**6.1 Oncologic evaluation**

On the oncologic point of view, evaluation of an elderly patient should be exactly the same as for a younger one. Clinical and pathological stage of disease should be determined with the same accuracy. The complete workup for lung cancer includes at least a complete history and physical examination, a bronchoscopy, a CT scan of the chest and upper abdomen and blood tests for assessment of liver and renal function. CT scan of the head should be done if there are any suspicions of metastasis, or in advanced cases, as well as a complete bone scan. Ideally, patients must have a Pet-Scan to complete the workup. As for younger patients, biopsy of the tumour for histology is always mandatory.

When surgery or radiation therapy treatment are anticipate, pulmonary function test are essential to determine the capacity of the patient to tolerate those procedure.

Unfortunately, in the elderly population, lung cancers are less susceptible to be diagnosed at an early stage and the evaluation is more often incomplete. More than 20% of cancers in patients aged more than 85 years of age are diagnosed on a clinical or radiologic basis without pathologic confirmation (Goddwin & Osborne, 2004).

#### **6.2 Geriatric evaluation**

The geriatric assessment of a patient is also a diagnostic process. It may be done by an individual clinician, but more often, the geriatric evaluation involve a more intensive multidisplinary program. This is often referred to a comprehensive geriatric assessment (CGA). The optimal goal is to evaluate the patients' global and functional status, in order to improve treatment decisions and outcomes. His use is now recommended by the International Society of Geriatric Oncology (SIOG) for all cancer patient aged more than 70 years old. This recommendation is based on the evidence that the incidence of geriatric problems increases sharply after 70 in cancer patients (Extermann et al., 2005, as cited in Balducci et al., 1990). The CGA permits to detect unaddressed problems, improve older cancer patients functional status and possibly their survival. The SIOG was not able to recommend any specific tool or approach above others for this assessment (Extermann et al., 2005).

Whatever the approach or the tools used to complete a CGA, different aspects should be included as; functional status, comorbid medical conditions, cognitive and nutritional status, psychological state, social support and review of the medication.

Lung Cancer in Elderly 229

previously demonstrated than even when treated in a specialized geriatric oncology program, cognitively impaired patients had a survival of cancer one third of that of nonimpaired patients in various tumor type and stages, even if they received similar treatments (Extermann & Hurria, 2007, as cited in Callen et al. 2004). Therefore, screening for cognition should be part of the evaluation in the elderly patient afflicted with lung

The importance of malnutrition on overall survival and morbidity is well known in the general cancer population. It is also demonstrated that aging is a factor for an increase risk of malnutrition. Other than mortality, poor nutritional status can have an impact on the

Many reports have shown that the incidence of psychological distress is approximately onethird of older patient with cancer. Studies of geriatric assessment show that 14% to 40% of older patients have depressive symptoms (Extermann & Hurria, 2007). A large epidemiologic studies of 24,696 older breast cancer in the SEER database (ages 67 to 90 years) revealed that a recent diagnosis of depression put them at risk for receiving less-thandefinitive treatment for their cancer, and they also experienced shorter survival (Extermann & Hurria, 2007 as cited in Goddwin et al, 2004). In addition, depressive symptoms have impact on quality of life, increased utilization of healthcare resources and can affect

Social support is a major factor that puts patients at risk for psychological distress. Even monthly telephone call was shown to reduce depression in older patients with cancer. This method was demonstrated to reduce significantly anxiety (p<0.0001), depression (p=0.0004), and overall distress (p<0.0001) compare to no similar support (Extermann & Hurria, 2007 as

Polypharmacy is a significant problem in the geriatric population. Many physiologic changes in the elderly may have impact on pharmacokinetic; a decrease in total body water, an increase in body fat, a decrease in renal function, decrease in hepatic mass and blood flow, and decrease in bone marrow reserve. The combination of those changes and polypharmacy is associated with an increase risk of drug interactions, adverse drug events and problem with compliance. Therefore, it is essential to regularly review the medication list to discontinue any unnecessary medications and avoid potential drug interactions.

Many trials have studied the impact of a CGA on outcome of elderly patients with cancer. A meta-analysis of 28 controlled trials had demonstrated that CGA if linked to geriatric interventions reduced early re-hospitalisation and mortality in older patients through early identification and treatment of problems (Pallis et al. 2010, as cited in Stuck et al., 1993). In a

quality of life, response to chemotherapy, and any other medical complications.

cancer.

**6.3.4 Nutritional status** 

**6.3.5 Psychological state** 

treatment compliance.

**6.3.6 Social support** 

cited in Kornblith et al., 2006).

**6.4 Impact of the CGA** 

**6.3.7 Review of the medication** 

#### **6.3 Components of a comprehensive geriatric assessment 6.3.1 Functional status**

Functional status represents the patient's ability to perform daily activities. The more commonly used performance status score are the Karnofsky or Eastern Cooperative Oncology Group (ECOG) scales. In older patients, these scores were showed to underrepresent the degree of functional impairment (Repetto et al., 2002). For that reason, it is important to include the autonomy for Activities of Daily Living (ADL), such as feeding, grooming, transferring and toileting and for the Instrumental Activities of Daily Living (IADL) such as shopping, housekeeping, managing finances, preparing meals and taking medications in the evaluation of functional status for these patients.

A study of 566 patients with advanced non-small cell lung cancer age ≥ 70 years receiving chemotherapy explores the impact of functional status on the overall survival. Improved overall survival was associated with independence in IADLs and higher quality of life scores. Limitations in basic ADLs and the presence of comorbidity were not predictors of a decrease in overall survival (Maione et al. 2005). However, limitation in basic ADLs was previously shown to predict chemotherapy toxicity and postoperative survival and morbidity (Extermann & Huria, 2007).

#### **6.3.2 Comorbidities**

In cancer patients, comorbidity can be seen as a competitive cause of death. It is well known that with increasing age, the number or comorbid medical conditions increases. It is important to consider these comorbid conditions in life expectancy and potential treatment tolerance when balancing the risks and benefits of them. Charlson Comorbidity Index (CCI) is a way to assess the number and severity of comorbid condition (Charlson et al., 1987).

Additional issues regarding the treatment of elderly cancer patients are the presence of geriatric syndromes as; dementia, delirium, depression, falls, neglect and abuse, failure to thrive, incontinence and spontaneous bone fracture.

A review of the National Cancer Institute of Canada (NCI) Clinical Trials Group in 2008 analyzed 1,255 patients enrolled in two large, prospectively randomized trials of systemic chemotherapy for NSCLC. Patients aged 65 and older were more likely to have a CCI score of ≥ 1 (42 % versus 26%). Age did not influence overall survival, but the Charlson Comorbidy Index ≥ 1 appeared prognostic for poorer survival (Asmis et al., 2008). The impact of comorbidity was recently studied in a population of 83 untreated lung cancer patients over the age of 70. It was shown that they have a high prevalence of comorbidity but these may not cause patient's death (Gironés et al., 2011).

#### **6.3.3 Cognitive status**

Cognitive deficits are associated in the geriatric population with an increase in mortality of over 150% at 5 years. They are also associated with an increase risk of complications, depression, and functional decline.

Cognitive deficits and dementia in oncology patient is often unrecognized. However, it was demonstrated that 25-50% of older patients with cancer had abnormalities in screening cognitive exam that warranted further evaluation. Cognitive dysfunction can have significant impact in the pathway of cancer treatment; dysfunction on the ability to weigh the risks and benefits of cancer therapy, compliance with treatment, and recognition of the signs of toxicity that require medical attention (Extermann & Hurria, 2007). It was

Functional status represents the patient's ability to perform daily activities. The more commonly used performance status score are the Karnofsky or Eastern Cooperative Oncology Group (ECOG) scales. In older patients, these scores were showed to underrepresent the degree of functional impairment (Repetto et al., 2002). For that reason, it is important to include the autonomy for Activities of Daily Living (ADL), such as feeding, grooming, transferring and toileting and for the Instrumental Activities of Daily Living (IADL) such as shopping, housekeeping, managing finances, preparing meals and taking

A study of 566 patients with advanced non-small cell lung cancer age ≥ 70 years receiving chemotherapy explores the impact of functional status on the overall survival. Improved overall survival was associated with independence in IADLs and higher quality of life scores. Limitations in basic ADLs and the presence of comorbidity were not predictors of a decrease in overall survival (Maione et al. 2005). However, limitation in basic ADLs was previously shown to predict chemotherapy toxicity and postoperative survival and

In cancer patients, comorbidity can be seen as a competitive cause of death. It is well known that with increasing age, the number or comorbid medical conditions increases. It is important to consider these comorbid conditions in life expectancy and potential treatment tolerance when balancing the risks and benefits of them. Charlson Comorbidity Index (CCI) is a way to assess the number and severity of comorbid condition (Charlson et al., 1987). Additional issues regarding the treatment of elderly cancer patients are the presence of geriatric syndromes as; dementia, delirium, depression, falls, neglect and abuse, failure to

A review of the National Cancer Institute of Canada (NCI) Clinical Trials Group in 2008 analyzed 1,255 patients enrolled in two large, prospectively randomized trials of systemic chemotherapy for NSCLC. Patients aged 65 and older were more likely to have a CCI score of ≥ 1 (42 % versus 26%). Age did not influence overall survival, but the Charlson Comorbidy Index ≥ 1 appeared prognostic for poorer survival (Asmis et al., 2008). The impact of comorbidity was recently studied in a population of 83 untreated lung cancer patients over the age of 70. It was shown that they have a high prevalence of comorbidity

Cognitive deficits are associated in the geriatric population with an increase in mortality of over 150% at 5 years. They are also associated with an increase risk of complications,

Cognitive deficits and dementia in oncology patient is often unrecognized. However, it was demonstrated that 25-50% of older patients with cancer had abnormalities in screening cognitive exam that warranted further evaluation. Cognitive dysfunction can have significant impact in the pathway of cancer treatment; dysfunction on the ability to weigh the risks and benefits of cancer therapy, compliance with treatment, and recognition of the signs of toxicity that require medical attention (Extermann & Hurria, 2007). It was

**6.3 Components of a comprehensive geriatric assessment** 

medications in the evaluation of functional status for these patients.

**6.3.1 Functional status** 

morbidity (Extermann & Huria, 2007).

thrive, incontinence and spontaneous bone fracture.

but these may not cause patient's death (Gironés et al., 2011).

**6.3.2 Comorbidities** 

**6.3.3 Cognitive status** 

depression, and functional decline.

previously demonstrated than even when treated in a specialized geriatric oncology program, cognitively impaired patients had a survival of cancer one third of that of nonimpaired patients in various tumor type and stages, even if they received similar treatments (Extermann & Hurria, 2007, as cited in Callen et al. 2004). Therefore, screening for cognition should be part of the evaluation in the elderly patient afflicted with lung cancer.

#### **6.3.4 Nutritional status**

The importance of malnutrition on overall survival and morbidity is well known in the general cancer population. It is also demonstrated that aging is a factor for an increase risk of malnutrition. Other than mortality, poor nutritional status can have an impact on the quality of life, response to chemotherapy, and any other medical complications.

#### **6.3.5 Psychological state**

Many reports have shown that the incidence of psychological distress is approximately onethird of older patient with cancer. Studies of geriatric assessment show that 14% to 40% of older patients have depressive symptoms (Extermann & Hurria, 2007). A large epidemiologic studies of 24,696 older breast cancer in the SEER database (ages 67 to 90 years) revealed that a recent diagnosis of depression put them at risk for receiving less-thandefinitive treatment for their cancer, and they also experienced shorter survival (Extermann & Hurria, 2007 as cited in Goddwin et al, 2004). In addition, depressive symptoms have impact on quality of life, increased utilization of healthcare resources and can affect treatment compliance.

#### **6.3.6 Social support**

Social support is a major factor that puts patients at risk for psychological distress. Even monthly telephone call was shown to reduce depression in older patients with cancer. This method was demonstrated to reduce significantly anxiety (p<0.0001), depression (p=0.0004), and overall distress (p<0.0001) compare to no similar support (Extermann & Hurria, 2007 as cited in Kornblith et al., 2006).

#### **6.3.7 Review of the medication**

Polypharmacy is a significant problem in the geriatric population. Many physiologic changes in the elderly may have impact on pharmacokinetic; a decrease in total body water, an increase in body fat, a decrease in renal function, decrease in hepatic mass and blood flow, and decrease in bone marrow reserve. The combination of those changes and polypharmacy is associated with an increase risk of drug interactions, adverse drug events and problem with compliance. Therefore, it is essential to regularly review the medication list to discontinue any unnecessary medications and avoid potential drug interactions.

#### **6.4 Impact of the CGA**

Many trials have studied the impact of a CGA on outcome of elderly patients with cancer. A meta-analysis of 28 controlled trials had demonstrated that CGA if linked to geriatric interventions reduced early re-hospitalisation and mortality in older patients through early identification and treatment of problems (Pallis et al. 2010, as cited in Stuck et al., 1993). In a

Lung Cancer in Elderly 231

Patients must have a very good evaluation and adequate scrutiny is necessary to evaluate those who will really benefit from surgery. Preoperative assessment of cancer in the elderly (PACE) incorporates validated instruments including the CGA, an assessment of fatigue and performance status and an anaesthesiologist's evaluation of operative risk. It is considered to be a valuable tool in enhancing the decision process concerning the candidacy of elderly patients for surgical intervention. It also reduce inappropriate age-related inequity

**7.2 Different types of surgery are used for the elderly. But which one is better?** 

Survival data from the SEER database with patient of all ages shown that survival for lung cancer stage I and II were 56 and 34% respectively (Chang et al., 2007). The most important question regarding surgical resection for lung cancer is how aggressive should it be? The choice of the type of surgery is particularly important in the elderly. Right pneumonectomy is likely to be avoided in octogenarians (Broks et al., 2007; Port et al., 2004; Van Meerbeeck et al., 2002), but low rate of pneumonectomy in different series make this difficult to assess. As an indication, the British Thoracic Society Guidelines indicates that pneumonectomy is

The sublobar pulmonary resection remains controversial in patients of any age. In a SEER analysis of 14,555 patients with stage I or II NSCLC, it was showed that benefit of a lobectomy was not evident for patients older than 71 years compared with limited resection (Meryet al., 2005). Okami did a non-randomized study to evaluate the different types of surgery in the elderly patients. A total of 764 patients, including 133 elderly and 631 younger patients had lobectomy or sublobar resection. The survival after sublobar resection was significantly lower than that after standard lobectomy in the younger group (64% vs 90.9%). Comparatively, no difference was seen in the elderly (67.6% vs 74.3%). However, locoregional recurrences were higher in patients with sublobar resection than lobectomy in young and older patients (Okami et al., 2009). A phase III study regarding this specific topic

Another study done in Pittsburg has compared lobectomy to the segmentectomy for stage I lung cancer. In a subgroup of 99 octogenarian patients, the segmentectomy was associated

A review of 10,761 patients with lung cancer stage IA showed the age of 67 years or more as an independent factor associated with long-term survival worse after surgery. One of the major criticisms of this study is that patients were not stratified based on their functional status or their comorbidities. It is known that these two factors are associated with advanced age and are predictors of mortality in elderly patients suffering from lung cancer (Maione et

In another study of 126 patients 70 years of age or older with lung cancer, the Charlson Comorbidity Index has been performed in patients for lung surgery. A low score was a predictor of major complications after surgery (Birim et al., 2003). Some studies in patients older than 80 years of age were also conducted (Brokx et al., 2007; Okami et al., 2009; Wada et al., 1998). At the Mayo Clinic, 294 patients aged between 80 and 94 years underwent pulmonary resection and their 1-year survival was 80% and 2-year survival was 62%

with an improvement of the 3-year survival (p=0.02) (Schuchert et al., 2009).

**7.1 Evaluation and selection of patients** 

in access to surgical intervention (PACE, 2008).

associated with higher risk of mortality.

would be necessary to confirm this information.

(Dominguez-Ventura et al., 2007).

**7.3 The impact of comorbidities on surgical outcomes** 

al., 2005; Frasci et al., 2000; Asmis et al., 2008; Schuchert et al., 2009).

recent French study it was shown that comprehensive geriatric evaluation did significantly influence treatment decisions in 82% of the older cancer patients. In this 161 patients group, with a median age of 82.4 years, cancer treatment was change in 79 patients (49%), including delayed therapy in 5 patients, less intensive therapy in 18% and more intensive therapy in 28% of patients (Chaïbi et al. 2010).

It is interesting to notice that even a simplified geriatric assessment, adapted to cancer and quicker to perform than a CGA was recently demonstrated effective in patients with thoracic cancer. It is an important aid to decision-making in the management of elderly patients with bronchial cancer (Cudennec et al., 2010).


Table 1. Simplified Geriatric Assessment of patients with bronchial cancer (Cudennec et al., 2010).
