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Original Study

Radiotherapy for Stage III NoneSmall-Cell LungCarcinoma in the Elderly (Age � 70 years)Paul D. Aridgides,1 Adam Janik,2 Jeffrey A. Bogart,1 Steven Duffy,3

Paula Rosenbaum,4 Ajeet Gajra5

AbstractIn this retrospective study, the outcomes after radiotherapy were studied in elderly patients (age ‡ 70 years)with locally advanced nonesmall-cell lung carcinoma in comparison with a younger cohort. A total of 189patients were treated at a single institution (Upstate Medical University, Syracuse, NY). Undertreatment (lowerradiotherapy dose, less utilization of systemic chemotherapy) was more common in elderly patients, as waspoor performance status. This analysis supported the use of definitive chemoradiotherapy in elderly patientswith good performance status, and enrollment in an elderly directed clinical trial should be encouraged giventhe underrepresentation of elderly patients in randomized studies.Background: Elderly patients are underrepresented in trials that establish definitive chemoradiotherapy as thestandard of care for inoperable stage III nonesmall-cell lung carcinoma (NSCLC). This study analyzed radiotherapytreatment delivery and outcomes at our institution according to elderly (� 70 years old) or younger (< 70 years) age.Methods: Records of patients who received radiotherapy for stage III NSCLC between January 1998 and February2010 were reviewed. Factors analyzed included Eastern Cooperative Oncology Group Performance Status (ECOGPS), weight loss, radiation therapy intent, and chemotherapy administered. Results: A total of 189 patients with stageIII NSCLC were analyzed (age range, 28-92 years). Elderly patients (n¼ 86) were more likely to have ECOG PS � 2 (P<

.05) and receive palliative treatment (P < .05). Elderly patients less often received concurrent chemoradiotherapy (P <

.05) as well as cisplatin (P < .05). Median survival was 10.3 months for elderly patients compared with 17.2 months foryounger patients (P < .05 ). In addition, elderly patients with ECOG PS (P < .05) as well as those who receiveddefinitive concurrent chemoradiotherapy (P < .05) had inferior outcomes compared with otherwise similar youngerpatients. However, on multivariate analysis, elderly age was not associated (P ¼ .428) with increased risk of death,whereas poor ECOG PS (� 2) was significant (P < .05). In elderly patients, definitive treatment (P < .05), chemotherapyadministration (P < .05), and ECOG PS of 0-1 (P < .05) were associated with improved outcome. Conclusions:Although elderly patients with stage III NSCLC experience inferior outcomes than younger patients with comparabledisease, they are also more likely to receive suboptimal therapy. On multivariate analysis, advanced age was notassociated with worse survival, which indicates that appropriately selected elderly patients should receive definitivechemoradiotherapy.

Clinical Lung Cancer, Vol. 14, No. 6, 674-9 ª 2013 Elsevier Inc. All rights reserved.Keywords: Chemotherapy, Elderly patients, Nonesmall-cell lung carcinoma, Radiotherapy, Stage III

IntroductionLung cancer deaths are estimated to be 226,190 in 2012, and the

median age of diagnosis is 70 years old.1 Modern advances innonesmall-cell lung cancer (NSCLC) treatment include earlierdetection, targeted therapies, and advanced radiotherapy (RT)

1Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, NY2Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA3Medical Oncology at St Mary’s, Richmond, VA4Department of Public Health and Preventive Medicine, SUNY Upstate MedicalUniversity, Syracuse, NY5Division of Hematology-Oncology, Department of Internal Medicine, SUNY UpstateMedical University, Syracuse, NY

Clinical Lung Cancer November 2013

techniques.2 Unfortunately, the outcomes of elderly patients withlung cancer (age � 70 years) appear to be lagging behind im-provements for younger patients.3 In an analysis of long-term cancermortality trends, Wingo et al4 found that, in the 1990s, cancermortality and incidence increased among persons aged 70 years or

Submitted: Jan 8, 2013; Revised: Apr 16, 2013; Accepted: May 6, 2013; Epub:Jul 25, 2013

Address for correspondence: Paul D. Aridgides, MD, Department of RadiationOncology, SUNY Upstate Medical University, 750 E Adams Street, Syracuse, NY13210Fax: (315) 464-5944; e-mail contact: aridgidp@upstate.edu

1525-7304/$ - see frontmatter ª 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.cllc.2013.05.001

Table 1 Patient Characteristics, Stage III NoneSmall-CellLung Carcinoma

Age ‡ 70years

Age< 70 years

Significant(P < .05)

No. patients 86 103

Median (range) patient age,years

75.5 (70-95) 59 (41-69)

Sex, no. (%)

Men 53 (62) 60 (58)

Women 33 (38) 43 (42)

ECOG PS, no. (%)

0-1 49 (57) 79 (77) Yes

�2 30 (35) 24 (23)

unknown 7 (8) 0

Histology, no. (%)

Squamous 33 (38) 35 (34)

Adenocarcinoma 25 (29) 40 (39)

Not specified or other 28 (33) 28 (27)

Stage, no. (%)

T3 13 (15) 17 (16)

T4 30 (35) 38 (36)

N2 44 (51) 60 (57)

N3 15 (17) 32 (30)

IIIA 37 (43) 44 (42)

IIIB 49 (57) 59 (58)

Abbreviation: ECOG PS ¼ Eastern Cooperative Oncology Group Performance Status.

older while it declined for those younger than 50 years old.Although trends in tobacco smoking do coincide with thesechanges, there is clearly a need for improvements in the treatment ofelderly patients with lung cancer.

For unresectable locally advanced NSCLC, concurrent chemo-therapy with RT is the proven standard of care.5 Elderly patientshave been notably underrepresented in clinical trials that have hel-ped define this standard of care. In an meta-analysis of trials thatcompared concomitant vs. sequential chemoradiotherapy, only 16%of patients were 70 years old or older.6 Trials of systemic chemo-therapy in advanced disease are also relatively lacking in elderlypatients.7 As a result, for locally advanced disease, the comparativebenefit and toxicity profile of combination chemoradiotherapy inolder patients is poorly understood. For this reason, we performed aretrospective analysis of elderly patients with stage III NSCLCtreated with RT at our institution compared with a younger cohort.The cutoff of age � 70 years old was chosen as a commonly useddefinition of elderly in patients with locally advanced NSCLC,although several additional age limits (� 65 years old or � 75 yearsold) have also been used.3

Patients and MethodsStudy Population

We identified 86 elderly (age � 70 years old) and 103 younger(age < 70 years old) consecutive patients with stage III A or BNSCLC treated with RT at Upstate Medical University between1998 and 2010. Stage definitions according to the year of treatmentwere followed up.8 Patients could not have received prior RT.

TreatmentRT was delivered with megavoltage (� 6 MV) equipment (Varian,

Palo Alto, CA). Three-dimensional conformal RT (which the vastmajority of patients received) and image guidance RT were imple-mented as they became available. Radiation was defined as definitive(curative intent) or palliative (relief of symptoms, temporizing tumorcontrol) according to the treating physician’s documentation on thewritten treatment prescription and confirmed on consultation notesfor accuracy. A 1-week gap in treatment constituted a treatmentbreak, and a cumulative dose less than the prescription was anincomplete treatment. In addition, the incidences of hospitalizationwhile receiving treatment were followed up for elderly patients.Systemic chemotherapy was either administered (concurrent oradjuvant) or omitted according to multidisciplinary assessment.

Outcome AnalysisSurvival was defined from the time of lung cancer diagnosis until

death or last follow-up. Statistical analysis (Graphpad Prism,GraphPad Software Inc, La Jolla, CA; SPSS version 21, SPSS Inc,Chicago, IL) included the Fisher exact test, Kaplan-Meier survival,log-rank (Mantel-Cox) testing, and Cox proportional hazards formultivariate analysis.

ResultsPatient Characteristics

Patient characteristics are shown in Table 1. The median age ofelderly patients was 75.5 years (range, 70-95 years). Whereas EasternCooperative Oncology Group Performance Status (ECOG PS) (0-1)

was less common in the elderly group (57% vs. 77%; P < .05),pretreatment characteristics were otherwise similar, including rates ofpatients with stage T4 (35% vs. 36%) and IIIB (57% vs. 58%).

Treatment DeliveryOverall, elderly patients were less likely to receive definitive RT

(71% vs. 87%; P < .05) than younger patients (Table 2). Even forpatients with ECOG PS 0-1, elderly patients were more likely toreceive less-intensive therapy. This included a lower definitive RTdose (median 60 vs. 66 Gy; P < .05), less utilization of concurrentchemoradiotherapy (49% vs. 86%; P < .05), increased treatmentwith definitive RT only (P < .0001), and more frequent palliativeRT intent (22% vs. 8.8%; P < .05). Palliative RT (administered to13% of younger and 29% of elderly patients) was given to a similarmean dose for the elderly (29 Gy) and younger cohort (34 Gy;nonsignificant). Concurrent chemotherapy was given with palliativeradiation to 4 younger patients (31%) compared with none (0%) ofelderly patients (P < .05).

Upon examination of only patients who received chemo-radiotherapy, chemotherapy was administered concurrently in asimilar percentage of elderly patients (64%, n ¼ 24) compared withyounger patients (68%, n¼ 59) (Table 3), which indicates that whenelderly patients were deemed fit for inclusion for chemotherapy, thestandard delivery schedule (concurrent) was used similarly to youngerpatients. However, there was less utilization of concurrent cisplatinchemotherapy in the elderly cohort vs. the younger cohort (5% vs.20%; P < .05). Chemotherapy regimens less commonly given

Clinical Lung Cancer November 2013 - 675

Table 3 Chemoradiotherapy Schedules and Regimens Usedfor Patients With Stage III NSCLC Who ReceivedDefinitive Treatment

Age‡ 70 years,no. (%)

Age< 70 years,no. (%)

Significant(P < .05)a

Chemotherapy given 42 (69) 87 (97)

Chemotherapy schedule

Sequential only 4 (10) 3 (3)

Concurrent 27 (64) 59 (68)

Concurrent þ sequential 11 (26) 25 (29)

Chemotherapy regimen

Cisplatin doublet 2 (5) 17 (20) Yes

Carboplatin/paclitaxel 25 (60) 62 (71)

Gemcitabine (induction) 1 (2) 10 (11)

Other 14 (33)b 5 (6)c

Abbreviation: NSCLC ¼ nonesmall-cell lung cancer.aEmpty cells indicate nonsignificant results; P values for statistical trends (P � .05 but < .10)are provided if available.bFor elderly patients, other chemotherapy regimens included Xyotax (Cell Therapeutics Inc,Seattle, WA)/carboplatin (institutional protocol), paclitaxel/vinorelbine, carboplatin only, andpaclitaxel only.cFor younger patients, other chemotherapy regimens included carboplatin/pemetrexed, car-boplatin/docetaxel, and carboplatin/Abraxane (Celgene Corp, Summit, NJ) þ erlotinib.

Figure 1 Survival of Patients With Stage III NoneSmall-CellLung Cancer Who Received Radiation TherapyAccording to Age Range (P < .01, Univariate Analysis)

Table 2 Treatment Characteristics of Patients With Stage IIINSCLC Treated With RT

Age‡ 70 yearsb

Age< 70 yearsb

Significant(P < .05)a

No. patients 86 103

RT intent, no. (%)

Definitive 61 (71) 90 (87) Yes

Palliative 25 (29) 13 (13)

Definitive RT

Median RT dose, Gy 60 66

Completed � 60 Gy,no. (%)

50 (82) 79 (88)

Concurrent chemotherapy,no. (%)

38 (62) 84 (93) Yes

Cisplatin doublet CRT,no. (%)

2 (3.3) 16 (18) Yes

ECOG PS 0-1, no. patients 49 79

Median RT dose, Gy 60 66 Yes

Definitive concurrent CRT,no. (%)

24 (49) 68 (86) Yes

Definitive RT þ seqchemotherapy, no. (%)

2 (4.1) 2 (2.5)

Definitive RT only, no. (%) 12 (24) 2 (2.5) Yes

Palliative RT, no. (%) 11 (22) 7 (8.8) Yes

ECOG PS � 2, no. patients 30 24

Median RT dose, Gy 60 58

Definitive concurrent CRT,no. (%)

11 (37) 16 (67) .054

Definitive RT þ seqchemotherapy, no. (%)

2 (6.7) 1 (4.2)

Definitive RT only, no. (%) 6 (20) 1 (4.2)

Palliative RT, no. (%) 11 (37) 6 (25)

Abbreviations: CRT ¼ chemoradiotherapy; ECOG PS ¼ Eastern Cooperative Oncology Group Per-formance Status; NSCLC¼ nonesmall-cell lung carcinoma; RT¼ radiotherapy; seq¼ sequential.aEmpty cells indicate nonsignificant results; P values for statistical trends (P � .05 but< .10) aregiven if available.bPercentages for definitive RT categories do not equal 100% because some groups areoverlapping, ie, “concurrent chemotherapy and cisplatin doublet CRT.”

Radiotherapy for Stage III Lung Cancer in the Elderly

676 -

(14 elderly patients, 33%) are listed in Table 3 and may indicate adesire to limit the toxicity compared with standard regimens.

Treatment TolerabilityOverall, 15 elderly patients (17%) were hospitalized while

receiving RT. RT records were reviewed for treatment breaks andincomplete treatment as a measure of tolerability (Table 4). Elderlypatients had higher rates of both treatment breaks (15% vs. 5% inyounger cohort; P < .05) and failure to complete RT (19% vs. 8%;P < .05). However, when analyzing only patients who receivedchemoradiotherapy, elderly patients had comparable treatmentbreaks and incomplete RT (10.5% vs. 7.1%; nonsignificant), whichindicates that elderly patients thought to be candidates for intensivetherapy (chemoradiation) tolerated the treatment well.

Treatment OutcomesWith a median follow-up for surviving patients of 28.8 months

(range, 17.8-109.8 months), the median survival of the elderly

Clinical Lung Cancer November 2013

cohort was 10.3 months (Table 3). On univariate analysis, elderlypatients experienced inferior survival compared with the youngercohort overall (Figure 1). Likewise elderly patients experiencedinferior survival with definitive RT (P < .05), definitive chemo-radiation (P < .05), and ECOG PS 0-1 (P < .05)(Table 5).Although this appeared to indicate inferior outcomes inthe elderly cohort (even for good ECOG PS or when receivingintensive treatment), on multivariate analysis for all elderly patients,age (� 70 years old) was not significant for increased risk of death;ECOG PS � 2 was associated with risk of death on multivariateanalysis, and the treatment-related factors of chemotherapyadministration (P < .05) and definitive radiation (approached sig-nificance, P ¼ .089) were found to be protective.

Table 4 The Incidence of Treatment Breaks or Failure toComplete RT According to Patient Age

Age‡ 70 years,

no./total no. (%)

Age< 70 years,

no./total no. (%)Significant(P < .05)a

RT treatmentbreak, �1 wk

11/71 (15) 5/93 (5) Yes

Definitive RT 6/49 (12) 4/83 (5)

Palliative RT 5/22 (23) 1/10 (10)

Definitive concCRT

0/21 (0) 0/68 (0)

RT courseincomplete

16/86 (19) 8/103 (8) Yes

Definitive RT 7/61 (11) 6/90 (7)

Palliative RT 9/25 (36) 2/13 (15)

Conc CRT 4/38 (11) 6/84 (7)

Abbreviations: Conc ¼ concurrent; CRT ¼ chemotherapy; NSCLC ¼ nonesmall-cell lungcancer; RT ¼ radiotherapy.aEmpty cells indicate nonsignificant results; P values for statistical trends (P � .05 but < .10) ifare provided if available.

Table 5 Median Survival (months) of Patients Who Received RTWith or Without Chemotherapy for Stage III NSCLCAccording to Patient Age

Age‡ 70 years, mo

Age< 70 years, mo

Significant(P < .05)

Overall 10.3 17.2 Yes

Definitive RT 11.9 18.9 Yes

Palliative RT 6.2 9.1 .096

Definitive RT withconcurrentchemotherapy

12.0 19.5 Yes

Definitive RT alone 6.6 3.0

ECOG PS

0-1 12.4 19.8 Yes

�2 6.9 7.6

Abbreviations: ECOG PS ¼ Eastern Cooperative Oncology Group Performance Status;mo ¼ months; NSCLC ¼ nonesmall-cell lung carcinoma; RT ¼ radiotherapy.

Paul D. Aridgides et al

Among elderly patients, factors associated with improved survivalon univariate analysis included definitive RT (P< .05), ECOG PS 0-1 (P< .05), and concurrent chemotherapy if receiving definitive RT(P< .05).Onmultivariate analysis, however, only ECOGPS� 2wasassociated (P< .05) with increased risk of death. For elderly patients,there was an 8% increase in risk of death with each year of age.

DiscussionThere is a paucity of prospective trials that evaluated potentially

curative treatment (concurrent chemoradiotherapy) for the elderlypopulation.9 A succession of trials over the past 30 years firstestablished the benefit of sequential RT and chemotherapy10,11 and,ultimately, the superiority of concurrent chemoradiotherapy oversequential treatment,12-14 In a meta-analysis of randomized trialsthat compared sequential vs. concurrent chemoradiotherapy, a 4.5%improvement in 5-year overall survival was seen for a concurrenttreatment.6 Although all subgroups (including age groups) appearedto benefit with concurrent treatment, only 189 (16%) patients of1205 enrolled were 70 years old or older. In a subset analysis of theRTOG (Radiation Therapy Oncology Group) 94-10 trial, elderlypatients (age � 70 years old) treated with concurrent chemo-radiotherapy lived longer (median survival, 22.4 months vs. 10.5months) than with sequential treatment.15 This analysis found thatin the relatively favorable prognosis patients enrolled (Karnofskyperformance status > 70, weight loss � 5%), acute but not long-term toxicity was higher in elderly patients. A retrospective analysisof 2 CALGB (Cancer and Leukemia Group B) trials likewiseshowed similar benefit to concurrent over sequential chemo-radiation in elderly patients who also exhibited higher rates ofmyelosuppression.16

The optimal assessment and management of locally advancedNSCLC in the elderly population continues to evolve. In this series,older patients with stage III NSCLC were less likely to receivedefinitive treatment (concurrent chemoradiotherapy) regardless ofperformance status. Even among patients with good ECOG PS(0-1), elderly patients were less likely to receive definitive

chemotherapy (only 49%) and a surprising number received palli-ative treatment (22%). Given that age was not predictive of survivalon multivariate analysis, our experience is in agreement with otherseries that suggest undertreatment for elderly patients with stage IIINSCLC.9 In a retrospective analysis of patients with stage IIINSCLC from the Mayo Clinic in Scottsdale, Arizona, combinedchemoradiotherapy was associated with a survival advantage forpatients � 75 years old.17 In agreement with our analysis, elderlypatients were less likely to receive combined modality therapy (21%vs. 45%; P < .0001) compared with the younger cohort.

One consideration that may result in undertreatment is theperception that elderly patients with locally advanced NSCLC maynot tolerate concurrent chemoradiotherapy as well as a youngerpopulation would. In the meta-analysis of Aupérin et al,6 grade 3/4esophageal toxicity occurred in 18% of patients who receivedconcurrent chemoradiotherapy (compared with 4% with sequentialtreatment).6 In a subset analysis of a combined modality trial, Schildet al18 found equivalent survival in elderly patients at the expense ofincreased hematologic and pulmonary toxicity. In our series, how-ever, although hospitalization (17%) and failure to finish plannedtreatment (19%) were more likely in elderly patients overall, theelderly patients selected for definitive chemoradiotherapy hadsimilar rates of treatment completion to the younger cohort. Takentogether, these data support aggressive treatment for stage IIINSCLC in suitable patients (good performance status) with pro-spective evaluation of appropriate regimens.

An emerging strategy for improving the toxicity profile of com-bined modality therapy is the use of targeted therapy (epidermalgrowth factor receptor inhibition) concurrently with radiation. In aphase II trial by the NCCTG (North Central Cancer TreatmentGroup), cetuximab was administered (loading and weekly doses)with thoracic RT (60 Gy) to 57 patients (median age, 77 years old)with NSCLC.19 Inclusion criteria were stage III NSCLC with eitherolder age (� 65 years old) or poor performance status. The regimenwas well tolerated, with a median survival of 15.1 months for thishigh-risk population. The CALGB (RTOG endorsed) reported on aphase II trial of induction chemotherapy (carboplatin and albumin-bound paclitaxel, 2 cycles) followed by concurrent RT (66 Gy) and

Clinical Lung Cancer November 2013 - 677

Radiotherapy for Stage III Lung Cancer in the Elderly

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erlotinib (150 mg daily). Enrolled patients had stage III NSCLCand “poor-risk” features, including weight loss � 10% and/or lowperformance status, of whom 32% were 75 years old or older.20 Themedian survival was 16 months, with neutropenia (grade 3/4) andesophagitis (grade 3) in 19% and 5% of patients, respectively.Although results with targeted therapy and radiation are encour-aging, the slow accrual seen with this trial is a common obstacle toconducting prospective trials in a high-risk (often elderly)population.

In advanced NSCLC, which has typically been defined as IIIB orIV disease, there is gaining interest for the study of the elderlypopulation. In a pooled analysis of trials of the NCCTG thatstudied unresectable or metastatic NSCLC, Jatoi et al21 found that,for elderly patients (defined as age � 65 years old), treatment inelderly-specific trials was associated with improved toxicity andequivalent survival. Several elderly-specific phase III trials of patientswith advanced disease support single-agent chemotherapy (vinor-elbine, docetaxel, or gemcitabine) as first-line treatment.22-24 Inaddition, phase II trials of first-line targeted agents (erlotinib orgefitinib) indicate good efficacy and tolerability in elderly pa-tients.25-27 Controversies exist, as with findings from a multi-institutional North American phase III study of erlotinib with orwithout gemcitabine showed modest results.28

Modern advancements in thoracic RT delivery may improvetolerability while maintaining or increasing efficacy for elderly pa-tients. In a Surveillance Epidemiology and End Results analysis ofpatients with stage III NSCLC treated from 2000 to 2005, theutilization of computed tomography simulation was associated witha lower risk of death compared with conventional simulation.29

However, the retrospective nature, geographic variations in treat-ment, and adoption of positron emission tomographyecomputedtomography staging limit the applicability of this finding. Involvedfield RT without targeting clinically uninvolved areas (elective nodalirradiation [ENI]) has been shown to both reduce toxicity andimprove outcomes. A phase III Chinese study that randomizedpatients with inoperable stage III NSCLC to concurrent chemo-radiotherapy with or without ENI found both improved survivaland lower pulmonary toxicity with involved field RT only.30 Majorcaveats that limit generalizability of this trial are the higher dose togross tumor volume for the involved field RT arm (68-74 Gy vs. 60-64 Gy with ENI) and 60-64 Gy for clinically uninvolved areas (ENIarm) is higher than typically given.30 Investigators from the Uni-versity of Pennsylvania retrospectively analyzed RT plans and foundomission of ENI to be associated with reduced severe esophagitiswithout affecting overall survival or risk of nodal failure.31 Tech-niques to analyze and deliver RT in conjunction respiratory motion(4-dimensional respiratory gating) allow further reduction in thevolume of normal tissue irradiated to potentially limit toxicity.32

Whereas advancements in chemoradiotherapy have demonstratedimproved survival in patients with NSCLC, elderly patients havebeen underrepresented in prospective trials. Both advances in ra-diation technology and molecular agents are promising for thetreatment of older patients, in whom not just toxicity but the po-tential for cure should be emphasized. Indeed, by implementingmodern RT techniques (stereotactic ablative RT) in the Netherlandsfor elderly patients with stage I NSCLC, a population analysisshowed a decrease in undertreatment, increased utilization of RT,

Clinical Lung Cancer November 2013

and improved survival.33 Likewise a survival gain for advanceddisease would be expected with increased utilization of chemo-radiotherapy with curative intent in the elderly population, withcontinued investigation into appropriate patient (ECOG PS, weightloss) and treatment (cytotoxic or targeted chemotherapy) selection.

ConclusionOur present analysis supports the finding that properly selected

patients with stage III NSCLC are good candidates for definitivechemoradiotherapy. Prospective trials tailored to elderly patients areneeded to evaluate both RT and chemotherapy aspects of definitivetreatment in this population.

Clinical Practice Points� Definitive treatment for inoperable stage III NSCLC consists ofRT delivered concurrently with systemic chemotherapy; how-ever, the randomized data that support this approach have arelative lack of elderly patients. This treatment carries the risk ofpotentially significant toxicity, that in some studies, was morefrequent in elderly patients.

� Elderly age alone was not found to be a predictor of poor survivalon multivariate analysis, and patients who received definitivechemoradiotherapy had similar rates of treatment completionand lack of RT breaks as the younger cohort. However, under-treatment with regard to treatment intent, RT dose, and systemicchemotherapy, as well poor performance status, contributed tooverall poor outcomes in elderly patients.

� Performance status should continue to be an important driver oftreatment decisions for elderly patients with locally advancedNSCLC, with the need for prospective clinical trials to betterdefine optimal therapy. Patients with good performance statusare appropriate candidates for definitive chemoradiotherapy.

DisclosureThe authors have stated that they have no conflicts of interest.

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