Lung Cancer Immunotherapy in Elderly Patients: Cause for Optimism?
Targeted and immunotherapies appear to be opening a new frontier in the management of elderly patients.
Lung cancer is common among elderly patients (those aged 70 years or older). Yet because clinical cancer trials tend to enroll younger patients and those without the comorbidities often seen among elderly patients, interpreting the real-world implications of clinical trial experience is not always easy. Biological senescence yields age-related declines in heart, liver, kidney and bone-marrow function; these changes can affect anticancer agent pharmacokinetics and pharmacodynamics.1 Combination chemotherapy and chemoradiation regimens were long believed to be too toxic for elderly patients to withstand.
“Older adults do fear the toxicities from chemotherapy, especially lung cancer,” noted Ravindran Kanesvaran, MD, of the National Cancer Centre Singapore.
Evidence has accumulated since 2010, however, strongly suggesting that some elderly patients tolerate standard of care chemotherapy regimens as well as younger adults.2,3
The key, Dr Kanesvaran said, is “the right patient selection, looking at clinical factors and not just age.”
Comprehensive geriatric assessments are becoming recognized as a potentially valuable tool in assessing treatment toxicity risks among elderly patients with cancer.4 Although the topic remains controversial, a developing evidence base led some experts to conclude that fit elderly patients' tolerance of these regimens — and the benefits they can derive from them — is similar to those seen among younger adults.5
“The current standards of care for fit elderly patients are the same as for younger patients,” said Carolyn J. Presley, MD, a geriatric oncology physician in medical oncology and a Robert Wood Johnson clinical scholar at the VA Connecticut Cancer Center and the Yale Cancer Center in New Haven, Connecticut.
“Older patients should receive standard genomic testing for oncogenic driver mutations such as EGFR, ALK, and ROS-1 and subsequent directed targeted treatment the same as younger patients.”
Immunotherapies for lung cancer are another welcome advance for the field.
Immune checkpoint inhibitors are “changing the landscape,” and appear to be relatively safe and tolerable, and therefore suitable for elderly lung cancer patients, Dr Kanesvaran said.
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Second-line therapy with the PD1 receptor inhibitor, pembrolizumab, may improve overall survival in elderly patients with non-small-cell lung cancer (NSCLC). A meta-analysis that pooled data for more than 3300 patients from 6 phase 3 clinical trials concluded that immune checkpoint inhibitors like ipilimumab, nivolumab, and tremelimumab improve overall survival to a similar degree among patients aged 65 to 70 years and younger adults.6