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Case history

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Image not available. An 84-year-old woman with a persistent cough was referred to the respiratory physicians by her GP. A CT scan identified a 3.5×2.6 cm mass in the left upper lobe, and a subsequent biopsy demonstrated a poorly differentiated adenocarcinoma (cytokeratin 7- and thyroid transcription factor-1-positive). Full staging (CT-PET and MR brain scans) confirmed a T2aN1M0 (stage IIA) lung adenocarcinoma. Her past medical history included a myocardial infarction in 2009 (managed medically) and atrial fibrillation (AF). Examination was unremarkable with adequate pulmonary function (>80% predicted FEV1 and diffusion factor). The patient was taking omeprazole, digoxin, warfarin and simvastatin. She was a widow with two daughters and an ex-smoker of 38 years with a 20 pack-year history. She was fully independent.

The lung multidisciplinary team (MDT) recommended primary resection and she proceeded to have a video-assisted left upper lobectomy. She recovered well postoperatively and the pathological stage was pT2pN1M0. After a further MDT discussion, the benefits and toxicities of vinorelbine/carboplatin were outlined to the patient and her family and she elected to receive chemotherapy. This was preferred over vinorelbine/cisplatin because of the potential cardiac and renal toxicities associated with cisplatin. Given her past medical history, early referral was made to the cardiologists, who converted her warfarin to rivaroxaban and continued her digoxin.

Cycle 1 of chemotherapy was complicated by grade 1 sensory neuropathy and cycle 2 by a urinary tract infection. The vinorelbine dose was reduced for cycle 3. The patient had ongoing difficulties with urinary symptoms, weight loss and worsening paraesthesia; therefore, cycle 4 was omitted.

What is the goal of treatment in this patient?

What preoperative assessments should be performed to risk-stratify older patients?

What is the evidence base for adjuvant treatment in older patients with lung cancer?

What considerations for heart disease need to be made in the older oncology patient?

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What is the goal of treatment in this patient?

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Limited-stage lung cancer is treated by surgery with curative intent. There are numerous series of surgical cases describing well-selected patients who tolerated the procedure as well as younger patients. However, population data in the 2014 UK National Clinical Lung Cancer Audit show that age is an independent prognostic factor and that patients aged over 80 have significantly worse outcome. If patients have adequate respiratory and cardiac function, regardless of age, they are offered surgery for early-stage non-small-cell lung carcinoma (NSCLC). Adjuvant chemotherapy trials have demonstrated consistently that the benefits at 5 years are a gain in overall survival (OS) of 5-10% and a 30% decrease in the rate of recurrence.1 In general, however, patients over the age of 70 were not included in these trials, although subsequent series suggest that older patients tolerate chemotherapy and therefore have the potential to benefit to the same extent as those under the age of 70.

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What preoperative assessments should be performed to risk-stratify older patients?

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Surgery remains the ...

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