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Chemotherapy linked to improved median survival in elderly patients with SCLC
Chemotherapy was associated with a more than 6-month improvement in median survival among elderly patients with small cell lung cancer.
Although numerous randomized clinical trials have demonstrated a benefit of chemotherapy for patients with SCLC, the trials typically compare different chemotherapy regimens rather than comparing chemotherapy with best supportive care. In addition, most randomized clinical trials excluded elderly patients or those with significant medical comorbidities.
To assess factors associated with administration of chemotherapy and study the effect of chemotherapy on survival, researchers selected elderly patients (n=10,428) aged at least 65 years with SCLC diagnosed between 1992 and 2001 from the SEER-Medicare database.
The researchers used logistic regression to calculate which covariates influenced receipt of chemotherapy. Cox proportional hazards regression was used to evaluate the influence of clinical and demographic variables on survival.
The independent effect of chemotherapy on survival was evaluated using propensity scores and quantile regression.
According to the SEER-Medicare database, 67.1% received chemotherapy (most commonly with etoposide combined with either cisplatin or carboplatin regimens), 39.1% received radiation, 3.4% received surgery and 21.8% received no treatment.
Patients aged at least 85 years were significantly less likely to receive chemotherapy vs. patients aged 65 to 69 years (OR=0.17; 95% CI, 0.14-0.21). Median survival for all patients was 7 months.
Factors correlated with improved survival included being female, black race, having limited-stage disease, receiving any treatment and having a lower comorbidity score.
Quantile regression demonstrated that chemotherapy provided a 6.5-month improvement in median survival (95% CI, 6.3-6.6).
“Our study demonstrates that treatment with chemotherapy is associated with a statistically significant greater than 6-month improvement in median survival among elderly patients with SCLC,” the researchers wrote. “This large retrospective cohort study is the first study to quantify the survival benefit of chemotherapy for SCLC in the community.”
Disclosure: The researchers reported no relevant disclosures.
Perspective
Back to TopThe article by Caprario et al. on the “Effects of chemotherapy on survival of elderly patients with small-cell lung cancer: Analysis of the SEER-Medicare database”, is an important study to better understand the factors associated with the administration of chemotherapy as well as evaluate the impact of chemotherapy on survival among elderly patients with SCLC in the community. This is by far the largest study published on SCLC, albeit a retrospective study analysis.
A total of 10,428 patients aged 64 years and older diagnosed of SCLC between 1992 and 2001 were included in this study; 67.1% received chemotherapy, most of whom (41.6%) received an etoposide and platinum (EP) regimen. Not surprisingly, it was found that receipt of chemotherapy was inversely correlated with age. A higher comorbidity score was also associated with a decreased likelihood of receiving chemotherapy. Importantly, the multivariate Cox proportional hazards regression model survival analysis showed that patients who underwent surgical resection had improved survival as did those who received radiation. Chemotherapy with EP regimen was also shown to confer significantly higher survival benefits compared with no chemotherapy (HR 0.37; P<0.001). When all chemotherapy regimens were combined, the HR was 0.40 (P<0.001). Extensive stage patients were found to have an inferior survival compared with patients with limited-stage disease (HR 1.78; P<0.001), which is not surprising.
Although this study has the inherent bias in the study design as a retrospective analysis, it is still an important report with highly informative results. The authors rightfully pointed out that with the lack of smoking history and brain metastasis information, the analysis has limitation and survival analysis with respect to prophylactic brain radiation cannot be performed. However, there are a number of merits worthy of highlighting. First, this is a very large retrospective study and the first one to quantify the survival benefit of chemotherapy for SCLC in the community, which can have direct relevance to extrapolate to the community-based oncology practices. The evidence of positive survival benefit seen in the elderly patients who received chemotherapy is strong and certainly noteworthy. While there can be selection bias in clinicians’ choice of patients to proceed with chemotherapy or not, without the context of a randomized clinical trial study, these results still provide a substantial basis to reasonably consider elderly patients aged 65 years or older for chemotherapy use in this unique disease group where the tumor is typically highly treatment-sensitive to both chemotherapy and radiation. Although dosing information is not available in this study, one could argue that it would be appropriate to adjust dosage due to age or performance status concern in chemotherapy use consideration rather than forgoing it all together in an elderly patient with SCLC.