age 70 and 89 that demonstrated that doublet chemotherapy was associated with increased overall survival, although greater toxicity, compared with monotherapy, which had been the standard of care for patients older than 70.5
Although there are no elderly-specific clinical trials of targeted therapy or immunotherapy, there are many subanalyses of this age group. Dr. Langer will present a subanalysis his group conducted of two phase III studies that suggested adding bevacizumab to paclitaxel-carboplatin conferred a survival benefit for patients younger than age 75, but not for those 75 and older.6
“Older individuals appear to be garnering the same survival benefit from immunotherapy that their younger counterparts do,” Dr. Langer said. However, he added that more studies are needed to determine whether there is an age above which benefits are no longer seen, as well as to determine whether treatments benefit individuals with poor performance status, including those with significant comorbidities or autoimmune disease.
*Program information updated as of March 15. For session time and location information, please refer to the ASCO iPlanner on the Attendee Resource Center.