The following variables were recorded: date of diagnosis, date of death, patient’s demographics information (sex, ethnicity, patient’s smoking status and pack-years), patient’s Eastern Cooperative Oncology Group (ECOG) performance status (PS), tumor histology, Charlson Co-morbidity Index (CCI) (2), and treatment received. Descriptive case reports were summarized for each identified nonagenarian.

Perhaps due to the limited and previously unknown survival benefit from conventional chemotherapies and out of concern for tolerability, the majority of elderly patients have historically not received systemic therapy for advanced NSCLC (1). Support for the use of chemotherapy in patients over 70 years of age with stage IV NSCLC evolved when phase II and III studies demonstrated the activity of third-generation therapies vinorelbine, gemcitabine, paclitaxel and docetaxel as single agents (5). At the time, this led to the incorporation of singleagent chemotherapy into some practice guidelines, particularly for the elderly (1,3). However, more recently, the 2009 American Society of Clinical Oncology Clinical Practice Guideline Update on Chemotherapy for Stage IV NSCLC recommends that age by itself should not preclude the choice of doublet chemotherapy in the elderly (3). This recommendation is now further supported by recent data showing improved response, progression-free and overall survival in patients age 70-89 with NSCLC who received platinum-doublet therapy, with carboplatin and paclitaxel, in comparison to single agent therapy in the form of gemcitabine or vinorelbine followed by second line therapy with erlotinib in both arms (median survival: 10.4 months vs 6.2 months; HR = 0.60; P=0.0001) (6). For the fit elderly with NSCLC, a platinum-doublet may be the new standard of care.

However, evidence-based data to guide therapy of the very elderly (≥ 90 years) with NSCLC are lacking. Our series shows the diversity of approaches used at one center over the course of three successive fit patients ≥ 90 years of age at the time of diagnosis. Case 1 reveals a more conservative approach, where single agent vinorelbine was offered as first-line, reflecting the standard of care at the time, but the patient ultimately declined chemotherapy. The patient’s survival of 6 months was consistent with expected survivals of best supportive care (1,3). Cases 2 and 3 reflect more of the current standards with regard to using first-line platinum-doublet and anti-EGFR targeted therapy, respectively (2,4,6). Both patients had an ECOG PS 1, lacked significant co-morbidities (based on CCI scores less than or equal to 2) and experienced survivals in excess of 6 months (Table 1). Such examples illustrate the importance of evaluating functional status rather than biologic age when making treatment decisions, as supported by current practice guidelines from the American Society of Clinical Oncology (3). Indeed, a recent series of cancer cases of mostly fit nonagenarians treated between 1993 and 2006 (10 of the 177 patients had lung cancer) demonstrated low treatment-related mortality and acceptable outcomes in patients receiving standard stage-specific therapies (7).