The role of biological age in lung cancer treatment decision making for elderly patients

The average age for a lung cancer diagnosis is 70, according to the American Cancer Society. With age, it can be harder for a person's body to tolerate cancer treatments like surgery and chemotherapy.

But some older people's bodies are considered "biologically young" and can handle cancer treatments better than their peers, said University of Chicago Medicine geriatric oncologist James Wallace, MD.

Biological age is one of the factors Wallace and his UChicago Medicine lung cancer care team colleagues consider when creating personalized care plans for advanced-age patients. They also account for a person's lifestyle, cognitive health and, most importantly, their wishes.

Cancer patients in their 80s and 90s face more "risk versus reward" decisions, said UChicago Medicine thoracic oncologist Marina Chiara Garassino, MD.

Some patients may want the most aggressive treatment their body can handle. Others might choose no treatment, opting to live with lung cancer and manage the symptoms, rather than face potentially debilitating side effects from surgery and chemotherapy, which offer no guarantee of remission.

You have to listen to the patient, ask what their goals are and respect what they want. Then you try to help them in the best way you can."

Marina Chiara Garassino, MD, UChicago Medicine thoracic oncologist 

Stage 3B lung cancer diagnosis at age 89

Mickey Allen was 89 when she was diagnosed with Stage 3B lung cancer in 2021.

The cancer was found during a routine bronchoscopy following her bout with COVID-19. It came as a surprise to the healthy, non-smoker from Chicago's South Side, who wasn't experiencing any issues with coughing, breathing or weight loss.

As Wallace devised a plan to treat Allen's lung cancer (Garassino took over her care after Wallace moved to UChicago Medicine Ingalls Memorial Hospital), they considered factors more specific to older cancer patients:

• Chronic health conditions: Allen was in excellent physical health (no serious diseases, no previous cancer, but a history of pulmonary embolisms and arthritis) and had no issues that could complicate treatment.
• Biological age: Allen was biologically young, meaning her body aged slower and functioned better than someone of the same chronological age.
• Cognitive function: Allen, a retired metallurgy engineer, was mentally sharp and still did bookwork for a friend's business.
• Extended at-home care: Allen had a strong support network of family and friends ready to help for as long as she needed them.
• Patient motivation and prognosis: Allen wanted the most aggressive treatment her body could handle to resume her active lifestyle of volunteering at church, working and spending time with friends and family.

"You need to find the right balance of where a patient is in their life and what they need to slow or fight the cancer," Wallace said.

Stage 3B lung cancer treatment in older adults

The standard treatment for Stage 3B lung cancer is simultaneous chemotherapy and radiation, followed by immunotherapy, an intravenous treatment that trains a person's own immune system to attack their cancer. (Surgery for Stage 3B lung cancer is not recommended at any age, since the tumors are widespread and difficult to reach).

Due to Allen's age, Wallace determined she could tolerate chemotherapy only, and at a 20% reduced dose. If the chemotherapy successfully shrunk her tumors, she could finish out her treatment with immunotherapy.

"She was empowered and proactively involved in all of the decisions, and she did very, very well," Garassino said. "She reacted not much differently than a young person would to that treatment."

Allen valued her role in the team approach to treatment.

"The doctors made my opinions count, and I appreciated that," she said.

Moving forward

The treatments put Allen's cancer in remission for more than two years, allowing her to continue enjoying life. She recently renewed her driver's license and is preparing to plant her spring garden.

However, at age 92, Allen recently learned her cancer is active again. With the help of her UChicago Medicine team, she has resumed treatment.

"You can live with lung cancer in your 90s," Wallace said. "The challenge is managing that with your age and other medical issues you're facing. Mickey is able to do that."