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Table of Contents
LETTER TO EDITOR
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 582-583

Can patients aged 60 years and over be called elderly?


Department of Medical Oncology, Silverline Hospital, Bhopal, Madhya Pradesh, India

Date of Submission09-Aug-2021
Date of Decision29-Aug-2021
Date of Acceptance07-Sep-2021
Date of Web Publication08-Oct-2021

Correspondence Address:
Tarini Prasad Sahoo
Silverline Hospital, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_183_21

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How to cite this article:
Sahoo TP. Can patients aged 60 years and over be called elderly?. Cancer Res Stat Treat 2021;4:582-3

How to cite this URL:
Sahoo TP. Can patients aged 60 years and over be called elderly?. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Dec 9];4:582-3. Available from: https://www.crstonline.com/text.asp?2021/4/3/582/327774



I read with interest the study published by Abraham et al. in Cancer Research, Statistics, and Treatment on the use of immunotherapy in the elderly[1] and the accompanying editorial.[2] Does the term “elderly” denote a state that begins after a fixed chronological age or is it when the physiologic and pharmacologic processes start to change in the human body? If that is so, then 75 years should be the ideal cutoff to call a patient “elderly.” It is important to correctly define the age cutoff, especially when evaluating the responses and toxicity data of patients receiving immunotherapy, as immunosenescence could play a role in how these patients respond to the immune checkpoint inhibitors (ICIs).[3] Unfortunately, in the study by Abraham et al., less than a quarter of the patients were aged 75 years and older. Even if the authors had included only patients over the age of 65 years, the results of the study may have been of more relevance.

Second, there is sufficient evidence that patients aged <65 years versus 65–75 years benefit equally from immunotherapy, regardless of the location of primary cancer. It is specifically for the patients aged over 75 years, for whom there is a lack of data due to their underrepresentation in clinical studies, although some published studies have reported conflicting data with regard to benefit with ICIs in this age group in patients with advanced non-small-cell lung cancer (NSCLC) and renal cell carcinoma.

I am also concerned about the use of single-agent ICI in driver mutation-positive advanced NSCLC in the second-line setting. There is enough evidence in the published literature about the lack of efficacy of these agents in this subset of patients. The only regimen that could possibly be of some benefit in this patient cohort is atezolizumab with bevacizumab, paclitaxel, and carboplatin as used in the IMpower150 study.[4] This is again important as the patients with driver mutation-positive NSCLC constituted 15% of the total patient load (27/150).

Although the patient population in this study was heterogeneous, it would have been worthwhile to report the response curves according to the tumor type; this would have provided additional insights regarding how these patients responded, especially with regard to the tumor type and the programmed death (PD)/PD ligand-1 status.

Limited evidence in the literature points towards increased toxicity of ICI in patients over the age of 80 years; patients aged between 65 and 75 years usually tolerate ICIs as well as the younger patients. In the study by Abraham et al., only 4% of patients were over 80 years old, and thus, no conclusions can be drawn with regard to how the older Indian patient with cancer tolerates ICI therapy. In addition, no in-depth geriatric evaluations were performed, although this study was specifically directed at evaluating the tolerability and responses to ICI in the elderly.

Poor performance status is a well-known poor prognostic factor across multiple published studies and leads to inferior oncological outcomes; the study by Abraham et al. further reiterates this point and gives us food for thought. For a country like India, where most patients pay for their medical expenses out of pocket,[5],[6] ICI may not a cost effective treatment in those with performance status 2 or lower. I also question the validity of the authors' interpretation regarding the other negative prognostic factors such as age, male sex, and chronic renal disease, as the respective confidence intervals were wide.[1]

In conclusion, I would like to congratulate the whole team for this effort, as this is the largest published data of ICI in patients aged 60 years and over from India (even though I remain unsure whether all of them can be labeled “elderly”), and this does give us confidence in treating this population with immunotherapy, especially when the toxicities are minimal, the treatment is tolerable and without morbidity with decent efficacy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abraham G, Jobanputra KN, Noronha V, Patil VM, Menon NS, Gattani SC, et al. Immune checkpoint inhibitors in older patients with solid tumors: Real-world experience from India. Cancer Res Stat Treat 2021;4:270-6.  Back to cited text no. 1
  [Full text]  
2.
Arora S, Kumar L. Immune checkpoint inhibitors in older patients with cancer: A new era in cancer therapy. Cancer Res Stat Treat 2021;4:368-9.  Back to cited text no. 2
  [Full text]  
3.
Müller L, Pawelec G. Aging and immunity - Impact of behavioral intervention. Brain Behav Immun 2014;39:8-22.  Back to cited text no. 3
    
4.
Reck M, Mok TS, Nishio M, Jotte RM, Cappuzzo F, Orlandi F, et al. Atezolizumab plus bevacizumab and chemotherapy in non-small-cell lung cancer (IMpower150): Key subgroup analyses of patients with EGFR mutations or baseline liver metastases in a randomised, open-label phase 3 trial. Lancet Respir Med 2019;7:387-401.  Back to cited text no. 4
    
5.
Philip CC, Mathew A, John M J. Cancer care: Challenges in the developing world. Cancer Res Stat Treat 2018;1:58-62.  Back to cited text no. 5
  [Full text]  
6.
Goyanka R. Economic and non-economic burden of cancer: A propensity score matched analysis using household health survey data of India. Cancer Res Stat Treat 2021;4:29-36.  Back to cited text no. 6
  [Full text]  




 

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