Practice pearls in the management of lung cancer in the elderly

Lung cancer is a disease that afflicts the elderly. It is a leading cause of cancer mortality worldwide. Treatment of lung cancer which was predominantly combination chemotherapy was initially thought to be too toxic for older patients with cancer due to their frail state. However a number of recent studies have shown that this is not necessarily true and many elderly can actually tolerate combination chemotherapy and derive just as much benefit from it as younger patients with lung cancer do. More recently it has been found that a significant proportion of lung cancer patients have tumors that harbor mutations that are targetable by molecularly targeted therapy (MTT). These targeted therapies have a much better tolerated side effect profile, hence have been used in elderly patient with lung cancer with great success. A new generation of drugs called immune checkpoint inhibitors have now come into the fray with exciting results in the second line treatment of lung cancer with a low side effect profile. A key element in deciding whether an elderly patient with lung cancer can tolerate treatment involves a detailed assessment using the comprehensive geriatric assessment (CGA). A number of CGA and clinical factors have also been found to be able to predict chemotherapy associated toxicity. This review of lung cancer in the elderly was part of a lecture on “Practice pearls in the management of lung cancer in the elderly” presented at the SIOG Annual Meeting in Prague in November 2015.     

Advanced Non–Small-Cell Lung Cancer in the Elderly

Systemic chemotherapy provides improvement in both survival and quality of life for patients with advanced non–small-cell lung cancer (NSCLC). Elderly patients have more comorbidities and tend to tolerate more poorly aggressive chemotherapy and radiation therapy than younger individuals. Our purpose in this article is to summarize recent studies of single-agent chemotherapy and combination regimens with cytotoxic or targeted therapies in the management of elderly patients with advanced NSCLC. We have reviewed the available evidence in the literature to gauge the results of therapy for elderly patients with lung cancer. We found that single-agent chemotherapy remains the standard of care for nonselected elderly patients. Retrospective analyses suggest that the efficacy of platinum-based combination chemotherapy is similar in fit older and younger patients, with increased but acceptable toxicity for elderly patients. Therefore, the outcomes in the fit elderly mirror results observed in younger patients, although toxicity is generally greater.     

Epidermal growth factor receptor tyrosine kinase inhibitors: present and future role in gastrointestinal cancer treatment: a review

BACKGROUND: Despite advances in conventional and targeted anticancer therapy, the prognosis remains poor for many patients with solid tumors. Ongoing research into the molecular basis of malignant disease, however, has yielded many novel agents with potential activity, including the epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs). DESIGN: This review summarizes current clinical data for EGFR-TKIs as monotherapy or in combination with 5-fluorouracil/leucovorin, irinotecan, or oxaliplatin, focusing on the rapidly developing area of colorectal, gastroesophageal, and pancreatic cancers. RESULTS: EGFR-TKIs have limited but valuable activity as monotherapy in non-small cell lung cancer patients who have received prior anticancer treatment. The potential for application as a single agent in colorectal, gastroesophageal, and pancreatic cancers has yet to be demonstrated conclusively and deserves further investigation, especially as second- or third-line therapy. In combination with oxaliplatin-based regimens and 5-fluorouracil/leucovorin-based regimens, TKIs have shown benefits, suggesting that there may be a synergistic effect with chemotherapy. However, combinations with irinotecan-based regimens have been limited by toxicities. CONCLUSIONS: EGFR-TKIs show benefits when used in combination with chemotherapy, and the favorable toxicity profiles observed suggest that these may be of value in frail or elderly patients.     

Chemotherapy in elderly patients with advanced lung cancer. Part I: General aspects and treatment of small cell lung cancer (SCLC)

There is much uncertainty whether chemotherapy is beneficial for elderly patients with advanced lung cancer. Whereas age alone is not an adverse prognostic factor, decline of physiological function and comorbidity can result in higher rates of treatment-related toxicity, in particular myelosuppression. The higher incidence of comorbid conditions, frequently sharing the risk profile of the malignancy, can translate into worse survival. Therefore, a geriatric assessment of the patient's overall situation should guide decision-making. Mainstay of treatment of small cell lung cancer (SCLC), also in the elderly, is combination therapy. Several retrospective analyses reveal that in elderly patients often lower drug doses are delivered. However, the treatment outcome of these patients does not appear to be worse compared to younger patients. For functionally independent elderly patients, combination chemotherapy with carboplatin and etoposide, supported by optimized supportive care, possibly including hematopoietic growth factors (G-CSF) to minimize toxicity, should be considered. Special attention to renal function should be given and individualized drug dosing, adapted to the glomerular filtration rate, is mandatory. For patients with some functional dependence or showing a certain degree of comorbidity, preliminary data indicate that single-agent therapy with carboplatin can confer the same benefit as combination chemotherapy, but with reduced toxicity. Single agent oral etoposide, however, seems to be inferior to combination treatment and should not be given routinely in the treatment of this cohort. Further evaluation of these topics is needed, and can be achieved by trials specifically designed for elderly patients or patients with reduced performance status.     

Treatment of small cell lung cancer in the elderly

Small cell lung cancer (SCLC) accounts for approximately 20% of lung carcinomas. Chemotherapy is the cornerstone of treatment for SCLC. In limited disease, the median survival time is about 12-16 months, with a 4%-5% long-term survival rate; in extensive disease the median survival time is 7-11 months. More than 50% of lung cancer patients are diagnosed when they are over the age of 65, and about 30% are over 70. Elderly patients tolerate chemotherapy poorly compared with their younger counterparts, because of age-related progressive reductions in organ function and comorbidities. The standard therapy for limited disease is combined chemoradiotherapy, followed by prophylactic brain irradiation for patients achieving complete responses. In the elderly, the addition of radiotherapy to chemotherapy must be carefully evaluated, considering the slight survival benefit and potential for substantial toxicity incurred with this treatment. The best approach is to design clinical trials that specifically include geriatric assessment to develop active and well-tolerated chemotherapy regimens for elderly SCLC patients. Survival improvement for SCLC patients requires a better understanding of tumor biology and the subsequent development of novel therapeutic strategies. Several targeted agents have been introduced into clinical trials in SCLC, but a minority of these new agents offers a promise of improved outcomes, and negative results are reported more commonly than positive ones. This review focuses on the main issues in the treatment of elderly SCLC patients.     

EGFR-TKI单药或联合放疗治疗非小细胞肺癌肺毒性研究进展

分子靶向药物表皮生长因子受体-酪氨酸激酶抑制剂（epidermal growth factor receptor-tyrosine kinase inhibitor,EGFR-TKI）单药为EGFR敏感突变非小细胞肺癌（non-small cell lung cancer,NSCLC）患者一线治疗方案。近年来多项研究证实,其与放疗联合治疗时具有放疗增敏作用,临床研究表明其可改善晚期NSCLC患者生存且亦有可能作为无法耐受放化疗时的替代方案。EG-FR-TKI单药治疗肺毒性发生率较低但死亡率较高,与放疗联合时肺毒性发生概率不一,本文将结合相关文献围绕EG-FR-TKI类药物单药或联合放射治疗时肺毒性发生状况做一综述,为联合治疗方案的安全性提供参考。      

吉非替尼一线治疗老年晚期非小细胞肺癌临床观察

目的：观察表皮生长因子受体酪氨酸激酶抑制剂吉非替尼单药一线治疗老年晚期非小细胞肺癌的疗效和不良反应。方法：2006年2月至2008年12月36例65岁以上晚期非小细胞肺癌患者进入研究,所有患者均为Ⅲ-Ⅳ期。口服吉非替尼250mg/d,至病情进展或者不能耐受不良反应。结果：36例均可评价疗效和不良反应。治疗后2个月进行评价,RR为41.67%（15/36）、DCR86.11%（31/36）。用药后最常见的不良反应为Ⅰ、Ⅱ度皮疹25例（52.78%）,腹泻11例（30.56%）,皮肤瘙痒5例（13.89%）,皮肤干燥5例（13.89%）,肝功异常2例（5.56%）。TTP为3.5-23.8个月,中位TTP8.2个月。结论：吉非替尼单药治疗老年晚期非小细胞肺癌疗效肯定,不良反应相对较小,患者耐受性好。可以作为该特殊人群的一线治疗。     

Satraplatin: an orally available platinum analog for the treatment of cancer

Satraplatin is a novel, orally bioavailable, platinum anticancer drug. Platinum analogs form the mainstay of treatment for a number of cancers, including lung, ovarian, colorectal and head and neck cancer. A disadvantage of the currently marketed platinum analogs is that they must all be administered via intravenous infusion. In addition, their utility is often limited by toxicity, particularly neurotoxicity, ototoxicity and renal toxicity. Satraplatin has preclinical antitumor activity comparable with that of cisplatin and, clinically, has a more manageable side-effect profile. Satraplatin is active in lung, ovarian and prostate cancer, and appears to have good efficacy in combination with radiation for lung and head and neck cancer. Preclinical data suggest it may also be effective for the treatment of certain cisplatin-refractory tumors. A large, randomized Phase III trial is currently evaluating satraplatin in combination with prednisone for the treatment of patients with hormone-refractory prostate cancer whose disease has progressed following prior systemic therapy. Positive results from this trial would support regulatory approval for satraplatin for this indication. The availability of an active oral platinum agent, such as satraplatin, with few of the serious toxicities associated with traditional intravenous platinum compounds makes satraplatin an alternative to other platinum agents and a new treatment option in the oncologist's armamentarium.     

Satraplatin: an orally available platinum analog for the treatment of cancer

Satraplatin is a novel, orally bioavailable, platinum anticancer drug. Platinum analogs form the mainstay of treatment for a number of cancers, including lung, ovarian, colorectal and head and neck cancer. A disadvantage of the currently marketed platinum analogs is that they must all be administered via intravenous infusion. In addition, their utility is often limited by toxicity, particularly neurotoxicity, ototoxicity and renal toxicity. Satraplatin has preclinical antitumor activity comparable with that of cisplatin and, clinically, has a more manageable side-effect profile. Satraplatin is active in lung, ovarian and prostate cancer, and appears to have good efficacy in combination with radiation for lung and head and neck cancer. Preclinical data suggest it may also be effective for the treatment of certain cisplatin-refractory tumors. A large, randomized Phase III trial is currently evaluating satraplatin in combination with prednisone for the treatment of patients with hormone-refractory prostate cancer whose disease has progressed following prior systemic therapy. Positive results from this trial would support regulatory approval for satraplatin for this indication. The availability of an active oral platinum agent, such as satraplatin, with few of the serious toxicities associated with traditional intravenous platinum compounds makes satraplatin an alternative to other platinum agents and a new treatment option in the oncologist’s armamentarium.     

Recent topics in chemotherapy for elderly patients with lung cancer

With the prolongation of life expectancy in Japan, lung cancer is increasing not only in the elderly but also in poor-risk patients who can not undergo standard chemotherapy. Because survival benefits from chemotherapy are clearly expected in patients with small-cell lung cancer (SCLC), standard chemotherapy should be established for the elderly as well as for poor-risk patients with SCLC. We recently reported that the combination of AUC-based carboplatin and a standard dose of intravenous etoposide was an active and relatively nontoxic regimen for elderly patients with SCLC (J Clin Oncol 17: 3540-3545, 1999). Had chemotherapy with concurrent chest irradiation been used for patients with limited disease (LD), better survival might have been achieved in this study. However, Pignon et al. reported that combined chemoradiotherapy in elderly patients with LD-SCLC is a possible poor prognostic factor in their meta-analysis. A recent randomized controlled clinical trial has shown that vinorelbine monotherapy contributed to longer survival in elderly patients with advanced non-small-cell lung cancer (NSCLC), compared to best supportive care. Several retrospective studies have shown that cisplatin can be safely and effectively administered to elderly patients who are eligible for protocol treatment. However, there have been no randomized trials indicating that cisplatin-based combination chemotherapy improves survival in elderly patients with advanced NSCLC, compared to single-agent chemotherapy. Similarly, the role of combined chemoradiotherapy remains controversial in elderly patients with locally advanced NSCLC. Thus, standard therapies proven to be beneficial to non-elderly patients with lung cancer have not always been proven to be beneficial to elderly patients. In order to solve these difficult problems, phase III studies are warranted in elderly or poor-risk patients with lung cancer. Moreover, new agents with relatively low toxicities recently approved in Japan should be applied in clinical trials for the elderly or poor-risk patients with lung cancer.     

多西紫杉醇与多西紫杉醇联合卡铂治疗老年晚期非小细胞肺癌的疗效观察

目的比较单药多西紫杉醇（Docetaxel,TXT）和TXT联合卡铂（Carboplatin,CBP）即TC方案治疗老年晚期非小细胞肺癌(Non-small cell lung cancer,NSCLC)的疗效及不良反应的差异。方法46例晚期NSCLC老年患者,随机分为两组: TXT组给予TXT 50mg/m²,第1天,每2周重复;TC组给予TXT 40mg/m²,第1天, CBP 300mg/m²,第1天,每2周重复。结果两组有效率(36.4% vs 41.7%, P=0.77)和中位生存期(9.2月 vs 7.9月,P=0.13)差异均无统计学意义。TXT组患者生活质量改善优于TC组（77.3% vs 45.8%,P=0.03）,且Ⅲ+Ⅳ度白细胞减少发生率明显低于TC组（18.2% vs 54.2%, P=0.02）。两组非血液学毒性较温和,耐受性良好。结论与TC方案相比,TXT单药2周方案治疗老年NSCLC疗效相当,耐受性及生活质量更好,值得临床进一步观察研究。     

Chemotherapy in elderly patients with advanced lung cancer. Part II: Treatment of non-small cell lung cancer (NSCLC)

Increasing interest in the treatment of elderly patients or patients with poor performance status (PS) with non-small cell lung cancer (NSCLC) has led to a number of subgroup analyses of clinical trials, and even more importantly, the conduction of trials specifically designed for this cohort. These studies allow some important conclusions. Data from retrospective studies and meta-analyses indicate that the use of platinum-based two-drug combinations in selected, fit elderly patients may produce response rates, survival, and toxicity comparable to those in younger patients. This excludes a per se inferior effectiveness of chemotherapy in the population of elderly patients with NSCLC. A number of more recently introduced agents with a favourable toxicity profile have significantly increased treatment options. Single- agent therapy with vinorelbine, when compared to best supportive care, has been shown to give a statistically significant survival benefit and improve quality of life. Conflicting data from phase II/III trials in elderly patients with NSCLC exist regarding a potential benefit of combination chemotherapy over single-agent treatment in the total cohort of elderly patients, including those with comorbidities or declining functional reserve. A review of the most important trials, assessing treatment options in elderly patients with lung cancer, either prospectively or retrospectively, is provided, and still unresolved issues are addressed.     

Epirubicin weekly in combination chemotherapy with cyclophosphamide and vincristine in untreated small cell lung cancer: a phase II trial

Thirty-three patients with untreated small cell lung carcinoma received 6 cycles epirubicin 30 mg/m2 i.v. on days 1, 8, and 15, in combination with cyclophosphamide 1,000 mg/m2 on day 1 and vincristine 2 mg i.v. on day 1 every 3 weeks. Thirty-one patients were evaluable concerning state of remission. Four out of 13 patients with limited disease had a complete, and 6 a partial remission, while 2 out of 18 patients with extensive disease had a complete and 8 a partial remission. The toxicity of this therapy regimen was very low. The results of this treatment did not differ significantly in comparison to the standardized treatment of small cell lung cancer, but it was easier to tolerate.     

Rituximab plus gemcitabine: a therapeutic option for elderly or frail patients with aggressive non Hodgkin's lymphoma?

The standard treatment for patients with aggressive B-cell lymphoma - particularly diffuse large-B-cell lymphoma [DLBCL) - is cyclophosphamide, doxorubicin, vincristine and prednisone [CHOP) plus rituximab, a chimeric monoclonal antibody against the CD20 antigen. However, some patients are not fit enough to tolerate CHOP or they relapse after previous therapy with CHOP. Gemcitabine as a monotherapy is active and relatively non-toxic in the treatment of NHL. We investigated the toxicity and efficacy of a combination of gemcitabine with rituximab in a small series of elderly patients with high-grade B-cell lymphoma who had either a relapse after CHOP, or were medically unfit to tolerate CHOP as a first-line therapy. Gemcitabine was given at 1000 mg/m²/week × 3, q28 days; rituximab at 325 mg/m²/week × 4 in the first cycle, and on day 1 of all subsequent cycles. Seven patients have been treated. The median number of cycles given was 4. The major toxicity was haematologic: grade 3/4 leukocytopenia occurred in 4 patients, grade 3/4 thrombocytopenia in 3 patients. There were no episodes of clinically significant bleeding. One patient developed febrile neutropenia and died in the course of treatment; another patient developed non-Q-wave myocardial infarction possibly related to hydration pre-treatment to rituximab and erythrocyte transfusion. He recovered well after symptomatic therapy. In 7 patients, 2 complete and 3 partial remissions were achieved, with an estimated median time to progression of 12 months. This series of patients shows that the combination of gemcitabine and rituximab is feasible in this population not able to undergo standard poly-chemotherapy, shows promising activity, and merits further evaluation.     

Weekly docetaxel in the treatment of elderly patients with advanced nonsmall cell lung carcinoma. A Minnie Pearl Cancer Research Network Phase II Trial

BACKGROUND: Weekly administration of docetaxel was found to reduce myelosuppression and other nonhematologic toxicities when compared with administration every 3 weeks. In the current Phase II trial, the authors evaluated the feasibility, toxicity, and efficacy of weekly docetaxel in the treatment of elderly patients with newly diagnosed advanced nonsmall cell lung carcinoma. METHODS: Thirty-nine patients with advanced, previously untreated nonsmall cell lung carcinoma entered this Phase II trial between February 1998 and January 1999. Patients were required either to be age >/= 65 years or to be poor candidates for combination chemotherapy due to coexistent medical illnesses. All patients received docetaxel, 36 mg/m(2), administered weekly for 6 consecutive weeks, followed by 2 weeks without treatment. Patients were reevaluated after 8 weeks of treatment; responding patients continued weekly docetaxel for a maximum of 32 weeks or until disease progression. RESULTS: Weekly docetaxel was well tolerated by this elderly group of patients with nonsmall cell lung carcinoma. Grade 3 leukopenia was noted in only 3 patients (8%), and no patient developed Grade 4 myelosuppression. Grade 3/4 nonhematologic toxicity also was uncommon; fatigue/asthenia was reported in 4 patients (10%). Seven of 38 evaluable patients (18%) had objective responses to weekly docetaxel whereas an additional 13 patients (34%) had a minor response or stable disease at first reevaluation. The median survival in this group of elderly patients was 5 months, with a 1-year actuarial survival rate of 27%. CONCLUSIONS: The results of the current study show that weekly docetaxel is active and well tolerated in elderly patients with advanced nonsmall cell lung carcinoma and provides an additional treatment option for these patients, who often tolerate combination chemotherapy regimens poorly.     

长春瑞滨单药治疗老年晚期非小细胞肺癌的临床研究

目的观察和评价长春瑞滨(NVB)单药治疗老年晚期非小细胞肺癌的临床疗效和毒性反应。方法21例晚期非小细胞肺癌患者均经病理组织学和(或)细胞学检查确诊。国产长春瑞滨(盖诺)25 mg/m2加NS100 ml快速静脉点滴,第1、8天。21 d为一个周期,至少治疗2个周期。结果21例患者均可评价,CR 1例,PR 5例,SD 6例,患者的近期有效率28.6%,TTP 5.1个月,中位生存期7.2个月,1年生存率30.1%。最主要的毒副反应为白细胞及血小板的降低,但均可以耐受。结论长春瑞滨(NVB)单药治疗老年晚期非小细胞肺癌有较好的临床疗效,可改善患者的生存质量,延长生存时间,毒性反应比较轻,老年患者亦可以耐受。     

The Role of the Taxanes in the Treatment of Older Patients with Advanced Stage Non‐Small Cell Lung Cancer

The treatment of older patients with advanced non‐small cell lung cancer (NSCLC) represents a considerable challenge for physicians. A patient 's suitability for chemotherapy is frequently based solely on chronologic age; as a consequence, older patients with NSCLC are less likely to receive standard chemotherapy than younger patients. Although age‐related factors, such as comorbid illness, should be taken into consideration when assessing a patient 's suitability for treatment, fit and functionally independent older patients should be considered candidates for standard chemotherapy. The taxanes are widely used in the treatment of advanced‐stage NSCLC and are well tolerated in older patients. The efficacy of both paclitaxel and docetaxel has been studied in older patients and appears to be comparable with that seen in younger patients either as monotherapy or in combination with a platinum compound as first‐line therapy. In addition to the available evidence, prospective evaluation of novel agents in elderly‐specific or ‐enriched studies is necessary to guide the treatment of older patients with NSCLC.     

Elderly patients with lung cancer: biases and evidence

Opinion statement Although 60% of those diagnosed with non-small-cell lung cancer are 60 years of age or older, the elderly are often undertreated. Furthermore, those older than age 70 are under-represented in clinical research trials. Tremendous bias exists against treating the elderly; therapeutic nihilism and constrained societal/financial resources conspire to maintain the status quo. In limited stage small cell carcinoma of the lung (SCLC), a pivotal meta-analysis by Pignon et al. showed no obvious benefit for chemoradiation over chemotherapy alone in patients older than 70 years of age. However, more recent trials have revealed a clear-cut benefit for fit elderly patients to receive combined modality therapy versus chemotherapy alone, even though outcome generally remains superior for younger patients. For patients with locally advanced non-small-cell lung cancer, conflicting results exist. Individual trials evaluating combined modality therapy have shown no impairment in survival for older patients, but retrospective analyses of the Radiation Therapy Oncology Group database have demonstrated that increased therapeutic intensity does not translate into improved outcome compared with standard, single daily fraction radiation alone. Weighted survival analyses that deduct time spent with progressive disease or significant toxicity have reinforced this notion. In advanced non-small-cell lung cancer, fit elderly patients who receive platinum-based regimens do as well, or nearly as well, as patients younger than age 70, although the incidence of neutropenia and fatigue is often higher. Platinum doses above 75 mg/m2 every 3 weeks to 4 weeks are relatively more toxic in the elderly than are lower doses. Three separate studies from Italy have formally assessed the elderly. One showed superiority for single-agent vinorelbine versus best supportive care regarding survival rates and quality of life. A second showed a marked survival advantage for combination vinorelbine and gemcitabine versus vinorelbine alone. However, a much larger, more credible study demonstrated no benefit for combination vinorelbine and gemcitabine versus the constituent single agents. To date, no elderly-specific trials have addressed the role of taxanes or of platinum-based combination therapy versus non-platinum monotherapy or doublets. Comprehensive evaluation of comorbidities and their influence on outcome have not been conducted, and there are virtually no data for patients older than age 80.     

Does chemotherapy have a role as palliative therapy for unfit or elderly patients with non-small-cell lung cancer?

Elderly patients and younger "unfit" patients with poor Eastern Cooperative Oncology Group (ECOG) performance status (PS) (> or = 2) suffering from advanced non-small-cell lung cancer (NSCLC) are two different populations--both of which require palliative treatments. Elderly patients frequently experience progressive decline of organ function and multiple comorbidities, which need to be considered when choosing therapy. ECOG 1594 showed that advanced NSCLC patients with an ECOG PS of 2 did not tolerate platinum-based chemotherapy (cisplatin/paclitaxel, carboplatin/paclitaxel, cisplatin/docetaxel, carboplatin/paclitaxel). These data confirm that treatments designed specifically for this patient subset are needed. Single-agent chemotherapy seems to be a reasonable approach, and non-platinum-based combination chemotherapy should also be investigated. The oncology community has become increasingly aware of the magnitude of the problem of cancer in the elderly. More than 30% of lung cancers arise in patients > or = 70 years old. Elderly patients tolerate chemotherapy poorly, according to the few published papers, and are not considered eligible for aggressive cisplatin-based chemotherapy in clinical practice. A phase III randomized trial (ELVIS [Elderly Lung Cancer Vinorelbine Italian Study]) demonstrated survival and quality-of-life benefits with single-agent vinorelbine versus best supportive care. Among the newer drugs, gemcitabine has demonstrated activity and low toxicity in phase II studies. With this background, we performed a randomized, multicenter phase III trial (MILES [Multicenter Italian Lung Cancer in the Elderly Study]) in 707 advanced NSCLC elderly patients. The MILES study compared single-agent chemotherapy with vinorelbine or gemcitabine versus polychemotherapy with gemcitabine plus vinorelbine. Results showed no benefit in response rate, time to progression, survival, and quality of life for the combination. Single-agent chemotherapy remains the standard treatment approach for elderly NSCLC patients with advanced disease.     

Treatment of lung cancer in elderly part II: small cell lung cancer

There is a general trend worldwide of an increasing incidence of elderly population. Age is the greatest risk factor for cancer; therefore, this demographic shift is a main reason for an increase of cancer incidence. Lung cancer is a typical disease of the elderly patients. Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancer cases. This review summarises the issues of treatment of SCLC in elderly. The number of randomised phase III trials concerning treatment of SCLC in elderly patients are very limited. Although currently most treatment decisions are based on lower grades of evidence, some conclusions can be drawn from the current studies. Age alone is a very uncertain prognostic criteria for outcome or tolerability of treatment. Much more important is the geriatric assessment of each individual patient. Current treatment standards for limited disease (LD)-SCLC (polychemotherapy plus local thoracic irradiation and additional prophylactic cranial irradiation in case of complete remission) seems to be also feasible for 'fit' elderly (>70 years) LD-SCLC patients with a good performance and full functional capacities. There are preliminary data indicating that a similar outcome in elderly patients can probably be achieved a with reduced number of treatment schedules (e.g. 2 instead of 4 cycles in combination with radiotherapy. Surgical resection is also feasible in selected elderly patients with very early stage SCLC, where this maybe an appropriate approach, although no phase III data are available, which demonstrated the benefit of additional surgery compared to chemotherapy alone in early stage SCLC. In patients with extensive disease-SCLC age alone does not necessarily restrict the use of multiagent regimen, although the risk of haematological toxicity seems to be higher than in the younger patients. When standard treatment is not feasible due to co-morbidity or loss of functional capacity, several alternative combination regimens are available, which appear to be slightly superior to single agent treatment, although randomised data for elderly on that issue are sparse. Carboplatin and etoposide seems currently the most appropriate two-drug combination in elderly patients, but there are a variety of active and low toxic third generation agents like taxanes, gemcitabine and vinorelbine which are active in both, non-small cell lung cancer and SCLC. For the comparison of trials in elderly patients it will be of key importance to include a comprehensive and standardised geriatric assessment in such studies.