Date Published: June 12, 2019
Publisher: Public Library of Science
Author(s): Julia Walter, Amanda Tufman, Rolf Holle, Larissa Schwarzkopf, Aamir Ahmad.
Although lung cancer is most commonly diagnosed in elderly patients, evidence about tumor-directed therapy in elderly patients is sparse, and it is unclear to what extent this affects treatment and care. Our study aimed to discover potential disparities in care between elderly patients and those under 65 years of age.
We studied claims from 13 283 German patients diagnosed with lung cancer in 2009 who survived for at least 90 days after diagnosis. We classified patients as “non-elderly” (≤ 65), “young-old” (65–74), “middle-old” (75–84), and “old-old” (≥ 85). We compared receipt of tumor-directed therapy (6 months after diagnosis), palliative care, opioids, antidepressants, and pathologic diagnosis confirmation via logistic regression. We used generalized linear regression (gamma distribution) to compare group-specific costs of care for 3 months after diagnosis. We adjusted all models by age, nursing home residency, nursing care need, comorbidity burden, and area of residence (urban, rural). The age group “non-elderly” served as reference group.
Compared with the reference group “non-elderly”, the likelihood of receiving any tumor-directed treatment was significantly lower in all age groups with a decreasing gradient with advancing age. Elderly lung cancer patients received significantly fewer resections and radiotherapy than non-elderly patients. In particular, treatment with antineoplastic therapy declined with increasing age (“young-old” (OR = 0.76, CI = [0.70,0.83]), “middle-old” (OR = 0.45, CI = [0.36,0.50]), and “old-old” (OR = 0.13, CI = [0.10,0.17])). Patients in all age groups were less likely to receive structured palliative care than “non-elderly” (“young-old” (OR = 0.84, CI = [0.76,0.92]), “middle-old” (OR = 0.71, CI = [0.63,0.79]), and “old-old” (OR = 0.57, CI = [0.44,0.73])). Moreover, increased age was significantly associated with reduced quotas for outpatient treatment with opioids and antidepressants. Costs of care decreased significantly with increasing age.
This study suggests the existence of age-dependent care disparities in lung cancer patients, where elderly patients are at risk of potential undertreatment. To support equal access to care, adjustments to public health policies seem to be urgently required.
Lung cancer was the fourth leading cause of death in Germany in 2016 . Among all types of cancer, lung cancer accounted for the highest proportion of cancer-related deaths in men and the second highest in women . Lung cancer is most commonly diagnosed in elderly patients with median age at diagnosis of around 68–70 years in developed countries [2–4]. In Germany in 2013, incidence rates ranged from 125 per 100 000 in 55- to 59-year-old men to 423 in 100 000 in 80- to 84-year-old men, and from 64 to 106 per 100 000 in women . Despite these numbers, historically, elderly patients are underrepresented in clinical trials ; therefore, evidence on treatment effects in this relevant patient group is insufficient. Efforts to address this issue by enrolling more elderly patients in clinical trials have been made  and, since the 1990s, numbers have improved . However, most elderly trial participants are enrolled in age-unspecific trials . In these trials, only patients who meet the strict eligibility criteria concerning comorbidities and performance status are included [6, 9, 10]; therefore, they most probably do not represent the average elderly patient . Recent guidelines include recommendations for elderly patients (>70 years), for example relating to performance status, but do not further differentiate between subgroups of elderly patients, for instance young-old, middle-old, and old-old . However, clinical experience suggests that differences exist between age-based subgroups of elderly patients, and that both chronological and biological age can be relevant to treatment decisions in the setting of lung cancer . Numerous studies have shown that treatments effective in younger adults can be of similar benefit to elderly patients [13, 14]; however, there is also evidence that treatment approaches in elderly patients are considerably different [15, 16]. Furthermore, survival in lung cancer is significantly associated with age as well [17, 18]. A study from Turkey found that patients over the age of 70 years had 1-year survival rates of 42.5% compared with 67.3% in patients 70 years or younger . Similarly, in an analysis of Surveillance, Epidemiology and End Results data, an age gradient of 7.4% vs. 12.3% vs. 15.5% was found concerning 5-year survival rates in lung cancer patients aged younger than 70 years, between 70 und 79 years, and 80 years or older respectively .
Care for elderly lung cancer patients differs widely from care for patients under the age of 65 years, regardless of the presence of metastases at the time of lung cancer diagnosis. Elderly lung cancer patients receive fewer lung cancer-directed treatments than non-elderly patients. The proportion of patients not receiving any treatment in our study was around 40%, and even 66% among “old-old” patients with and without metastases, but only between 3% and 7% among “non-elderly” patients. An interesting finding was that the proportions of patients not receiving any tumor-directed treatments were higher in the group of patients without metastases. We hypothesized that a reason for this was a problem of misclassification of patients to this stratum. By refining our sample in the sensitivity analysis, we believe we were able to address this issue appropriately, as now proportions in the younger age groups were similar. In particular, the use of antineoplastic therapy declined with increasing age in both metastases strata. Recent studies and guidelines support the use of carboplatin-based doublets in fit elderly patients and single-agent treatment in less fit patients . However, for patients aged 80 years and older, there are limited data from trials; therefore, specific recommendations for this age group are lacking . The extreme drop seen between the “middle-old” and “old-old” might be related to the reluctance of patients and physicians to administer antineoplastic therapy in a setting with little evidence from trials.
In conclusion, our study describes a significant age gradient across all care aspects studied, affecting tumor-directed therapies as well as palliative care and the treatment of pain and depression. Evidence from this study suggests that this effect cannot be explained completely by patient preferences and a certain degree of undertreatment in elderly patients is plausible. As a majority of lung cancer patients are over the age of 65 years, this is of great public health concern. Although efforts to enhance palliative care in Germany have been made, lawmakers should further adjust public health policies to address these disparities.