Lung cancer in older patients

Prof Dr Lore Decoster, a medical oncologist at UZ Brussels specialising in lung cancer, presented a summary of a dedicated lung cancer session at the SIOG meeting in Ghent. The session focused on current evidence and evolving strategies for screening and treating lung cancer in older adults, a population in whom the majority of diagnoses occur, particularly in individuals aged over 70 years. Despite this demographic reality, older adults are frequently underrepresented in clinical research and excluded from screening initiatives. In Belgium, for example, lung cancer screening is not yet standard practice and older patients are often not considered eligible. To address this gap, the SIOG International Working Group is developing screening guidelines emphasising that chronological age alone should not determine eligibility. Instead, decisions should be guided by functional status assessed through geriatric evaluation, as well as patient preferences. Fit older adults who express interest in screening should be offered screening and subsequent treatment when appropriate.

Systemic therapy for lung cancer in older patients was discussed extensively, including targeted therapies, chemotherapy, immunotherapy, and antibody–drug conjugates. Evidence specific to older adults remains limited due to their historical exclusion from clinical trials. Published SIOG recommendations based on available literature indicate that targeted therapies demonstrate comparable efficacy and toxicity profiles in older and younger patients. However, the clinical consequences of adverse events may be more severe in older individuals due to comorbidities or reduced physiological reserve; for example, QTc prolongation can have greater implications in patients with pre-existing cardiac disease.

Regarding immunotherapy, recent reviews suggest similar treatment efficacy across age groups, though some studies report slightly reduced benefit in patients aged 75 years and older. These observations remain uncertain because of small sample sizes. As with targeted agents, toxicity may carry greater functional and logistical impact in older adults, including increased hospitalisation requirements and prolonged impairment from symptoms such as arthralgia.

Chemotherapy remains a treatment option, and trials have demonstrated that single-agent chemotherapy offers a survival advantage over best supportive care in older adults. A weekly carboplatin–paclitaxel regimen has shown superiority to single-agent therapy but is associated with higher toxicity, reinforcing the need for careful patient selection. Comprehensive geriatric assessment is strongly advised prior to systemic therapy initiation to evaluate frailty, comorbidities, cognition, nutrition, functional status, and social context. Tools such as the Cancer and Aging Research Group (CARG) chemotherapy toxicity score may support individualised risk–benefit discussions by integrating patient- and tumour-related variables.

The session also included expert discussions on radiotherapy and surgery for early-stage lung cancer in older adults. Both modalities offer effective and potentially curative treatment in fit older adults. Stereotactic radiotherapy may be suitable for patients with reduced physiological reserve who are not surgical candidates, although treatment-related toxicity must still be considered. 

Across all therapeutic domains, the central theme emphasised was that treatment and screening decisions should not be guided by chronological age alone. Instead, individualised assessment of physical fitness, geriatric vulnerabilities, expected treatment tolerance, and patient goals of care should form the basis of clinical decision-making.