Co-morbidity and Age in Lung Cancer

Transcription

1 Co-morbidity and Age in Lung Cancer Date: August 2012 Date Presented to Cancer Committee: October 2012 By: Ian Thompson, MD INTRODUCTION The literature is increasingly replete with articles critical of the pattern of delivering less aggressive care to the elderly based solely on their chronological age. This is also an observation that applies to cancer care, with the argument that physiologic age ought to be the driver for aggressiveness of care as opposed to chronologic age alone. A recent article in the Journal of Clinical Oncology (JCO) studied the treatment choices of VA patients treated for lung cancer. They compared treatment choices based on chronologic age and on co-morbidities. That study reported that age was the strongest negative predictor for guidelinerecommended treatment regardless of stage of disease, and that co-morbidity played a much less important role in compliance with guideline recommendations. In fact the study reported that younger patients with severe co-morbidities were far more likely to receive treatments according to recommended guidelines than elderly healthy patients. STUDY The JCO article used the Charlson Co-morbidity Index (CCI) to classify comorbidities. The PeaceHealth St. Joseph Tumor Registry records co-morbidities that are reported in the patient s hospital record. The CCI is readily available on the internet with a plug-in nomogram.

2 It was possible to assess the community s compliance to recommended guidelines for differing age and co-morbidities, and compare those findings with the VA study. All Stage 3 and Stage 4 non-small cell lung cancer cases for 2011 had a review of their tumor registry abstracts, and the reported co-morbidities were classified using the CCI. Stage 3 and Stage 4 patients were separately reviewed. The groups were divided by age and also by CCI co-morbidity numbers. Age was divided into 3 groups for the VA study with the youngest group starting at age 65, but due to small numbers, the age in the local evaluation was divided into 55-75, and over 75 only. CCI comorbidity numbers in the local community evaluation used the same 3 classifications as the VA study. NCCN recommendations for Stage 3 disease allow for surgery plus radiation and chemotherapy, surgery plus chemotherapy, or radiation and chemotherapy. NCCN recommendations for Stage 4 disease include chemotherapy as appropriate. FINDINGS For the 28 Stage 3 patients over the age of 55, Table I documents the CCI comorbidity number breakdown. In the 2011 Lung Cancer, Stage III, N=28 younger group there was predominately an average amount of co-morbidity using the Age definition of the VA group. The average amount in the older age group was also the most common or > 3 3 Table I

3 Table II documents the treatment choices delivered to this group by age and by CCI co-morbidity, and Table III summarizes NCCN compliance based on age and CCI co-morbidity. 63% of patients under the age of 75 received treatment using NCCN guidelines, whereas only 11% over the age of 75 did. Ratio of treatment given for Stage III nonsmall cell lung cancer Table II or > Comorb R/C S/C S/R/C R/C S/C S/R/C 0 2/4 0/4 0/4 1/2 0/2 0/ /12 3/12 1/12 0/4 0/4 0/4 4 or > 2/3 0/3 0/3 0/3 0/3 0/3 Ratio of any NCCN recomm tx Stage IIII nonsmall cell lung cancer 0 2/4 1/ /12 0/4 4 or > 2/3 0/3 TOTAL 12/19 1/9 Table III In the VA study only 35% of all regional disease patients received recommended care, while locally, 46% did. The degree of co-morbidity seemed to make no difference in treatment choices for the younger age group and the small numbers do not allow for a definitive answer in the older patients.

4 There were 52 Stage 4 patients over the age of 55. Table IV documents the breakdown by age and CCI co-morbidity number. There were a surprisingly low number of high co-morbidities in this group of patients 2011 Lung Cancer, Stage IV, N=52 Age or > 2 4 Table IV Table V documents the breakdown of patients who received chemotherapy. 38% of those under 75 received chemotherapy, whereas 11% over the age of 75 received chemotherapy. In the stage 4 patients, CCI co-morbidity may have played some role in treatment choice in the younger age groups and no role (or an inverse one?) in the older age group. Ratio of treatment given Stage IV nonsmall cell lung cancer or > Comorb Chemo given 0 6/14 (42%) 0/ /18 (38%) 1/10 4 or > 0/2 (0%) 1/4 TOTAL 13/34 (38%) 2/18 (11%) Table V In the VA study, the rates of receiving chemotherapy dropped from 34% in the youngest age group to 10% in the oldest age group, which pretty much mirrored the local community s numbers. The number of no co-morbidity unrelated to age local community patients who received chemotherapy was 33% while the VA study number was 30%, and the severe co-morbidity unrelated to age local community number who received chemotherapy was 16% compared to the VA study number of 23%.

5 SUMMARY PeaceHealth St. Joseph cancer patients, like most patients of all disease types seem to have aggressive treatment choices made based on chronologic age more than on co-morbidity status. This age discrepancy is most noted in stage 3 lung cancer patients but also noted in Stage 4 patients. It is reassuring to note, that regardless of age and co-morbidity choices, more patients were treated according to guidelines than the published VA study. References: 1. Cuffe S, Booth CM, et al. Adjuvant Chemotherapy for Non-Small-Cell Lung Cancer in the Elderly: A Population-Based Study I Ontario, Canada. J Clin Oncol 2012; 30 (May 20): Wang S, Wong,MI, et all. Impact of Age and Comorbidity on Non-Small-Cell Lung Cancer Treatment in Older Veterans. J Clin Oncol 2012; 20 (may1): PeaceHealth St. Joseph Medical Center, Cancer Registry data, accessed August 2012.