Role of Chemoradiotherapy in Elderly Patients With Limited-Stage Small-Cell Lung Cancer

Abstract

PurposeTo investigate outcomes for elderly patients treated with chemotherapy (CT) alone versus chemoradiotherapy (CRT) in the modern era by using a large national database.Patients and MethodsElderly patients (age ≥ 70 years) with limited-stage small-cell lung cancer clinical stage I to III who received CT or CRT were identified in the National Cancer Data Base between 2003 and 2011. Hierarchical mixed-effects logistic regression with clustering by reporting facility was performed to identify factors associated with treatment selection. Overall survival (OS) of patients receiving CT versus CRT was compared by using the log-rank test, Cox proportional hazards regression, and propensity score matching.ResultsA total of 8,637 patients were identified, among whom 3,775 (43.7%) received CT and 4,862 (56.3%) received CRT. The odds of receiving CRT decreased with increasing age, clinical stage III disease, female sex, and the presence of medical comorbidities (all P < .01). Use of CRT was associated with increased OS compared with CT on univariable and multivariable analysis (median OS, 15.6 v 9.3 months; 3-year OS, 22.0% v 6.3%; log-rank P < .001; Cox P < .001). Propensity score matching identified a matched cohort of 6,856 patients and confirmed a survival benefit associated with CRT (hazard ratio, 0.52; 95% CI, 0.50 to 0.55; P < .001). Subset analysis of CRT treatment sequence showed that patients alive 4 months after diagnosis derived a survival benefit with concurrent CRT over sequential CRT (median OS, 17.0 v 15.4 months; log-rank P = .01).ConclusionIn elderly patients with limited-stage small-cell lung cancer, modern CRT appears to confer an additional OS advantage beyond that achieved with CT alone in a large population-based cohort. Our findings suggest that CRT should be the preferred strategy in elderly patients who are expected to tolerate the toxicities of the combined approach.

Treatment of limited-stage small cell lung cancer in the elderly, chemotherapy vs. sequential chemoradiotherapy vs. concurrent chemoradiotherapy: that’s the question

“…Propensity score matching confirmed a survival benefit of CRT over CT (HR =0.52; 95% CI, 0.50-0.55; P<0.001), with a 3-year OS of 20.6% (95% CI, 19.2-22.1%) for the matched CRT group and 6.6% (95% CI, 5.7-7.5%) for the CT group (19).…”

“…A subset analysis restricting the CT cohort to patients for whom RT was explicitly recommended but not delivered (335 of 3,775 patients) was performed to reduce selection bias of this retrospective trial. The survival benefit for CRT persisted, with a median OS and 3-year OS of 15.6 months and 22.0% (unchanged) respectively, compared to 11 months and 10.6% for the cohort of 335 patients receiving CT (19).…”

“…Based on this premise, in the here discussed study Corso et al have recently investigated outcomes for elderly patients treated with CT alone compared to chemoradiotherapy in the modern era (19). Investigators conducted a populationbased retrospective analysis using the National Cancer Data Base (NCDB), and identified 8,637 elderly patients (age ≥70 years) with LD-SCLC (defined as clinical stage I to III disease, cT0-T4, cN0-N3, cM0) who were treated with CT (3,775 patients; 43.7%) or CRT (4,862 patients; 56.3%) between 2003 and 2011.…”

“…Corso et al (19) try to define the best strategy of treatment in elderly conducting this retrospective analysis on more recent data [2003][2004][2005][2006][2007][2008][2009][2010][2011], although it was weighed by inherent multiple bias and by the lacks information on performance status, on prophylactic cranial irradiation, and on CT regimens used. Notably, they not clarified the reasons why patients treated with CT alone did not receive thoracic radiotherapy, probably unfit to thoracic radiotherapy or with an early disease progression and so never eligible to thoracic irradiation.…”

Treatment of limited disease small cell lung cancer: the multidisciplinary team

“…Typically, multiple disciplines are involved during radiochemotherapy; side-effects such as neutropenic fever, pneumonia or oesophagitis require rapid and precise communication to initiate timely counter-measures and potentially adapt treatments, avoiding unnecessary treatment breaks. It should be noted that age alone should not be considered a prohibiting factor to concurrent treatment [66].…”