Case Study: Treating an Elderly Patient With Squamous NSCLC

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In the first installment of the series, moderator Corey J. Langer, MD, introduces the panelists for an in-depth discussion on current and emerging treatments for patients with non-small cell lung cancer (NSCLC). The panelists include: Roy S. Herbst, MD, PhD, Karen L. Reckamp, MD, MS, Anne S. Tsao, MD, and Everett E. Vokes, MD.

To begin the discussion, Langer describes a scenario detailing the diagnosis of a functional 77 year-old man with squamous cell NSCLC. The patient presented with right upper quadrant pain and a cough. The initial chest x-ray showed a right upper lobe mass. As a result, a CT scan was administered and found a 4 cm spiculated lesion and hepatic metastases. Additionally, a physical examination by the patient's primary care physician found an enlarged right supraclavicular node and rhonchi at the right base. As a result, the patient underwent a core biopsy that revealed purely squamous cell carcinoma. However, Langer notes, the patient's performance status is intact and he wishes to continue with his daily activities, which include golf.

For elderly patients it is important to look at the performance status (PS), explains Tsao. In this case, the PS is low enough that a platinum-based doublet can be administered safely. In most cases, Tsao utilizes carboplatin with paclitaxel or docetaxel; however, she notes, other regimens have showed efficacy, including platinum-based therapy with gemcitabine or nab-paclitaxel (Abraxane). These alternate regimens offer unique attributes; for instance, Tsao notes, nab-paclitaxel allows for a higher taxane dose with less neuropathy, which is ideal in an elderly population.

There is a clear benefit for treating patients in this setting with a chemotherapy doublet, explains Reckamp. In a phase III trial comparing carboplatin plus paclitaxel to single-agent vinorelbine or gemcitabine the doublet was associated with a significant survival advantage. This trial included patients with PS 0-2, notes Reckamp. While the doublet did result in higher toxicities, the overall outcome was superior. As such, it is important to discuss these factors with the patient before proceeding with a treatment.

Herbst supports a platinum-based doublet; however, focusing on quality of life, the toxicity profile of nab-paclitaxel is promising, specifically since the patient mentioned a desire to continue playing golf.