Therapeutic choice with regard to life expectancy and cost benefit analysis in cancer diagnosis and treatment

Abstract

The medical decisions concerning treating an older patient affected by cancer with cytotoxic drugs or aggressive surgical treatment is a complex process that should always take into account the balance between potential advantages and the risks of side effects. As is always true of medical interventions, the ultimate goal is deliver to the patient the best available treatment. Central to this issue is the consideration that the actual life expectancy of most older individuals affected by cancer is longer than the prognosis for their disease. Therefore, one of the primary objectives of the treatment is to maximize the chance that the patient will benefit fully from his natural life expectancy. Indeed, considerations of potential gains in life expectancy should always be matched to expected changes in quality of life associated with different therapeutic alternatives. For example, the therapeutic control of tumour growth generally represents the best achievement in terms of survival, but the effect on quality of life in the elderly is questionable [1]. Unfortunately, there is still little agreement on the general guidelines which should be used to select which older patients should receive surgical or chemotherapeutic treatment. Many studies have shown that both general practitioners and medical oncologists tend to base their therapeutic choices simply on the chronological age of the patients. For example, as far as surgical treatments are concerned, data from the literature show that older patients affected by solid tumours (i.e. breast and lung cancer), are less likely to receive potentially curative treatments than younger adults, despite the established notion that elderly subjects frequently present with localized disease at diagnosis [2,3]. Even though in older patients with lung cancer, such a trend could be in part related to concerns for thoracotomyrelated complications, there are no reasons justifying similar attitude in patients affected by breast carcinoma. These and many other observation lend testimony to the fact that chronological age still represents an important barrier to adequate treatment of malignant cancer in older patients. There is a general unspoken agreement that chemotherapeutic treatment in older patients should be simpler and milder. Indeed, provided that comparable clinical results are expected, single agent therapy is obviously to be preferred, due to its better compliance and tolerability. As an example, oral etoposide has been claimed to provide good results in the clinical control of small cell lung carcinoma (SCLC) leading to an overall survival competitive with the most effective combination chemotherapy, but this is discussed (see chapter by Repetto et al. on Lung Cancer). In contrast, studies have clearly demonstrated that the survival of older patients affected by aggressive non-Hodgkin’s lymphoma (NHL) improved when combination chemotherapy (i.e. the CHOP regimen) is administrated