Most lung cancers aren’t diagnosed until you’re older. In fact, on average, lung cancer shows up around the age of 70. The most common type is non-small-cell lung cancer (NSCLC), which grows from the lining of your lung’s airways.
Finding the best treatment for lung cancer as you get older can be a challenge. Nonmutated NSCLC means that testing can’t find DNA damage called “driver mutations" in your tumor.
This type of lung cancer may be harder to treat because targeted therapies don't work as well. And when your're 65 or older, your plan may depend on things such as:
- Lung cancer stage and tumor traits
- Overall health
- Organ function
- Medical conditions
- Memory and mental health
- Support system
Learn how each factor can steer your lung cancer journey and how options might change when you're 65 or older.
Lung cancer treatment disparities in older people
The American Cancer Society suggests a yearly low-dose CT scan to screen for lung cancer if:
- You're 50 to 80 years old
- You smoke or used to
- Have a 20 pack-year smoking history
This helps doctors find and treat early-stage lung tumors. But lung cancer most often gets diagnosed when you’re 65-74 years old.
More side effects are possible
The FDA looked at lung cancer clinical trials and found that fewer than 24% of the participants were 70 or older. It’s complex, but medication side effects are more likely as you get older.
In fact, recent studies show that certain lung cancer medicines may cause more side effects when you’re older. So, older people are more likely than younger ones to get a plan that’s different from clinical guidelines or to have worse complications.
Learning more about what can change your treatment options can help you be better prepared.
The Journey to Find Your NSCLC Treatment
Your doctor runs tests to gather information about your lung tumor to help choose the best treatment. To start, they’ll find out your cancer stage and do a biopsy to test for biomarkers and DNA mutations inside the cancer cells.
Why does stage matter?
Tumor size and how far it’s spread tells your doctor the cancer stage. It’s what your doctor uses to decide which treatments might work best for you, says Allan Pickens, MD, a thoracic surgeon with Piedmont Healthcare in Atlanta.
Experts use the TMN system to describe your cancer:
- T for tumor size and spread
- N for the spread into lymph nodes
- M for how far the tumor spreads (metastasis) into other body parts
The TNM system tells your doctor the stage of your tumor:
Stage 0. Cancer cells are in the lining of the airways of your lungs. Surgery can often cure your lung cancer without chemotherapy or radiation later.
Stage I. If surgery is possible, your surgeon removes your tumor, some nearby lymph nodes in your lungs, and any in the space between them. Your doctor checks to see if you need another surgery, radiation, or ablation, which is a procedure to kill cancer cells with extreme heat or cold.
Stage II. Chemo with or without immunotherapy before surgery can shrink your tumor. After surgery, you might get more treatment such as chemo, immunotherapy, or targeted treatment.
Stages III and IV. Advanced stage lung cancer treatment involves stage III and IV tumors. Your doctor may combine chemo, radiation, surgery, immunotherapy, and targeted treatments.
Your doctor will try to balance your treatment with improved quality of life. And a biopsy can help your doctor get the right information.
What’s the difference between a biopsy and biomarker?
A biopsy is a procedure to remove tissue but a biomarker is a protein. Actually, your doctor uses the biopsy to find biomarker proteins inside your cancer cells.
The biopsy removes a small piece of lung tumor for testing. There are three main types of NSCLC:
Adenocarcinoma. It is the most common kind of NSCLC and starts in the outer layers of your lung. It often happens even if you don’t smoke.
Squamous cell carcinoma. Often found in smokers, this type of NSCLC can grow from the flat cells lining the tubes (bronchi) that carry air from your windpipe to your lungs.
Large cell carcinoma. It's a rare form of NSCLC that can quickly spread from any part of your lung.
The cancer type can sometimes guide treatment options. Biomarkers are another way to guide treatment choices.
Driver mutations and biomarkers
Your doctor can test and treat any driver mutations, like EGFR, if targeted treatments are available. They’ll do a tissue biopsy or a blood test called a liquid biopsy to find these mutations. Sometimes, the biopsy can’t find any driver mutations.
So your doctor may focus on a protein called programmed death-ligand 1 (PD-L1) — a checkpoint protein found on your cancer cells. Knowing your PD-L1 levels can help your doctor choose your best treatment. That’s because without driver mutations, “nonmutated NSCLC is much harder to treat, since many precision-targeted drugs have little or no effect on these tumors,” says Pickens.
Checkpoint Inhibitors for NSCLC Without Driver Mutations
Your oncologist may suggest immune checkpoint inhibitors. This type of immunotherapy is especially helpful for later-stage lung cancer with higher levels of PD-L1.
Making checkpoint proteins is one way cancer cells hide from your immune system. Cancer cells can make more checkpoint proteins to escape death. But checkpoint inhibitors block these proteins to help your immune system find and kill cancer cells.
These medications provide long-lasting benefits for some lung cancer patients, says Sope Ulugbile, MD, board-certified medical oncologist with Piedmont Healthcare in Atlanta.
Checkpoint inhibitors for NSCLC
Here are some immunotherapy options if your tumor expresses PD-L1:
- Atezolizumab (Tecentriq and Tecentriq Hybreza)
- Cemiplimab (Libtayo)
- Durvalumab (Imfinzi)
- Nivolumab (Opdivo and Opdivo Qvantig)
- Pembrolizumab (Keytruda and Keytruda QLEX)
These are CTLA-4 inhibitors which block another type of checkpoint to kill lung cancer:
- Ipilimumab (Yervoy)
- Tremelimumab (Imjudo)
Checkpoint inhibitors when you’re older
If you’re older and your PD-L1 levels are 50% or higher, pembrolizumab may be a good choice. Your doctor may also suggest combining chemotherapy and checkpoint inhibitors.
They may also add bevacizumab (Avastin) to a checkpoint inhibitor and chemo if your NSCLC isn’t a squamous cell carcinoma. Bevacixumab can block vascular endothelial growth factor (VEGF) proteins to shrink the tumor’s blood supply and kill cancer cells.
Lower PD-L1 levels
If you have low PD-L1 levels, your oncologist may suggest:
- Pembrolizumab combined with chemotherapy
- Combining checkpoint inhibitors such as ipilimumab and nivolumab
- Chemotherapy
You and your medical oncologist will review the best option and any possible side effects. The lack of clinical trial information for older people makes it harder to predict these side effects. So let your cancer care team know if you notice anything unusual; they can help.
Your Well-Being Matters
How old you are can’t predict which treatment is best or how well you’ll recover. Chemotherapy and surgery to treat lung cancer can be hard on your body, especially as you get older.
To predict how your body might recover, your doctor reviews your medical history, runs blood tests, and imaging scans such as CT and PET. They’ll also look at things such as your:
- Physical health, including any recent hospitalizations
- Daily functions (bladder and bowel control)
- Activity levels, including recent falls
- Nutrition, including tests for vitamin or mineral deficiency
These can play a big role in how your body recovers from surgery and treatment.
Performance status
Your doctor might use a test called the Eastern Cooperative Oncology Group (ECOG) Performance Status Scale. It ranks your ability to function independently and tries to predict if you can tolerate chemo, surgery, or radiation.
Before your doctor decides on a treatment plan, talk about treatment goals and wishes. Let your oncologist know if you need help getting to appointments. Another important factor is how well your body parts work.
How Well Your Body Works
Cancer treatments such as chemotherapy can put stress on your body. Your doctor will talk to you about liver and kidney function. For some cancer medicines, they’ll monitor your liver health over time.
If you’re having surgery, your cancer care team may test your lung function using pulmonary function tests (PFTs). Your doctor may order:
- Spirometry to measure how much and how well the air flows through your lungs. The test tells your doctors about the strength of your lungs and how well you breathe.
- Lung diffusion test (DLCO) to find out how well oxygen moves from your lungs into your blood.
- Arterial blood gas (ABG) test which takes blood from an artery to measure the oxygen and carbon dioxide levels in your blood. You may get this test if you have chronic obstructive pulmonary disease (COPD) or a higher risk for lung problems.
Your other medical conditions can also affect your treatment plan.
Review Your Medical Conditions
Your doctor goes over your health history, especially any medical conditions that might influence your lung cancer treatment, such as:
- COPD
- Diabetes
- Emphysema
- Kidney disease
- Heart disease
- Obesity
Getting better can be harder on your body as you get older because:
- Some medications can interact
- You may have a higher risk for complications
- Some health conditions can slow recovery after surgery or cancer treatment
Your care team can help you get your chronic conditions under control beforehand. This can help speed your healing.
Organ Health
Lung cancer can spread to other parts of the body, such as your other lung, bones, or brain. If the cancer cells started in your lungs before spreading to your brain, it’s called metastatic brain cancer.
Most people who get diagnosed with a metastatic brain tumor from NSCLC are over 65 years old. Your doctor may treat your symptoms using:
- Steroids to lower swelling around your brain
- Anticonvulsant to help prevent seizures
They’ll also look at how well your kidneys and liver work. One review found that older people taking many medicines with cancer treatment had more treatment interactions and side effects.
How your cancer care team can help
Let your doctor know about any symptoms after you start treatment. If needed, they can:
- Adjust your dose
- Suggest another medicine
- Change your treatment
Advocate and Get Support
Your mental health and a good support system can help you advocate for yourself. This can also help you feel part of your treatment plan. Your health care team may recommend options, but you get the final say in your treatment.
If you don't understand something, ask your doctor to explain it again. Sharing what you’re going through can also help you feel less isolated. Reach out to your oncologist; they can help point you to others who can help.
Questions to ask your cancer care team
- Has my lung tumor sample (biopsy) been sent for genetic testing?
- What is the process to find out exactly where my lung cancer has spread?
- Do I need to have more tests or procedures before I start treatment?
- What are my options if my cancer comes back or stops responding to treatment, after I’ve completed my first treatment?
- Which therapist do you suggest?
- Are there clinical trials for my NSCLC subtype? If so, am I eligible to join?
Your way to treat NSCLC without mutations
There is no one “right” way to treat your nonmutated NSCLC. There’s just the right way to treat it for you.
Ask questions and let your health care team know if you have concerns. They’re here to support you on this journey.
“The most critical step is to find the right treatment for each patient,” says Ulugbile.
