According to the data of the sixth national census in 2010, the number of people over 60 years old in China has reached 177,648,705, accounting for 13.26% of the total population, which is 2.93% higher than the fifth survey in 2000. The data shows that with the continuous improvement of living standards, the ageing era of China has arrived.
Lung cancer is one of the most dangerous malignant tumors to human health and life in the world today, with the highest morbidity and mortality rate among malignant tumors. In China, according to statistics, 60% of cancer occurrence and 70% of cancer deaths occur in elderly people over 65 years old, which is also one of the reasons for the increase of cancer incidence and mortality in China. Among them, the incidence rate of elderly lung cancer patients is increasing year by year, with about 1.2 million new cases each year, accounting for 17.8% of cancer deaths. Among them, patients over 65 years old account for more than 50%; patients over 70 years old account for 30% to 40%. Furthermore, current evidence-based findings confirm that the only poor prognostic factor for elderly lung cancer patients is untreated disease. Therefore, research on lung cancer in the elderly has become an increasing social concern.
A 74-year-old woman, Wang Danyang, visited a local hospital 9 months ago for dizziness without obvious cause. Brain MRI suggested bilateral lacunar infarct lesions; lung CT suggested a mass-like shadow in the lower lobe of the left lung, about 2.0 cm in size. The patient then consulted a tertiary hospital in the provincial capital to prepare for lung tumor resection surgery. Although the patient had no cough, sputum, chest pain, dyspnea and hemoptysis since the onset of the disease, and there were no obvious positive signs on physical examination. However, the patient had a history of smoking for nearly 50 years, diabetes mellitus for 18 years, and hypertension for 10 years, and his blood pressure had been unstable despite regular oral antihypertensive medication. After admission, he was diagnosed with early adenocarcinoma of the lower lobe of the left lung (stage IIA) after a thorough examination. However, surgery was abandoned because of the patient’s poor pulmonary function, hypertension and diabetes mellitus, which made him unable to tolerate anesthesia and surgery. At this time, the family was at a loss, not knowing what treatment to choose next. After detailed examination and combined with the patient’s specific condition, Director Xu developed a standardized treatment plan for the patient after comprehensive evaluation. After two cycles of induction chemotherapy, the lung CT was repeated to show a significant reduction of the tumor, followed by precise radiation therapy of the lesion plus enlarged lymph nodes and then two cycles of consolidation chemotherapy. Although the patient experienced nausea and vomiting during radiotherapy and chemotherapy, the patient tolerated them all and no significant hematologic toxicity was observed, and the patient was discharged from the hospital.
I. The concept of old age
In epidemiological studies in China, 65 years of age is usually used as the criterion of old age; while in clinical trials, 70 years of age is mostly used as the lower limit of screening; foreign scholars unanimously use 70 years of age as the lower limit of screening for lung cancer in the elderly, and it is recognized by the International Health Organization.
II. Physiological characteristics of the elderly
1. elderly patients have more comorbidities, such as hypertension, coronary heart disease, chronic obstructive pulmonary disease, atherosclerosis, diabetes mellitus and cerebrovascular disease, etc.
2, the stress capacity and physiological functions of elderly patients have decreased, so the incidence of adverse events to surgical stimulation and drug treatment is higher than that of young adults.
3. Phenomena unique to the elderly: such as depression and other mental states, cognitive level, family social support, etc.
As we all know, the main treatment means of lung cancer include surgery, radiotherapy, chemotherapy and targeted therapy. The choice of tumor treatment should take into account the clinical stage, pathological type and patient’s status, etc., and only after comprehensive judgment can we choose the next treatment plan. For patients with early stage IIA lung cancer like Diana Wang, surgery should be the first choice for most of them. However, for patients with older age, more underlying diseases such as previous hypertension and diabetes, poorer lung function and physical status, they are not able to accept the risk of anesthetics and surgery. Therefore, elderly patients, especially lung cancer in the elderly, should be treated with adequate consideration of pathological type, clinical stage and patient status, etc. to select suitable treatment.
III. How to treat lung cancer in the elderly
Some studies show that nowadays, about 50% or more lung cancer patients are >65 years old at the time of diagnosis, and 30%-40% are >70 years old, and age has become one of the main reasons why patients cannot receive surgery. As the director of radiotherapy quality control center in Heilongjiang Province, Prof. Xu Xiangying introduced to us that due to the special characteristics of elderly patients with lung cancer, they should carefully choose suitable treatment options such as surgery, radiotherapy, chemotherapy and targeted therapy according to their age, tumor pathological type, clinical stage and concomitant medical diseases, such as hypertension, cardiovascular diseases, diabetes mellitus and chronic diseases of respiratory system. The treatment of early stage lung cancer in the elderly
1.Treatment options for early stage lung cancer in the elderly
Usually, early stage lung cancer patients can be treated well with surgery as long as the general condition of the patient allows and the cardiopulmonary function can be tolerated. If an elderly lung cancer patient is not suitable for surgical resection or refuses to undergo surgical treatment due to poor physical condition or many comorbidities, what treatment should we choose?
At present, the principles of early stage lung cancer treatment: Stage I, II, IIIA; as long as there is no contraindication to surgery, surgery or surgery-based comprehensive treatment should be preferred, and after surgery, according to different pathological types and clinical stages, radiotherapy should be combined with comprehensive treatment as appropriate. For patients who cannot undergo surgery or refuse surgery due to advanced age, poor physical status or medical diseases, radiation therapy can be used as a radical treatment and can obtain similar local control rates as surgery.
Radiation therapy as a radical treatment has been clearly stated in the 2013 IUCN treatment guidelines: Stereotactic body radiation therapy (SBRT) is recommended for early-stage patients who are inoperable or refuse surgery, and it can achieve local control rates and overall survival rates comparable to those of surgery. Moreover, SBRT is also suitable for patients aged ≥75 years with high surgical risk and poor lung function, and is considered appropriate for elderly patients and high-risk patients. SBRT is becoming more and more widely recognized in clinical practice.
A large number of clinical studies in Europe and America have confirmed that the 3-year local control rate and overall survival rate of inoperable elderly patients with early-stage lung cancer are 98% and 56%, respectively, after only 3 sessions of stereotactic radiation therapy. It is fully proved that SBRT is effective and safe for elderly NSCLC with better efficacy.
There are earlier and more studies on elderly lung cancer in Japan. In a study conducted in Japan on 13 radiotherapy centers for elderly stage I lung cancer, the median age was 76 years old, and only 1.1% of the patients had mild or higher pulmonary toxicity with SBRT, and the 5-year survival rates were 72% and 62% for stage IA and IB patients, respectively, and the local control rates were 92% and 73% for T1 and T2 tumors, respectively. It is fully confirmed that radiotherapy has achieved clinical effect similar to that of surgery.
Professor Xu Xiangying, director of the quality control center of radiotherapy department in Heilongjiang province, talked to us: In the past, the results of traditional radiotherapy for early stage NSCLC were disappointing, with local control rate of 40%-70% and 5-year survival rate of only 10%-30%. The main reason for this is that the dose given is insufficient and the local control rate of the lesion is low, which is due to the large target area of conventional radiotherapy, and it is difficult to increase the dose to the lesion without increasing the dose to the surrounding tissues. However, with the improvement of radiotherapy technology, 3D and 4D precise radiotherapy techniques such as conformal radiotherapy 3DCRT, image guided radiotherapy IGRT, rotational intensity modulated radiotherapy VMAT, respiratory gating, etc., have been carried out, so that the dose in the radiotherapy target area is highly concentrated, the dose is highly conformal, and the dose outside the target area decreases rapidly, which can improve the dose of the lesion and reduce the amount of surrounding normal tissue irradiated, thus improving the local control rate, reducing the adverse effects, and prolonging the patient’s survival. This can improve the local control rate, reduce the adverse reactions, prolong the survival of patients and improve the quality of life.
2.The choice of treatment for locally advanced lung cancer in the elderly
The treatment principle of locally advanced (stage IIIB) lung cancer: Since the mediastinal organ involvement and metastasis with supraclavicular region are no longer suitable for surgery, radical radiotherapy, chemotherapy or radiotherapy combination therapy can be reasonably used according to the pathological type.
In the latest cancer treatment guideline in 2013, it is stated that radiotherapy treatment for patients with locally advanced lung cancer is better than chemotherapy alone or radiation therapy alone. Circumstances permitting, concurrent radiotherapy should be chosen because the efficacy of simultaneous radiotherapy is better than sequential radiotherapy. For elderly patients with locally advanced lung cancer, simultaneous radiotherapy can achieve a better survival rate, but at the same time, it will correspondingly increase the toxic side effects of patients. However, numerous studies have shown that synchronous radiotherapy and chemotherapy are the preferred treatment for elderly patients with locally advanced lung cancer. For patients with poor physical status, multiple comorbidities, poor lung function, older age and intolerance to synchronous radiotherapy and chemotherapy, sequential radiotherapy or milder chemotherapeutic agents can be chosen, and chemotherapy and radiotherapy can be separated and performed sequentially. The survival benefit of combined radiotherapy and chemotherapy is much better than that of radiotherapy or chemotherapy alone.
3.The choice of treatment for advanced lung cancer in the elderly
Treatment principles for advanced stage (stage IV): If the patient’s general condition is still acceptable, systemic chemotherapy may be appropriate, or local symptom-reducing radiation therapy or supportive therapy aimed at reducing symptoms and improving survival quality may be used.
The 2013 cancer treatment guidelines also state that radiotherapy is recommended for elderly IV patients to relieve local symptoms, such as pain, bleeding, and obstruction. For older patients with stage IV lung cancer, there is evidence that the use of platinum-based first-line chemotherapy can significantly improve quality of life. Aggressive radiation therapy for elderly stage IV patients with distant metastatic lesions such as brain metastases and bone metastases section can achieve symptom relief, improve patients’ quality of life and prolong survival time.
Xu Xiangying, director of radiotherapy department of the hospital, said that the treatment of lung cancer in the elderly is receiving increasing attention due to the increasing incidence of lung cancer today, especially the number of elderly lung cancer patients is increasing year by year. For early-stage lung cancer patients, surgery is preferred, but most of the elderly patients are not suitable for surgery because of their comorbidities, poor lung function and poor physical condition, etc. Then, for early-stage elderly lung cancer patients, precise radiotherapy has become a radical treatment, especially SBRT with stereotactic radiotherapy, which has a short course, single high-dose irradiation, less impact on lung function, less side effects and higher survival rate. For stage III locally advanced elderly lung cancer patients, synchronous radiotherapy and chemotherapy can be preferred, but if patients with severe medical diseases and poor lung function cannot tolerate synchronous radiotherapy, sequential radiotherapy or milder chemotherapy drugs can be chosen. For IV advanced lung cancer patients with distant metastases such as brain and bone, local radiotherapy can be used to relieve symptoms, improve life quality and prolong survival time.