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Lung Cancer Concurrent Chemoradiation in Inoperable, Locally Advanced Non-small Cell Lung Cancer—Comparison of Efficacy and Toxicity in the Elderly Christine Collen, MD, 1 Denis Schallier, MD, PhD 2 and Mark De Ridder, MD, PhD 3 1. Resident Radiation Oncologist, Radiation Oncology Department; 2. Senior Medical Oncologist, Medical Oncology Department; 3. Head, Radiation Oncology Department, University Hospital, Vrije University, Brussels Abstract Clinicians are faced with the challenge of treating increasing numbers of elderly patients with locally advanced non-small cell lung cancer (LA-NSCLC) and comorbid conditions. In the younger patient, the benefit of combined chemoradiation using the concurrent modality compared with the sequential administration of both modalities has been established in several randomised trials and recent meta-analyses. Because of the underrepresentation of elderly patients in clinical trials on concurrent chemoradiation (CCRT) in LA-NSCLC, treatment guidelines for this age group are not well established. The objective of this article is to summarise the data on efficacy and toxicity of CCRT in the elderly. Keywords Locally advanced non-small cell lung cancer, concurrent chemoradiation, elderly, efficacy, toxicity Disclosure: The authors have no conflicts of interest to declare. Received: December 2, 2011 Accepted: December 15, 2011 Citation: Oncology & Hematology Review, 2012;8(1):39–41 Correspondence: Christine Collen, MD, Radiotherapy Department, Oncology Centre, UZ Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium. E: ccollen@uzbrussel.be The incidence of lung cancer diagnosed in the elderly population is rising as a result of increasing life expectancy. Patients aged over 65 years at diagnosis represent half of the population newly diagnosed with non-small cell lung cancer (NSCLC), while 30–40 % of cases are diagnosed in patients older than 70 years. 1 As reported by Balducci, the cut-off point at which an adult is considered ‘elderly’ has not been well defined, but commonly 70 years is considered to be the reference point in clinical trials. The age-related physiological changes that increase the risk of toxicity related to systemic therapy occur around 70 years of age. 2 Extermann et al. have defined the geriatric oncology group of patients as “when the health status of a patient population begins to interfere with oncological decision-making guidelines”. 3 Within clinical trials, this is defined by exclusion criteria and, as pointed out in the review by Pallis et al., a number of barriers (other than comorbid conditions) to the recruitment of older patients to cancer clinical trials have been revealed, 4 such as difficulty in accessing university hospitals, lack of adequate information about the availability of clinical trials, and perception of the individual physician that the patient would not be able to tolerate treatment. The conclusion of a prospective, population-based trial by De Ruysscher et al. on eligibility for concurrent chemoradiation (CCRT) concluded that more than half of patients with LA-NSCLC were theoretically not eligible because they had one or more important comorbid conditions or were 75 years or older. 5 Consequently, prospective elderly-specific trials are lacking and treatment recommendations are made on the basis of retrospective © TOUCH BRIEFINGS 2012 data. These might suffer from selection bias, since elderly patients who meet protocol eligibility criteria often do not present with comorbid conditions or organ function failures that present in the real-life situation. Because of the rising incidence of NSCLC in the elderly population, biological age rather than chronological age should guide clinicians in deciding on treatment strategy. Geriatric scoring systems can be implemented in an attempt to better define the role of comorbid disease in the elderly population. In addition, technological advances in the field of radiotherapy could contribute to increased efficacy 6 and reduced side effects 7 of treatment in the LA-NSCLC patient population. Available Evidence Supporting Concurrent Chemoradiation in the Elderly Population Regarding the use of radiotherapy in elderly patients, it has been reported that elderly patients are not at risk of increased acute or late toxicity after radiotherapy with curative doses. 8,9 The addition of chemotherapy to radiation has an additional effect on survival in LA-NSCLC at the price of increased toxicity. 10 Concurrent chemoradiation (CCRT) has a temporary impact on quality of life, primarily because of fatigue and esophagitis during and shortly after treatment. However, the quality of life usually recovers to baseline values within three months. 11 The recent meta-analysis of concurrent versus sequential chemoradiation by Aupérin et al. 12 demonstrated the improved overall survival of the concurrent approach, with an absolute benefit of 5.7 % at three years and 4.5 % at five years, as compared with sequential chemoradiation, primarily because of a better locoregional control. The effect of CCRT on distant progression was not different from that of the sequential approach. Acute 39