In lung cancer, mainly non-small cell lung cancer, there have been many advances so far, especially with the introduction of immunotherapy and then targeted therapies. But still in older patients we don’t have that much data, we lack data especially in those patients aged 75 years or more. They only represent about 10% in clinical trials while they are more than 30% in real life. So we do have some data for immunotherapy; hazard ratios in patients aged 65 years or more are similar to the younger patients but really for 75 years or more we don’t have that much data. There’s one clinical trial in phase II, a phase II trial with nivolumab in second line, where you do see that in patients aged 70 years or more survival is similar and toxicities are similar than in younger patients.
What else is new in immunotherapy?
There’s different, there’s targeted therapies, so you have a small group of patients that are EGFR mutant and they can be treated in first line with what we call an EGFR tyrosine kinase inhibitor, which is very targeted against the mutation. Again we lack data in older patients aged 75 plus. There are small phase II studies, mainly from Asian populations where they have more patients with an EGFR mutation, and there you see that these patients also have good responses and long progression free survival when they take such a tyrosine kinase inhibitor. Important now is that we have a third generation EGFR tyrosine kinase inhibitor called osimertinib which is more precisely targeting the EGFR mutant and not the EGFR wildtype like the other ones. So it has less toxicities because the other ones had mainly toxicity – diarrhoea and rash, which is very disturbing for older patients. You must imagine that a grade 1 diarrhoea is four times a day loose stools; when you’re older, already lacking some mobility, this is not easy. With osimertinib the diarrhoea is less frequent, they also have less rash and some even older patients are very concerned about their appearance and when you have an acne form rash it’s, for them, not very good for their social life sometimes. So osimertinib is a good option and now it is registered for patients that have a specific resistance mutation on the first and second generation. There have been some studies that we believe osimertinib may be moving up to first line and if this would be the case I believe this would be a huge step forwards for older patients because of the toxicity profile.
How do you balance toxicity and quality of life?
For older patients, and especially for lung cancer patients, most lung cancer patients are metastatic, are stage 4, and you’re not going to cure these patients. Toxicity and quality of life are primordial endpoints, are sometimes more important than overall survival. Of course it is something that we have to discuss with the patient and every patient has his own expectations of the treatment. Sometimes an older patient wants to survive until the marriage of a grandchild or the birth of someone. So it’s what they expect from life but sometimes they really want to have a good quality of life, a maintenance of their functional status, and then you have to take into account toxicities of treatment and discuss this with them.
