Age no bar for treatment selection in older NSCLC patients
medwireNews: Age should not be a selection factor for treatment decisions in older individuals with non-small-cell lung cancer (NSCLC), suggest two studies published in Cancer.
One study demonstrated comparable outcomes with immune checkpoint inhibitor (ICI) therapy in patients aged at least 65 years to those observed in younger patients, while the other showed that individuals aged 70 years or more can benefit from second-line treatment with nab-paclitaxel monotherapy.
These data “have confirmed that there is no longer room for therapeutic nihilism in the management of older adults,” say the authors of an accompanying editorial.
“Fit elderly patients with preserved ECOG PS [performance status] should be treated with standard-of-care therapies similar to their younger counterparts,” they add.
The first study – by Bora Youn (Brown University, Providence, Rhode Island, USA) and colleagues – used the linked SEER–Medicare database to identify 1256 people aged at least 65 years who initiated nivolumab (92%) or pembrolizumab (8%) for stage I–IV NSCLC between 2014 and 2016.
Just under half (48.7%) of patients had at least two comorbid conditions, 11.5% were classed as having a poor PS on the basis of a proxy variable, and 12.6% had prior autoimmune conditions.
Overall survival (OS) from the initiation of ICI therapy was a median of 9.3 months in the overall cohort, with 12- and 18-month OS estimates of 43.0% and 31.3%, respectively.
Editorialists Charu Aggarwal and Corey Langer, both from the University of Pennsylvania in Philadelphia, USA, note that “[t]hese results appear favorable and are approximately comparable to our expectations with immunotherapy in younger patients.”
Multivariable analysis identified various factors that were significantly associated with worse OS, such as the presence of multiple comorbidities and squamous histology. But, interestingly, neither patient demographics nor a history of autoimmune disease were significant predictors of survival.
In light of these data and the findings from seminal clinical trials that excluded individuals with an ECOG PS higher than 1, Aggarwal and Langer recommend that “immune checkpoint inhibitors should be offered to elderly patients with conserved ECOG PS.”
They additionally highlight that “decisions should not be based on chronological age, comorbidities, or the presence of autoimmune disease alone.”
The second study was a phase 2 trial that enrolled 42 patients with stage IV NSCLC who were at least 70 years of age (mean 76 years); all had received prior treatment with a platinum doublet regimen, and prior use of an ICI was also permitted. Twenty-one percent of participants had an ECOG PS of 2, while baseline geriatric assessment identified 19% as robust, 39% as pre-frail, and 42% as frail.
Following treatment with nab-paclitaxel 100 mg/m2 on days 1, 8, and 15 of each 28-day cycle, 33.7% experienced adverse events (AEs) of grade 3–5, with decreased white blood cell count and fatigue the most common events, each occurring in 11.9% of patients.
As the incidence of grade 3–5 AEs was less than the 60% rate observed in patients aged 65 years or older in a recent trial of docetaxel, the current LCCC 1210 trial met its primary endpoint, say Jared Weiss, from the University of North Carolina at Chapel Hill in the USA, and co-investigators.
Moreover, the objective response rate was 34.2%, with one complete and 12 partial responses, and the median progression-free survival and OS durations were 5.2 and 9.3 months, respectively.
The only parameter that was significantly associated with OS in this study was frailty; median OS was 7.5 months for frail participants and 14.2 months for those who were not frail.
Weiss et al caution that these findings are “not definitive due to the nonrandomized nature of the data,” but point to “the promising efficacy of nab-paclitaxel in older patients with lung cancer.”
They add: “The results of the current study support a broad body of data demonstrating that chronologic age alone should not be used as a selection factor and that older patients can benefit from additional therapy after treatment with a platinum doublet.”
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