1. Adjuvant Chemotherapy for Non–Small-Cell Lung Cancer in the Elderly: A Population-Based Study in Ontario, Canada JOURNAL OF CLINICAL ONCOLOGY, VOLUME 30 NUMBER 15 MAY 20 2012 Sinead Cuffe, Christopher M. Booth, Yingwei Peng, Gail E. Darling, Gavin Li, Weidong Kong, William J. Mackillop, and Frances A. Shepherd R1 김형오 / Prof. 정재헌

2. Introduction NSCLC –Predominantly a disease of the elderly median age at diagnosis of 70 years –Surgery survival outcome similar to younger patients Surgery increasingly offered to elderly patients Relapse is common with 5 year overall survival rate less than 50%

3. Introduction Cisplatin based adjuvant chemotherapy was established as standard of care in resected stage II to IIIA NSCLC –Retrospective analyses of the National Cancer Institute of Canada Clinical Trials –Lung Adjuvant Cisplatin Evaluation (LACE) meta-analysis

4. Purpose To evaluate the uptake and outcome of adjuvant chemotherapy, by age, among patients with surgically resected NSCLC

5. Methods All patients with NSCLC diagnosed in Ontario and undergoing surgery within 24 weeks of diagnosis from 2001 to 2006 –Excluding patients with preop. RTx or CTx –Pre-adoption(diagnosed 2001~2003) –Post-adoption(diagnosed 2004~2006) Elderly : >70 years old –70~74, 75~79, 80~

6. Patients and methods Comorbidity –Non-cancer diagnosis recorded on any hospital admission within 5 years before surgery Surgical resection –Pneumonectomy, lobectomy, or segmentectomy, minimum length of stay 3 days Adjuvant chemotherapy –Within 16 weeks following surgery

7. Result Study population –6,570 underwent surgical resection among 28,862 patients diagnosed 2001~2006 –Surgical patients increased in who were elderly (2001~2003 : 42.5%, 2004~2006 : 45.0%) –Final population 6,304 patients(43.8% elderly) Elderly –Male dominent (P<0.001) –More comorbidities(P<0.001) –Less likely to undergo pneumonectomy(P<0.001) –More squamous ca. than adeno ca. (P<0.001)

8. Adjuvant chemotherapy Uptake of adjuvant CTx among the elderly increased –3.3% : 2001~2003, 16.2% : 2004~2006 Receiving chemo declined with advanced age, ‘04~’06 –42.7% ; <70yrs, –23.1% ; 70~74, 13.3% ; 75~79, 4.6% ; >80 Elderly uptake is significantly lower than younger’s

9. Regimen Cisplatin-vinorelbine –More than 2/3 of overall patients –Validated by phase III trials Absolute 5-yr survival improved, ranging from 8.6% to 15% Carboplatin-paclitaxel –Increased significantly with advancing age 7% for 80 yrs CALGB9633 ealry closure, only phase III study to evaluate carboplatin CALGB9633 shows survival benefit became insignificant(HR 0.83, P 0.12) vs Only 344 patients lacked to confirm 17% risk of death reduction

10. Regimen

11. Outcomes 4 year survival –Of patients with surgical resections improved 2001~2003 : 52.5% 2004~2006 : 56.1% –Of elderly patient also improved 2001~2003 : 47.1% 2004~2006 : 49.9% Suggesting possible benefit from adoption of adjuvant chemotherapy Hazard ratio of mortality Post-adoption CTx vs. pre-adoption CTx 80yrs : 1.00 No survival improvement in age>80 years old group

12. Outcomes Uptake of adj. CTx is unlikely associated with an increase in severe toxicity

13. Discussion Strength of this study –Large population size –Province wide evaluation Avoided selection and referral bias –Well defined temporal difference Before/after adoption of the new treatment Limitation –Large portion of patients without pathologic data –No routine usage of PET CT in ‘01~’06 of Ontario

14. Discussion Conclusion –Adoption of adjuvant CTx for NSCLC in the elderly appears to be associated with survival benefits Clinical trials suggested benefits, realized in general practice –Benefit of the adjuvant CTx in patients age>80 is unclear –Although adoption of adjuvant CTx for NSCLC increased in the elderly, it still lag behind of younger patients –Need to improve understanding of the reasons of low usage in the elderly, and them not to be denied potentially curative therapy on the basis of age alone