Lung cancer in the very elderly: incidence, presentation, and diagnostic decision-making. A retrospective analysis at a teaching community hospital

BACKGROUND AND OBJECTIVES: Lung cancer presentation and decision-making in the very elderly patient population, 80 years of age and older, was studied given the projected increase in cancer incidence in the very elderly and yet only limited management guidelines. DESIGN AND SETTING: A 10-year experience at the Unity Health System of Rochester, NY, was reviewed using tumor registry data for the entire lung cancer population plus focused medical record review of very elderly patients. A questionnaire survey on the clinical approach to lung cancer in the elderly was distributed to medical staff involved in their care. PARTICIPANTS, MEASUREMENTS, AND RESULTS: Of 997 patients, approximately 100 cases each year, the very elderly comprised 18% of patients from year 1998 through 2002, and 23% from year 2003 through 2007. One-third of the very elderly were diagnosed with lung cancer on clinical grounds without tissue confirmation. The majority of this group had cardio-pulmonary symptoms and an advanced clinical stage. The very elderly had no tissue sampling as per their own decision in 12 of 44 of cases, per family decision in 28 of 44, and per physician and other input in 4 of 44. Physicians stated that patient wishes and health-related factors, more so than socio-economic factors, were primary concerns for management decision-making. CONCLUSIONS: The number of very elderly lung cancer patients in this community setting has been significant and appears to be increasing. These patients were more likely to have an incomplete diagnostic work-up, with patient and family wishes being the major factor in medical decision-making. The physician approach to these patients emphasized patient autonomy and medical factors.