NSCLC in the elderly--the legacy of therapeutic neglect.

Although the majority of patients diagnosed with non-small cell lung cancer (NSCLC) are elderly, most clinical trials available to guide care either exclude the elderly or underrepresent them. This disregard for the elderly lung cancer patient extends to the clinical realm, where the elderly with lung cancer are less likely to be treated with either curative, or life-extending, palliative therapy. Few elderly-specific phase III trials are available to provide level I evidence. However, subgroup analyses and meta-analyses of large clinical trials enrolling substantial numbers of elderly patients are available to guide care, although these are potentially subject to selection bias. These trials suggest that the fit elderly derive as much benefit from surgery, chemoradiation, and platinum-based doublet chemotherapy as younger patients across all stages of disease. For the less fit elderly, in particular those with limited performance status or significant co-morbidities, less aggressive regimens are likely preferred, with the goal of extending life and delaying or suppressing cancer symptoms. Ultimately, care decisions must incorporate knowledge of the literature, evaluation of the patient's clinical characteristics, and patient priorities. The elderly should be aggressively recruited to clinical trials, including elderly-specific trials and trials of patients with limited performance status and co-morbidities.