Dr. West: We have seen converging evidence over the last several years that fit elderly patients should really be treated identically to the way we would treat younger patients with a good performance status, with the potential exception of whether to include bevacizumab or not. With regard to chemotherapy, studies have shown that elderly patients enjoy the same kind of benefit with a carboplatin-based chemotherapy doublet compared with single-agent therapy that younger, fit patients do.1
With bevacizumab, a subset analysis by Dr. Ramalingam and colleagues looking at the ECOG 4599 trial suggested that patients over 70 [years of age] did not experience a survival benefit with the addition of bevacizumab, unlike younger patients.2,3 This might have been because they experienced disproportionally greater toxicity issues with the addition of bevacizumab. There was also an analysis of the SEER database that suggested that there was no survival benefit with the addition of bevacizumab to carboplatin and paclitaxel in elderly patients, as well.4
So, I think that [the] addition of bevacizumab is a debatable point and still worth individualizing, based on judgment and the patient in front of you. However, I think that the approach with carboplatin-based chemotherapy would be a very appropriate choice for a good–performance-status elderly patient; and you can use whatever doublet—based on histology and other individual factors, [such as] schedule, desire to avoid toxicity—that you would be inclined to do for a patient who is younger.
Narrator: A phase 3 study comparing cisplatin plus gemcitabine with cisplatin plus pemetrexed in chemotherapy-naïve patients demonstrated that overall survival was superior for the cisplatin/pemetrexed combination in patients with adenocarcinoma, with a better tolerability profile.5
Dr. West: I have personally favored a combination of carboplatin and nab-paclitaxel for patients with a squamous histology, [in part] because of a subset analysis of the pivotal trial that appeared to demonstrate particularly favorable results with the nab-paclitaxel combination in older patients and those with a squamous histology.6
Narrator: In addition, Dr. West notes that because it is a weekly regimen, this allows clinicians to get quick feedback on how well patients are tolerating the treatment, and adjust the regimen as needed.
Dr. West: So, in our older patients, we certainly do want to be especially mindful of potential tolerability issues, and I've found that both of those regimens have been very promising. And I think we are moving toward a more histology-specific approach to treatment with our chemotherapies, as well as targeted treatments.