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DR LOVE: Ed, can you talk about how you would think through this case?

DR KIM: Performance status and overall clinical health are important factors in how aggressively we can treat these types of patients. Her advanced age makes it difficult to even consider doublet chemotherapy, and I would not, even setting her performance status aside.

We have several options. We have to mention hospice. It may not be the right option at this time, but it has to be something that the patient and the family have heard about.

A second option is that we have oral drugs now, such as erlotinib, which are generally well tolerated with few side effects, although in a first-line setting, the overall benefit is unclear. Some benefit probably exists, but it’s untested (4.1).

Chemotherapeutic agents such as pemetrexed or weekly docetaxel are options in patients with poorer performance status.

These agents have been tested in the elderly and are being tested in patients with poor performance status (Le Caer 2005; Gridelli 2005; Mainwaring 2005).

Her disease is everywhere, and her outcome will not be very good. It will be hard to manage her diabetes, especially with some of the chemotherapies that require steroids. I would probably start her on erlotinib as the single-agent choice right now.

DR HERBST: I agree completely. I think the most you can accomplish here is symptom control and supportive care.

No treatment is clearly a reasonable choice here, but this is a case where front-line erlotinib serves a good purpose. It’s easy to administer, it is generally well tolerated, and the patient can take it at home.

You can give her a trial for a couple of months and see how she does.

DR LOVE: Roy, how would you approach this patient if she had no comorbidities and her poor performance status was directly related to the presence of the tumor?

DR HERBST: If, in fact, the tumor is causing the performance status decrease and you believe you have effective therapy for the tumor, I might want to be a bit more aggressive.

Potentially, you could treat the tumor and alleviate the symptoms at the same time, so I may lean more toward a cytotoxic chemotherapy up front.

DR LOVE: Would you start with a platinum doublet or single-agent chemotherapy?

DR HERBST: If a patient truly has a performance status of two, it is difficult to start with a platinum doublet. So I would probably recommend a single agent, either docetaxel or pemetrexed.

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