Elderly Lung Cancer Patients Benefit From Dual-Modality Therapy

PHILADELPHIA—"Do not exclude the fit elderly from combined modality therapy for locally advanced non-small-cell lung cancer (NSCLC)," Corey. J. Langer, MD, of Fox Chase Cancer Center, reported in his poster presentation (ASCO abstract 1193). The statement was based on an evaluation of outcomes for elderly vs younger patients enrolled in RTOG 94-10, a phase III trial comparing concurrent chemotherapy/thoracic radiotherapy with standard sequential chemotherapy/thoracic radiotherapy.

In past Radiation Therapy Oncology Group (RTOG) studies of chemoradiotherapy for NSCLC, conducted between 1988 and 1993, Dr. Langer said, the combination did not appear to offer any benefit to elderly patients, compared with radiotherapy alone.

In RTOG 94-10, patients on the sequential arm (SEQ) received cisplatin (Platinol), 100 mg/m² on days 1 and 29, and vinblastine, 5 mg/m² weekly for 5 weeks, followed by 60 Gy of thoracic radiotherapy starting on day 50. The concurrent therapy-daily radiotherapy arm (CON-QD) used the same chemotherapy and 60 Gy of thoracic radiotherapy starting on day 1. The concurrent therapy-twice daily radiotherapy arm (CON-BID) used cisplatin, 50 mg/m² on days 1, 8, 29, and 36, and etoposide, 50 mg/m² twice daily on days 1-5, 8-12, 29-33, and 36-40, plus 69.6 Gy (1.2 Gy twice daily) of thoracic radiotherapy starting on day 1.

From 1994 to 1998, 610 patients with unresectable stage IIIA/B NSCLC were enrolled, with 591 evaluable. Of these patients, 103 were 70 years of age or older and 488 were less than 70 years old. Patients were fit, with Karnofsky performance status of 70 or more, 5% or less weight loss, adequate physiologic indices, and FEV₁ of 1 L or higher.

Median survival in the elderly favored concurrent chemoradiotherapy: 22.4 months for CON-QD vs 16.4 months for CON-BID vs 10.8 months for SEQ (P = .069). For those under age 70, median survival for each arm was 15.5 months, 16 months, and 15.7 months, respectively. Overall survival did not differ significantly for each arm between elderly and younger patients.

Other Outcomes Data

The researchers found that grade 3 or greater neutropenia was more pronounced in the elderly in each of the three arms. In patients receiving CON-QD and CON-BID, grade 3 or greater esophagitis was higher in the elderly (33% and 60%, respectively) vs those under age 70 (23% and 42%, respectively). "Short-term toxicities were acceptable, though more pronounced in the elderly," Dr. Langer said. Long-term toxicities were similar for both age groups.

For patients on CON-BID, the elderly were significantly less likely to complete therapy than younger patients (69% vs 87%, P = .0001), but there were no differences in therapy completion according to age for the other two arms.

Overall, elderly patients in 94-10 had "far better outcomes" than seen in previous RTOG trials of combined modality therapy, Dr. Langer said. Possible explanations include the fact that patients in 94-10 had fewer comorbidities than those in earlier trials, the physician learning curve, and improvements in toxicity management.

Dr. Langer and his colleagues concluded: "In contrast to historic precedent, fit, elderly patients enrolled on RTOG 94-10 benefited from concurrent chemoradiotherapy. CON-QD appeared superior to CON-BID with respect to survival and esophagitis rates."