VA considerations

Assess the relevance of lung cancer to a growing elderly population, the challenges associated with eldercare, and the importance of emotional care—particularly among veterans, who have a higher rate of significant depressive symptoms than the general population.1,2


Lung cancer is primarily a disease of the elderly1

  • Although patients may be diagnosed with lung cancer at any age, the majority are aged 65 years or older1

*Includes lung and bronchus.

Source: Howlader N, et al, eds. SEER Cancer Statistics Review 1975-2012. Bethesda: MD; National Cancer Institute; 2014. Accessed July 28, 2015.


The United States is projected to experience rapid growth in its elderly population4

  • Number of people aged ≥65 years is expected to almost double between 2012 and 2050
  • Veterans, on average, are older than the general population5
    – In 2011, the median age of male veterans was 64 years old and the median age of males in the general population was 41 years old

Source: US department of Veterans Affairs, Profile of Veterans: 2011.

References: 1. National Cancer Institute. SEER stat fact sheets: lung and bronchus cancer. Accessed March 31, 2015. 2. Zivin K, Kim HM, McCarthy JF, et al. Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics. Am J Public Health. 2007;97(12):2193-2198. 3. Howlader N, et al, eds. SEER Cancer Statistics Review 1975-2012. Bethesda: MD; National Cancer Institute; 2014. Accessed July 28, 2015. 4. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. United States Census Bureau. Issued May 2014. Accessed August 5, 2015. 5. U.S. Census Bureau, American Community Survey PUMS, 2011. Prepared by the National Center for Veterans Analysis and Statistics: Published March 2013.


There are special challenges associated with elderly patients

Elderly patients often present with medical and physiological challenges1-3
  • Higher frequency of comorbidities2
  • Higher prevalence of polypharmacy2
  • Reduced hepatic, renal, and bone marrow reserve2,3
  • Greater susceptibility to toxicity from treatment regimens3
The Comprehensive Geriatric Assessment (CGA) is helpful in managing the complex needs of elderly patients
  • CGA utilizes an interdisciplinary healthcare team and multiple standardized assessment scales examining1:
    – Functional Status
    – Comorbidities
    – Polypharmacy
    – Nutritional status
    – Socioeconomic issues
    – Geriatric syndromes
    – Mental status and emotional conditions
Effective communication is key to caring for elderly patients
  • Recommendations from the National Institute on Aging4
    – Speak respectfully
    – Establish rapport
    – Use active listening
    – Show empathy
    – Don’t rush or interrupt
    – Avoid jargon
    – Reduce barriers to communication
    – Assess and compensate for hearing and visual deficits
    – Ensure understanding
    – Keep cultural differences in mind
    – Establish a plan for next steps
The medical and physiological challenges of elderly patients may contribute to poor performance status (PS)
  • PS is commonly used to determine appropriateness of treatment5
  • PS is measured most often by ECOG and KPS scores6
  • Prevalence of poor PS is quite high in lung cancer patients7,8
    – 35% to 40% to total NSCLC population present with ECOG ≥2
  • Low PS predicts lower response, higher toxicity, and worse survival5
  • Providers tend to underestimate the number of patients with poor PS9

ECOG = Eastern Cooperative Oncology Group Performance Status.
KPS = Karnofsky Performance Status.

Monitoring adverse effects is particularly important in elderly patients
  • Elderly patients are less able to tolerate treatment than younger individuals2,3,10
  • Prognostic functional and clinical risk factors must be identified to prospectively identify those at high risk for severe treatment-associated toxicity10
Patients with lung cancer may experience complications from their disease and benefit from palliative, or
supportive care, aimed at relieving symptoms and improving quality of life11
  • A pleural effusion—a buildup of fluid in the chest outside of the lungs-can press on the lungs and cause trouble breathing11
    – Thoracentesis, pleurodesis, or placement of a chest catheter may be used to drain fluid and provide relief to the patient
  • A pericardial effusion—fluid buildup inside the sac around the heart—can press on the heart, affecting how well it works11
    – Pericardiocentesis or creation of a pericardial window may be used to drain fluid away from the heart
  • If the cancer is growing into an airway in the lung, it can block the airway and cause problems like pneumonia or shortness of breath11
    – Photodynamic therapy (PDT) or laser therapy may be used in early stages of the disease
    – Sometimes a stent may be placed in the airway to help keep it open

References: 1. Repetto L, Venturino A, Fratino L, et al. Geriatric oncology: a clinical approach to the older patient with cancer. Eur J Cancer. 2003;39:870-880. 2.Quoix E. Therapeutic options in older patients with metastatic non-small cell lung cancer. Ther Adv Med Oncol. 2012;4(5):247-254. 3. Vora N, Reckamp KL. Non-small cell lung cancer in the elderly: defining treatment options. Semin Oncol. 2008;35(6):590-596. 4. National Institute on Aging. Talking with your older patient. Published October 2008. Accessed July 6, 2015. 5. Salloum RG, Smith TJ, Jensen GA, Lafata JE. Survival among non-small cell lung cancer patients with poor performance status after first line chemotherapy. Lung Cancer. 2012;77(3):545-549. 6. ECOG-ACRIN Cancer Research Group. Accessed July 16, 2015. 7. Vardy J, Dadasovich R, Beale P, Boyer M, Clarke SJ. Eligibility of patients with advanced non-small cell lung cancer for phase III chemotherapy trials. BMC Cancer. 2009;9:130. 8. Somer RA, Sherman E, Langer CJ. Restrictive eligibility limits access to newer therapies in non-small cell lung cancer: the implications of Eastern Cooperative Oncology Group 4599. Clin Lung Cancer. 2008;9(2):102-105. 9. Lilenbaum RC, Cashy J, Hensing TA, Young S, Cella D. Prevalence of poor performance status in lung cancer patients: implications for research . J Thorac Oncol. 2008;3(2):125-129. 10. Zauderer MG, Sima CS, Korc-Grodzicki B, Kris MG, Krug LM. Toxicity of initial chemotherapy in older patients with lung cancers. J Geriatr Oncol. 2013;4(1):64-70.11. American Cancer Society. Lung cancer (non-small cell). Last medical review August 15, 2014. Last revised March 11, 2016. Accessed March 14, 2016.


There are numerous psychosocial aspects associated with lung cancer diagnosis

  • A diagnosis of lung cancer may leave patients feeling isolated and facing social stigma
    – Lung Cancer is sometimes called the “invisible cancer” due to lack of public attention1
    – Patients may be blamed, rejected, and/or discriminated against by those around them2
    – The result can be stigmatizing1

There are recommended interventions to help patients with cancer cope with emotional disturbances

  • The prevalence of significant depressive symptoms among US veterans are 2 to 5 times higher than among the general population4


It’s important to help patients and their caregivers understand the goals of therapy

  • Many advanced or metastatic cancer patients do not understand treatment goals9
  • A 2013 study showed that 69% of patients with metastatic lung cancer did not understand that the chemotherapy they were receiving was not at all likely to cure their cancer, despite discussing this treatment with at least 1 physician10
  • Patients and their caregivers should clearly understand9,11:
    – Prognosis
    – Treatment and care options
            — Goals of treatment
            — Cost of treatment
            — Expected toxicities

It’s important to provide support for caregivers, who often fail to take care of themselves

  • While providing support for their partners of family members with cancer, caregivers often fail to address their own needs and feelings12,13
    – Caregivers are at a high risk of a wide spectrum of mental, physical, and social morbidities13
            — Distress
            — Depression
            — Anxiety
            — Poorer health
            — Lower marital satisfaction
            — Lower social support

References: 1. American Lung Association. Addressing the stigma of lung cancer. Chicago, IL: American Lung Association.
sets/documents/lung-disease/lung-cancer/addressing-the-stigma-of-lung-cancer.pdf. Accessed July 28, 2015. 2. Westmass JL. Stigma presents an extra burden for many lung cancer patients. American Cancer Society. http:/
stigma-presents-an-extra-burden-for-many-lung-cancerpatients.aspx. Published October 28, 2013. Accessed May 4, 2015. 3. National Cancer Institute. Feelings and cancer. Accessed July 9, 2015. 4. Zivin K, Kim HM, Mccarthy JF, et al.
Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics . Am J Public Health. 2007;97(12):2193-2198. 5. Smith PR, Cope D, Sherner TL, Walker Dk. Update on research-based interven- tions for anxiety in patients with cancer. Clin J Oncol Nurs. 2014;18(6):5-16. 6. Fulcher CD, Kim HJ, Smith PR, Sherner TL. Putting evidence into practice: evidence-based interventions for depression. Clin J Oncol Nurs. 2014;18(6):26-37. 7. Page MS, Berger AM, Johnson LB. Putting evidence into practice: evidence-based interventions for sleep-wake disturbances. Clin J Oncol Nurs. 2006;10(6):753-767. 8. Mitchell SA, Hoffman AJ, Clark JC, et al. Putting evidence into practice: an update of evidence–based interventions for cancer–related fatigue during and following treatment. Clin J Oncol Nurs. 2014;18(6):38-58. 9. Smith TJ, Dow LA, Virago EA, Khatcheressian J, Matsuyama R, Lyckholm LJ. A pilot trail of decision aids to give truthful prognostic and treatment information to chemotherapy patients with advanced cancer. J Support Oncol. 2011;9(2):79-86. 10. Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J. Med. 2012;367(17):1616-1625. 11. Shockney LD. Fulfilling hope: supporting the needs of patients with advanced cancers. New York, NY: Nova Science Publishers, Inc; 2014. 12. Lopez V, Copp G, Molassiotis A. Male caregivers of patients with breast and gynecologic cancer: experiences from caring for their spouses and partners. Cancer Nurs. 2012;35(6):402-410. 13. Li Q, Loke AY. A spectrum of hidden morbidities among spousal caregivers for patients with cancer, and differences between the genders: a review of the literature. Eur J Oncol Nurs 2013;17(5):578-587.

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