Abordagem terapêutica do carcinoma pulmonar de não pequenas células no idoso

 

Treatment of non-small cell lung cancer in elderly patients

 

 

Filipa Costa 1

Fernando J Barata 2

 

 

Resumo

O cancro do pulmão é a primeira causa de morte por cancro. Dado o envelhecimento global da população, actualmente mais de 50% de todos os doentes com carcinoma pulmonar de não pequenas células (CPNPC) têm mais de 65 anos. Até há poucos anos, imperava o cepticismo no tratamento dos doentes neste grupo etário, prevalecendo a noção de que qualquer que fosse o tratamento instituído, o balanço entre o benefício e os efeitos secundários era desfavorável. A falência orgânica dependente da idade, as comorbilidades, a polimedicação e a fragilidade do idoso explicavam esta opinião geral. Nos últimos anos, mudou- -se radicalmente esta atitude. Quando se decide na estratégia terapêutica destes doentes, é a idade biológica (baseada no performance status – PS e nas comorbilidades) e não a idade cronológica que deve ser tida em conta, e a não administração do tratamento standard ou a sua modificação só deverá ser feita perante uma razão válida. Isto aplica-se dimide igual forma à cirurgia, quimioterapia, radioterapia e às novas terapêuticas moleculares, as armas terapêuticas ao nosso dispor para combater esta patologia.

Os estudos publicados recentemente e que se dedicaram especificamente à avaliação dos doentes idosos vieram comprovar que, se tratados de forma adequada, os doentes idosos com bom PS e sem comorbilidades major têm uma sobrevida e uma qualidade de vida semelhante à dos doentes mais jovens.

Dado o número crescente de doentes com cancro do pulmão em idade avançada, os autores fazem uma revisão bibliográfica da literatura existente sobre este tema.

Palavras-chave: CPNPC, idoso, terapêutica.

 

 

Abstract

Lung cancer is the most common cause of cancer death. With the aging of the population, more than 50% of patients with non-small cell lung cancer (NSCLC) are older than 65 years. Until recently, there was some scepticism regarding treatment of patients in this age group, prevailing the notion that whatever treatment was given, the balance between the benefits and the side effects was unfavourable.

The organ failure dependent of age, the comorbidities, the polimedication and the fragility of elderly people, were responsible for this generalized opinion. In the last few years, this nihilistic approach has changed radically. When deciding what treatment strategy should be used in these patients, the biological age (based on performance status: PS and comorbidities) rather than the chronological age should be taken into account, and the modification of standard treatment plans should only be made when there is a valid reason. This applies equally to surgery, chemotherapy, radiotherapy and the new targeted agents, the therapeutic weapons available to treat this disease. Recently published studies, that specifically analysed elderly patients, proved that if treated adequately, elderly patients with a good PS and without major comorbidities have the same survival rates and quality of life as younger patients. The rising number of elderly patients with lung cancer led the authors to do a review of the literature on this topic.

Key-words: NSCLC, elderly, treatment.

 

 

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Bibliografia

1. Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol 2001; 2:533-43.        [ Links ]

2. Havilk RJ, Yancik R, Long S, et al. The National Cancer Institute SEER: Collaborative Study on comorbidity and early diagnosis of cancer in the elderly. Cancer 1994 (suppl 7); 74:2101-6.

3. Borges M, Sculier JP, Paesmans M, et al. Prognostic factors for response to chemotherapy containing platinum derivatives in patients with unresectable non-small cell lung cancer. Lung Cancer 1996; 16:21-33.

4. Albain KS, Crowley JJ, LeBlanc M, et al. Survival determinants in extensive stage non-small cell lung cancer: The Southwest Oncology Group experience. J Clin Oncol 1991; 9:1618-26.

5. Finkelstein DM, Ettinger DS, Ruckdeschel JC. Lung- -term survivors in metastatic non-small cell lung cancer: An Eastern Cooperative Oncology Study Group. J ClinOncol 1986; 4:702-9.

6. Stanley KE. Prognostic factors for survival in patients with inoperable lung cancer. J Natl Cancer Inst 1980; 65:25-32.

7. Pereira JP, Martins SJ, Andrade LM, et al. Age and treatment of lung cancer in Brazil. Proc Am Soc Clin Oncol 2000; 19:548a.

8. Earle CC, Venditti LN, Neumann PJ, et al. Who gets chemotherapy for metastatic lung cancer? Chest 2000; 117:1239-46.

9. Gridelli C, Aapro M, Ardizzoni A, et al. Treatment of advanced non-small cell lung cancer in the elderly: Results of an international expert panel. J Clin Oncol 2005; 23:3125-37.

10. Repetto L, Frationo L, Audisio RA, et al. Comprehensive geriatric assessment ads information to Eastern Cooperative Oncology Group performance status in elderly patients: An Italian Group for Geriatric Oncology Study. J Clin Oncol 2002; 20:494-502.

11. Fried LP, Tangen CM, Waltson J, et al. Frailty of older adults: evidence for a phenotype. J Gerontol A Biol Sci Med 2001; 56:M146-M156.

12. Salibs D, Elliot M, Rubenstein LZ, et al. The vulnerable Elders Survey: a tool for identifying vulnerable older people in the comunity. J Am Geriatr Soc 2001; 49:1691-9.

13. Perrone F, Gridelli C, Cigolari S, et al. Baseline assessment of quality of life (QoL) is a strong prognostic factor for survival of elderly patients with advanced non-small cel lung cancer (NSCLC). A secondary analysis of the MILES study. Proc Am Soc Clin Oncol 2002; 21:337a.

14. Smith TJ, Penberthy L, Desch CE, et al. Differences in initial treatment patterns and outcomes of lung cancer in the elderly. Lung Cancer 1995; 13:235-52.

15. Sherman S, Guidot CE. The feasibility of thoracotomy for lung cancer in the elderly. JAMA 1987; 258:927-30.

16. BTS guidelines. Guidelines on the selection of patients with lung cancer for surgery. Thorax 2001; 56:89-108.

17. Rajdev L, Keller SM. Surgery for lung cancer in elderly patients. In American Society of Clinical Oncology. 2006 Educational Book, Atlanta:ASCO 2006; 463-7.

18. Landreneau RJ, Halzelrigg SR, Mack MJ, et al. Post-operative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993; 56:1285-9.

19. Mackinlay TA. VATS lobectomy: An International Survey. Fourth International Symposium on thoracoscopy and video-assisted thoracic surgery. São Paulo, 1997.

20. Walker WS. VATS lobectomy : The Edinburgh experience. Semin Thorac Cardiovasc Surg 1998; 10:291-299.

21. Sioris T, Salo J, Perhoniemi V, et al. Surgery for lung cancer in the elderly. Scand Cardiovasc J 1999; 33:222-7.

22. Mery CM, Pappas AN, Bueno R, et al. Similar long-term survival of elderly patients with non-small cell lung cancer treated with lobectomy or wedge resection within the surveillance, epidemiology and end results database. Chest 2005; 128:237-45.

23. Bach PB, Cramer LD, Schrag D, et al. The influence of hospital volume on survival after ressection of lung cancer. N Engl J Med 2001; 345:181-8.

24. Gauden SJ, Tripcony L. The curative treatment by radiation therapy alone of stage I non-small cell lung cancer in a geriatric population. Lung Cancer 2001; 32:71-9.

25. Gaspar LE. Optimizing chemoradiation therapy approaches to unresectable stage III non-small cell lung cancer. Curr Opin Oncol 2001; 13:110-5.

26. Jeremic B, Shibamoto Y, Milicic B, et al. A phase II study of concurrent accelerated hyperfractionated radiotherapy and carboplatin/oral etoposide for elderly patients with stage III non small cell lung cancer. Int J Radiat Oncol Biol Phys 1999; 44:343-8.

27. Elderly Lung Cancer Vinorrelbine Italian Study (ELVIS) Group. Effects of vinorrelbine on quality of life anda survival of elderly patients with non-small cell lung cancer. J Nat Cacer Inst 1999; 91:66-72.

28. Altavilla G, Adamo V, Buemi B, et al. Gemcitabine as single agent in the treatment of elderly patients with advanced non-small cell luna cancer. Anticancer Res 2000; 20:3675-8.

29. Ricci S, Antonuzzo A, Galli L, et al. Gemcitabine monotherapy in elderly patients with advanced non-small cell luna cancer: a multicentre phase II study. Lung Cancer 2000; 27:75-80.

30. Martoni A, Di Fabio F, Guaraldi M, et al. Prospective phase II study of single agent gemcitabine in untreated elderly patients with stage IIIB/IV non small cell lung cancer. Am J Clin Oncol 2001; 24:614-7.

31. Nakamura Y, Sekine I, Furuse K, et al. Retrospective comparison of toxicity and efficacy in phase II trials of 3h infusions of paclitaxel for patients aged 70 of age or older and patients under 70 of age. Cancer Chemother Pharmacol 2000; 46:114-8.

32. Fidias P, Supko JG, Martins R, et al. A phase II study of weekly paclitaxel in elderly patients with advanced non-small cell lung cancer. Clin Cancer Res 2001; 7:3942-9.

33. Takigawa N, Segawa Y, Kishino D, et al. Clinical and pharmacokinectic study of docetaxel in elderly non-small cell luna cancer patients. Cancer Chemother Pharmacol 2004; 54:230-6.

34. Yoshimura N, Kudoh S, Negoro S, et al. A phase II study of docetaxel in elderly patients with advanced non-small cell lung cancer (NSCLC). Proc Am Soc Clin Oncol 2000; 19:532a.

35. Hainsworth JD, Burris IIA, Litchy S, et al. Weekly docetaxel in the treatment of elderly patients with advanced non-small cell lung carcinoma. Cancer 2000; 89:328-3.

36. Hesketh PJ, Chansky K, Lau DH, et al. Sequential vinorrelbine and docetaxel in advanced non-small cell lung cancer patients aged >70 or with performance status 2. A SWOG phase II trial (S0027). Proc Soc Clin Oncol 2004; 23:627.

37. Gridelli C, Perrone F, Gallo C, et al. Chemotherapy for elderly patients with advanced non-small-cell lung cancer: The Multicenter Italian Lung Cancer in the Elderly Study (MILES) Phase III randomized trial. J Natl Cancer Inst 2003; 95:362-72.

38. Pfister DG, Johnson DII, Azzoli CG, et al. American Society of Clinical Oncology treatment of unresectable non-small cell lung cancer guideline: update 2003. J Clin Oncol 2004; 22:330-53.

39. American Society of Clinical Oncology: Clinical practice guidelines for the treatment of unresectable non-small cell lung cancer. Adopted on May 16, 1997 by the American Society of Clinical Oncology. J Clin Oncol 1997; 15:2996-3018.

40. ESMO Minimum Clinical recommendations for diagnosis, treatment and follow-up of non-small cell lung cancer (NSCLC). Ann Oncol 2001; 12:1049-50.

41. Oshita F, Kurata T, Kasai, et al. Prospective evaluation of the feasibility of cisplatin based chemotherapy for elderly lung cancer patients with normal organ functions. Jpn J Cancer Res 1995; 86:1198-202.

42. Berardi R, Porfiri E, Scartozzi M, et al. Elderly patients with advanced non-small cell lung cancer: A phase II study with weekly cisplatin and gemcitabine. Oncology. 2003; 65:198-203.

43. Feliu J, Martin G, Madronal C, et al. Combination of low dose cisplatin and gemcitabine for treatment of elderly patients with advanced non small cell lung cancer. Cancer Chemother Pharmacol 2003; 52:247-52.

44. Martins SJ, Pereira JR, Ikari FK, et al. Chemotherapy with cisplatin and vinorrelbine for elderly non-small cell lung cancer patients. Proc Am Soc Clin Oncol 1999; 18:468a.

45. Ohe Y, Niho S, Kakinuma R, et al. A phase II study of cisplatin and docetaxel administered as three consecutive weekly infusions for advanced non-small cell lung cancer in elderly patients. Ann Oncol 2004; 15:45-50.

46. Lilnbaum RC, Herndon J, List M, et al. Single agent (SA) vs combination chemotherapy (CC) in advanced non-small cell lung cancer (NSCLC): a CALBG randomized trial of efficacy, quality of life (QoL) and cost-effectiveness. Proc Am Soc Clin Oncol 2002; 21:1a.

47. Maestu IC, Gómez-Aldaravi L, Torregrossa MD, et al. Gemcitabine and low dose carboplatin in the treatment of elderly patients with advanced non-small cell lung cancer. Lung Cancer 2003; 42:345-54.

48. Choi IS, Kim BS, Park SR, et al. Efficacy of modified regimen with attenuated doses of paclitaxel plus carboplatin combination chemotherapy in elderly and/or weak patients with advanced non-small cell lung cancer. Lung Cancer 2003; 39:99-101.

49. Copin M, Kommareddy A, Behnken D, et al. Gefitinib in elderly patients with non-small cell lung cancer (NSCLC). Proc Am Soc Clin Oncol 2003; 22:758.

50. Cappuzzo F, Bartolini S, Ceresoli GL, et al. Efficacy and tolerability of gefitinib in pre-treated elderly patients with advanced non-small cell lung cancer (NSCLC). Br J Cancer 2004; 90:82-6.

51. Shepherd FA, Pereira J, Ciuleanu TE, et al. A randomized placebo-controlled trial of erlotinib in patients with advanced non-small cell lung cancer (NSCLC) following failure of 1st and 2nd line chemotherapy: A National Cancer Institute of Canada Clinical Trials Group (NCIC CTG) trial. Proc Am Soc Clin Oncol 22:622S.

 

 

1 Interna do Internato Complementar de Pneumologia

2 Assistente Hospitalar Graduado de Pneumologia

Serviço de Pneumologia

Centro Hospitalar de Coimbra

Director: Dr. Jorge Pires

Quinta dos Vales

São Martinho do Bispo

3046-853 Coimbra

 

Recebido para publicação/received for publication: 07.04.10

Aceite para publicação/accepted for publication: 07.06.01