Which, in your view, is more important when evaluating therapeutic options for this patient age or performance status?
This gentleman is a good performance status, an ECOG performance status of 1. The patients who fall into the 0 to 1 category, so either fully ambulatory asymptomatic or fully ambulatory, doing all their activities of daily living, and not having too much of a symptom burden, those would identify the PS 0 and 1 patients. Those patients are suitable for platinum-based doublets, those are the patients that were included in the pivotal trials for bevacizumab, and so those are the considerations that I would do or have in that patient population.
Performance status 2 patients are reasonably common, these are patients that have a greater symptom burden and require help with their activities of daily living, but are still spending more than 12 hours out of bed during a 24 hour period. Those patients, I tend to use platinum-based doublets if I think that their performance status is being driven by their disease, and that's a very hard assessment. Sometimes patients with lung cancer have many co-morbidities. Lung cancer is still linked to smoking, patients can have heart disease, they can have COPD, and sometimes these co-morbid illnesses may impact their performance status. The most common reason to affect your performance status is your disease burden. If I'm convinced that your disease burden puts you in the PS 2 population, I will use chemotherapy doublets in that setting, because I want to give them the optimal chance to have a reduction in their disease volume to improve their symptoms and hopefully their performance status.
I often ask the patient "what were you like a year ago? If you're now diagnosed, are you any different than you were a year ago?" If you're the same, then I'm thinking it's really not the cancer that's driving the performance status. Maybe it's the co-morbidities. In chemotherapy, it's not going to improve your co-morbidities. In many of those patients, I would generally use monotherapy.
The PS 3 and 4 patients, those patients we don't know that there's any benefit chemotherapy and there's a real concern that we cause harm in that population. If you look at the NCCN guideline recommendations, or any other recommendations, for the PS 3 and 4 patients, it's best supportive care as the standard of care.
Both age and performance status are important. Age is a relative number. There are certainly some very healthy, active 78 year olds and there are some very sick, not active 58 year olds. It's a consideration because I think the older you are, there are 2 things factor into my thinking about this. One is the older you are, the more likely you are to have other medical problems and co-morbidities. That's just a fact. Second, the older you are, the less reserve you have. Giving treatments in that setting, you have to be aware that there may be more toxicities because of the reserve of that particular patient.
Again, there's not a cutoff. I've treated patients in their early 90s with chemotherapy, but these were special patients. It's not the average 90 year old that I would treat. I think as we age, we have different preferences. Everything we're talking about in stage IV disease is treatable if you're a good performance status, but not curable disease. So trying to understand the goals of the patient and the patient preferences what are they trying to get out of treatment and what are they looking for – is important. I find as patients age, their preferences and goals may be somewhat different than say if you're 50 years old. That's another area where age factors into it, in terms of what patients want from treatment and what they're willing to take for treatment.
mNSCLC: Case 1
RP is a 72 year old whose past medical history is notable for hypertension (well-controlled), hyperuricemia, and gout. He presents to his PCP with fatigue, progressive dyspnea, and a persistent, nonproductive cough of approximately 1 month’s duration. He is a former smoker and quit approximately 30 years ago.
Chest X-ray in October 2015 showed a large mass in the upper left lobe and CT scan showed a left pleural effusion and enlargement of the left mediastinal and hilar lymph node.
MRI of the brain was negative for intracranial metastases.
The patient underwent resection of the primary mass which showed large cell carcinoma. Pleural fluid was tapped and also positive.
His lung cancer was staged as 4. His biopsy was sent for molecular testing and showed no actionable mutations in EGFR or ALK.
His current performance status is 1.