A 75-year-old man has a 3 month history of cough and weight loss. He also complains of back pain and difficulty breathing. He was initially wheelchair bound, but now he is bedbound and unable to perform any of his activities of daily living. He has a long history of cigarette smoking.
On examination, he is thin and appears tired. Vital signs are within normal limits. Breath sounds are decreased at the left lung base. A stage 2 presacral pressure ulcer is present.
CT scan of the chest demonstrates a left perihilar mass, multiple enlarged mediastinal lymph nodes, and bone metastases. A biopsy at bronchoscopy confirms a diagnosis of squamous cell cancer.
Which of the following is the best next step in the management of this patient?

Question

A 75-year-old man has a 3 month history of cough and weight loss.  He also complains of back pain and difficulty breathing.  He was initially wheelchair bound, but now he is bedbound and unable to perform any of his activities of daily living.  He has a long history of cigarette smoking.
On examination, he is thin and appears tired.  Vital signs are within normal limits.  Breath sounds are decreased at the left lung base.  A stage 2 presacral pressure ulcer is present.
CT scan of the chest demonstrates a left perihilar mass, multiple enlarged mediastinal lymph nodes, and bone metastases.  A biopsy at bronchoscopy confirms a diagnosis of squamous cell cancer.
Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

This patient has advanced non-small cell lung cancer (NSCLC) with a very poor performance status. Initial management of advanced NSCLC is based on tumor molecular markers, the patient's age, functional status, and comorbidities. Non-elderly patients with a good performance status may be treated with cytotoxic agents (e.g., platinum compounds) or targeted agents (e.g., EGFR inhibitors, ALK fusion inhibitors, or monoclonal antibodies). Elderly patients with good performance status may also respond to each of these treatments. However, this patient has a poor performance status, given his bedbound state and inability to perform any activities of daily living. Studies have shown limited benefit in these patients with either chemotherapy (single or combination) or targeted therapies (Choices A and B). Early palliative care with hospice referral may help prolong survival and enhance quality of life, and it is the most appropriate choice for this patient. (Choice D) Risedronate is generally used for the treatment of Paget's disease and both the treatment and prevention of osteoporosis. However, zoledronic acid (instead of risedronate) is approved for bony metastases of solid cancers (e.g., lung, breast). (Choice E) Patients with good performance status should undergo tissue analysis for EGFR mutation and ALK fusion oncogene. However, this patient's poor performance status does not warrant this testing. Educational objective: Elderly patients with poor performance status who present with advanced NSCLC typically do not respond well to aggressive therapy. Early palliative care with hospice referral may help prolong life and enhance quality of life. __________ References: Randomized phase II study of gefitinib compared with placebo in chemotherapy-naïve patients with advanced non-small cell lung cancer and poor performance status. (http://www.ncbi.nlm.nih.gov/pubmed/19289623) The impact of age on toxicity, quality of life and survival in patients with advanced stage III-B or IV non-small call lung carcinoma treated with carboplatinum and paclitaxel. (http://www.ncbi.nlm.nih.gov/pubmed/12910523) Early palliative care for patients with metastatic non-small-cell lung cancer. (http://www.ncbi.nlm.nih.gov/pubmed/20818875)

A 75-Year-Old Man Has a 3 Month History of Cough