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The US lung cancer population is aging, the majority of which receive a diagnosis of incurable advanced non-small cell lung cancer (NSCLC). In US clinical oncology practice, elderly is defined as patients older than 70 years. Treatment of elderly patients with advanced NSCLC is complex. Choosing appropriate chemotherapy in this setting is complicated by multiple chronic conditions in addition to geriatric syndromes, challenging the traditional oncology practice. Although promising new options are on the horizon, the standard of care remains either platinum-based doublet or single-agent chemotherapy. Clinical trials have determined doublet therapy is appropriate for elderly patients; however, out of concern for excessive toxicity, many elderly patients do not receive appropriate treatment. Determining which patients are most likely to benefit from doublet chemotherapy versus monotherapy is a difficult challenge. Researchers have started to implement geriatric assessment and predictive chemotherapy toxicity tools in prospective clinical trials; however, knowledge gaps remain on how to appropriately select and treat elderly patients with advanced NSCLC in efforts to improve disease management and symptoms, maintain functional status, and minimize toxicity.

Background: Because the elderly are underrepresented on clinical trials, physicians have few sources of information to estimate the risks (ie, toxicities) and benefits of chemotherapy administration to the elderly. Objective: Our goal was to determine whether the standard measures of toxicity used in clinical trials could be captured from observational Medicare claims data. Methods: We identified 175 elderly clinical trial patients treated on 2 Cancer and Leukemia Group B (CALGB) trials (9344, adjuvant breast study and 9730, advanced lung cancer study) and merged participants’ CALGB data with their Medicare data. From CALGB data, we identified the most frequent Extended Clinical Toxicity Critieria grade III/IV toxicities. We reviewed diagnostic and procedure codes from Medicare manuals, developed algorithms to measure the toxicities, and then finalized the algorithms after empiric review of patients’ codes. We compared results of Medicare algorithms to gold standard CALGB toxicity information to calculate test characteristics. Results: CALGB data documented that 15 grade III/IV chemotherapy-related toxicities occurred in 3% of the 175 patients: white blood cell, hemoglobin, platelets, anorexia, nausea, vomiting, diarrhea, stomatitis, sensory neuropathy, motor neuropathy, motor or sensory neuropathy, dyspnea, hyperglycemia, infection, and malaise. Vomiting was the only toxicity identified by the Medicarebased algorithm with a sensitivity, specificity, and area under the receiver operator curve of 80%. Conclusions: The results of this preliminary study suggest that Medicare diagnostic and procedure codes may be of only limited value in measuring clinically significant chemotherapy-related toxicities in elderly Medicare beneficiaries. Future research includes confirming these findings in a larger and more diverse sample.

The treatment of patients with advanced non-small cell lung cancer has changed considerably in the past decade. This paper reviews the most significant changes seen in chemotherapy and the most promising new agents in development for this disease.Chemotherapy prolongs survival and improves quality of life in patients with a good performance status and appears to alleviate disease-related symptoms in patients with a lower performance status. Platinum-based regimens became standard; none of the third-generation drug combinations seemed to be superior to the others. Nonplatinum combinations are reasonable alternatives now and offer a better toxicity profile in certain populations. Attempts to add molecular-targeted therapy to combination chemotherapy have failed except for bevacizumab. New compounds such as pemetrexed, bortezomib, TLK286, bevacizumab, and the epothilones are currently being evaluated in non-small cell lung cancer.Management of non-small cell lung cancer has improved considerably in the past decade. The overall benefit of chemotherapy over supportive care has been shown, platinum-based doublets have been established, nonplatinum regimens have been developed, chemotherapy has been used more broadly in subgroups of patients who have been previously neglected, and a shorter chemotherapy duration has been shown to be equally effective. After hitting a plateau in the benefit of chemotherapy, new drugs with novel action mechanisms such as the ones described here offer hope to improve therapy for this disease.