Decision making in elderly patients with lung cancer

Abstract

In the Netherlands, over 12.000 patients are diagnosed with lung cancer annually. It is mainly a disease of the elderly as half of the patients are over 70 years of age and 30% is older than 75 years. Benefit of treatment for lung cancer varies, especially in the heterogeneous population of older patients because aging is an individual process determined by a great variety in comorbidity, functional reserves and presence of geriatric syndromes in the elderly. In Part I, we analyzed current clinical practice of care for older patients with lung cancer. We found that in 88% of the currently ongoing clinical trials on lung cancer elderly patients were explicitly or implicitly excluded from participation. When analyzing the decision making progress in different age categories, we found that this process and course of treatment for lung cancer varied per age category. However, we have also found that selected oldest old patients (85 years older) can experience similar benefit from therapies as younger patients. Currently used measures for quantifying a patient’s health status and reserves, such as performance status or pulmonary function testing, do not appear to differentiate sufficiently within the heterogeneous elderly population. Care dependency, malnutrition, depressive symptoms or decreased mobility can be present in patients with normal performance status (PS). Therefore, the International Society of Geriatric Oncology (SIOG) task force recommended that a geriatric assessment should be implemented for all elderly patients with cancer. This systematic procedure is used to objectively appraise the health status across multiple domains, focusing on somatic, functional and psychosocial domains aimed at constructing a multidisciplinary treatment plan. Based on our analyses in part III, we can conclude that a GA can detect multiple health issues that are not reflected in the PS. Impairments in geriatric domains have predictive value for mortality and appear to be associated with completion of treatment. In addition, a GA can guide treatment decisions. Due to the time-consuming aspect of a GA cancer specialists are seeking for shorter screening tools to distinguish fit and frail patients. We have found that screening with G8 (geriatric8) is useful for prognostication of elderly patients with lung cancer and might be used in combination with ISAR-HP (identification of seniors at risk – hospitalized patients) to increase specificity at the cost of sensitivity. In the final part of this thesis, we have focused on patient reported outcome measures (PROMs). Scientific communities focusing on cancer research have urged for the development of trials that address patient-centered outcome measures instead of solely focusing on cancer as a disease-centered process. Based on the analysis of Part III, we can conclude that patient-centered outcome measures are included in a minority of the currently clinical trials in pulmonary malignancies and other poor prognosis malignancies. This needs to be changed in research and clinical practice, because being able to inform our patients about these aspects of treatment can help to optimize both the quality of life and the quality of dying in patients with cancer.