Lung Cancer Treatment: Joe Paterno, a Teaching Moment

At age 85 a person’s life balance is quite fragile.  Medical problems that at a younger age have no effect on the quality or quantity of life can at age 85 have major consequences.  Flu may lead to pneumonia; a simple fall may break a bone and lead to complications; cancer treatments may have life threatening consequences.

At one time aggressively treating a person over age 80 with chemotherapy, much less chemotherapy combined with radiation, would have been unthinkable.  With medical “progress,” however, we believe that we can aggressively treat everyone, including the aged.

This was todays headline:  Joe Paterno, Penn State’s legendary football coach, dies:

Former Penn State head coach Joe Paterno, his body ravaged by chemotherapy and radiation treatments for lung cancer, died early Sunday morning at Mount Nittany Medical Center in State College.

Medicynical Note:  I don’t know how the advantages and disadvantages of treatment were spun to Mr. Paterno by his doctors. 

I can infer from the approach, chemo and radiation, that the disease was nonresectable (not amenable to surgery).  That is, it was either locally advanced or metastatic.  It is a fact that virtually all such patients (young and old) will have  limited benefit from aggressive treatment, and not be cured, regardless of age.  The results of studies in stage 3 and 4 lung cancer range  from  no survival benefit to a  few month’s longer life (median benefit).   Meanwhile many of these patients will have significant side effects, often debilitating and life threatening. 

Regarding those over age 80 and the benefits of lung cancer treatment,  see here:

The > or =80 age group was less likely to be subjected to surgery or chemotherapy, and had inferior outcomes when compared with the 70-79 age group and the <70 age group. Survival improvement was not observed in the > or =80 age group.

Regarding elderly patients with lung cancer: (note the difference between the elderly (age 70-79 and those over age 80)

Evidence supports that elderly patients with good PS and limited comorbidity may benefit from combination chemotherapy. Age alone should not dictate treatment-related decisions in patients with advanced NSCLC. Elderly patients with a good PS enjoy longer survival and a better quality of life when treated with chemotherapy compared with supportive care alone. Caution should be exercised when extrapolating data for elderly patients (aged 70–79 years) to patients aged 80 years or older because only a very small number of patients aged 80 years or older have been enrolled on clinical trials, and the benefit in this group is uncertain. (Medicynical emphasis)

Mr. Paterno’s treatment decision was, I’m sure, his own choice, influenced by his physicians as well as his personal beliefs.  His poor outcome is within the range of expected results for this terrible disease. 

Addendum:  Mr. Paterno is reported to have been diagnosed with small cell cancer of the lung with metastasis at diagnosis.  As with non-small cell lung cancer there is little data indicating a significant benefit for patients over age 80 from aggressive treatment.

The optimal therapeutic approach in older patients remains unclear. A population analysis showed that increasing age was associated with a decreased performance status and increased comorbidity.  Older patients were less likely to be treated with combined chemoradiation therapy, more intensive chemotherapy, and PCI. Older patients were also less likely to respond to therapy and had poorer survival outcomes. Whether this was a result of age and its associated comorbidities or suboptimal treatment delivery remains uncertain.

And:

Among patients with limited disease, the proportion receiving chemoradiation increased from 35% to almost 60% for those aged 60–69, from 28% to 48% in age group 70–74, from 17% to 33% in age group 75–79, but remained <10% for those aged 80+. Among patients with extensive disease, the proportion receiving chemotherapy (CT) decreased from 81% of patients aged 60–64 to 23% of those aged 85+, without substantial changes over time. Survival has only improved for patients <80 years.

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