Impact of age and comorbidity on non-small-cell lung cancer treatment in older veterans

Abstract

Purpose: Because comorbidity affects cancer treatment outcomes, guidelines recommend considering comorbidity when making treatment decisions in older patients with lung cancer. Yet, it is unclear whether treatment is targeted to healthier older adults who might reasonably benefit.

Patients and methods: Receipt of first-line guideline-recommended treatment was assessed for 20,511 veterans age ≥ 65 years with non-small-cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry from 2003 to 2008. Patients were stratified by age (65 to 74, 75 to 84, ≥ 85 years), Charlson comorbidity index score (0, 1 to 3, ≥ 4), and American Joint Committee on Cancer stage (I to II, IIIA to IIIB, IIIB with malignant effusion to IV). Comorbidity and patient characteristics were obtained from VA claims and registry data. Multivariate analysis identified predictors of receipt of guideline-recommended treatment.

Results: In all, 51% of patients with local, 35% with regional, and 27% with metastatic disease received guideline-recommended treatment. Treatment rates decreased more with advancing age than with worsening comorbidity for all stages, such that older patients with no comorbidity had lower rates than younger patients with severe comorbidity. For example, 50% of patients with local disease age 75 to 84 years with no comorbidity received surgery compared with 57% of patients age 65 to 74 years with severe comorbidity (P < .001). In multivariate analysis, age and histology remained strong negative predictors of treatment for all stages, whereas comorbidity and nonclinical factors had a minor effect.

Conclusion: Advancing age is a much stronger negative predictor of treatment receipt among older veterans with NSCLC than comorbidity. Individualized decisions that go beyond age and include comorbidity are needed to better target NSCLC treatments to older patients who may reasonably benefit.

Conflict of interest statement

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

Figures

Fig 1.

Exclusions used to define the final cohort of older veterans with non–small-cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry.

Fig 2.

(A) Local disease: Other treatment (gray) includes radiation and/or chemotherapy, and guideline-recommended treatment (blue) includes surgery. (B) Regional disease: Other treatment (gray) includes chemotherapy or radiation alone, and guideline-recommended treatment (blue) includes surgery or chemotherapy plus radiation. (C) Metastatic disease: Other treatment (gray) includes surgery or radiation, and guideline-recommended treatment (blue) includes chemotherapy.