lung cancer ( lc ) is one of the most important causes of cancer morbidity and mortality worldwide . in sweden , lc is the number one cause of cancer mortality . due to a general increase in life expectancy in most countries , the proportion of elderly in the general population is steadily growing , causing new social and health problems . the risk of cancer also increases with age ; consequently , the number of patients with lc aged > 65 years is increasing . this trend is expected to continue over the next decades   and the proportion of the population aged > 70 years is expected to double by 2020 . currently , over 50% of lc patients are aged > 65 years and 3040% are aged > 70 years [ 5 , 6 ] , whilst in sweden , the median age at diagnosis is 71 years . in a recent community hospital - based survey in france , these figures were lower ; only 32% of lc patients were aged 70 years and 18% were aged > 80 years . conversely , in the us , patients aged > 65 years represented two - thirds of lc cases and the median age at diagnosis was almost 70 years . non - small cell lung cancer ( nsclc ) accounts for 8085% of all lc types . at time of diagnosis , the tumour is often advanced , leaving only systemic palliative chemotherapy or molecular targeted therapy in those who are fit to choose from as possible therapeutic options . thus , despite the fact that patients aged > 70 years also derive a clinical benefit from systemic chemotherapy [ 8 , 9 ] , they are at risk of being undertreated [ 10 , 11 ] . some investigators use 65 years as a cut - off point , but the majority of studies specify 70 years , having been described as the lower limit of senescence , that is , the age at which the incidence of comorbidity increases sharply . the purpose of this study was to describe chemotherapy treatment provided to elderly patients with nsclc in clinical practice in our hospital and to assess their chemotherapy tolerance and survival . we also sought to identify the reasons for discontinuation of planned chemotherapy . in the absence of clear evidence from clinical trials , analysis of the elderly nsclc population through retrospective population - based studies , such as this study , helps physicians to assess and quantify the value of treating elderly cancer patients . since diagnostic work - up and treatment of lc in the northern part of stockholm is centralized to the solna site of karolinska university hospital , this study included practically all patients in a population base of 1.1 million inhabitants . this was a single - centre , retrospective cohort study in all elderly patients ( aged 70 years ) diagnosed in the department of respiratory medicine and allergy at the karolinska university hospital in solna , stockholm , from 1st january , 2003 , to 31st december , 2009 . patients were identified using the stockholm - gotland cancer registry , which is known for its high level of comprehensive data reporting . the following variables were included in the retrospective analysis : gender , smoking history , performance status ( ps ) according to who , comorbidities , charlson comorbidity index ( cci ) , tnm stages , lc type , total numbers of lines of treatment , type of chemotherapy given and overall survival , whether the patient received all chemotherapy cycles , number of cycles received , and reasons for discontinuing chemotherapy . a complete course of chemotherapy was defined as the patient having received any of the regimens once every three weeks for four cycles . information about other treatments patients had received , such as second- or third - course treatment , was also collected . a multidisciplinary meeting , always attended by oncologists , pulmonologists , a radiologist , a pathologist , and lc nurses , was held once a week at the hospital , during which all lc cases were discussed and determined the course of treatment in lc patients based on swedish lc guidelines . notably , almost all patients with suspected lc are referred to hospital pulmonary departments in sweden . patient characteristics at point of diagnosis were summarized using standard descriptive statistics . observed frequencies in categorical variables were calculated . survival time after diagnosis was analysed using kaplan - meier estimates , and differences in survival distributions for different patient subgroups were tested using log - rank tests . differences in categorical variables between subgroups were statistically tested using fishers exact test , using monte carlo simulation with 20  000 replicates for variables with more than two categories . in total , 2351 patients were newly diagnosed with lc during the period 200309 in this department . of these , 267 ( 11.3% ) had small cell lung cancer and were excluded from this study , leaving 2084 patients with nsclc in the study . of these 2084 patients , 1059 patients ( 50.8% of all nsclc patients ) were aged 70 years . of the 1059 elderly patients with nsclc , 243 ( 22.9% ) received chemotherapy ; 49 patients were aged 80 years ( almost 20% of the elderly , treated patients ) . there were 126 ( 51.9% ) males with a mean age of 75.8 years ( median 75.5 , range 7086 ) and 117 ( 48.1% ) females , also with a mean age of 75.8 years ( median 75.0 , range 7089 ) . of the treated male patients , 30.2% were smokers , 61.9% were ex - smokers , and 7.9% had never smoked ; corresponding figures for female patients were 35.9% , 43.6% , and 20.5% , respectively . the difference in smoking habits between genders was statistically significant ( p = 0.003 ) ( table 1 ) . adenocarcinoma was the most prevalent histology type and occurred in 136 ( 56.0% ) patients ; squamous cell carcinoma was the second most prevalent and occurred in 63 ( 25.9% ) patients . a histological diagnosis was not available in 3 ( 1.2% ) patients for ethical reasons . of those treated , 44 patients ( 18.1% ) had a performance status ( ps ) of 0 , 140 ( 57.6% ) ps 1 , and 59 ( 24.3% ) ps 2 . stage iv was the most common lc stage , seen in 131 patients ( 53.9% ) ; stages iiib and iiia were found in 75 ( 30.9% ) and 28 ( 11.5% ) patients , respectively . there were no significant gender differences in lc staging ( p = 0.3 ) ( table 1 ) . of the chemotherapy treated patients , 182 ( 73.8% ) received carboplatin plus gemcitabine and a further 6 ( 3.5% ) patients received another platinum combination . in total , therefore , all 77.3% of patients were treated with a platinum doublet , 17 ( 7.3% ) patients received gemcitabine single , and 17 ( 7.3% ) received vinorelbine single ( table 2 ) . most patients ( 115 , 49.9% ) received at least four cycles and another 37 ( 15.9% ) patients received three cycles . chemotherapy was discontinued in 30 patients ( 13.1% ) due to nonhaematological toxicities , in 35 ( 15.3% ) due to haematological toxicity , and in 38 ( 16.6% ) due to disease progression or death ( table 3 ) . in total , therefore , 121 patients ( 52.8% ) completed their treatment . the median overall survival for the whole , treated group was 308 days with no significant gender differences ( p = 0.414 ) ( figure 1 ) . second- and third - line chemotherapy were given to 76 ( 31.4% ) patients and third - line chemotherapy was given to 33 ( 13.9% ) patients . survival among patients with ps 0 was 410 days , was 314 days in those with ps 1 , and was 204 days in those with ps 2 . there was a significant survival difference between ps 0 and both ps 1 ( p = 0.084 ) and ps 2 ( p = 0.003 ) ( figure 2 ) . there was also a significant survival difference between ps 1 and ps 2 ( p = 0.055 ) . the median survival was 310 days in patients aged 7079 years and 285 days in patients aged 80 years ( p = 0.963 ) ( figure 3 ) . the cci had no effect on survival , with a median survival in cci 0 , 1 , 2 , and 3 of 283 , 324 , 270 , and 262 days , respectively ( p = 0.663 ) . there was no significant difference in overall median survival during the periods 200306 and 200709 ( 286 and 320 days , resp . this is , to our knowledge , the first study to comprehensively evaluate chemotherapy treatment in elderly patients with nsclc in real - life , clinical practice . this study demonstrates that more than 50% of the nsclc patients diagnosed at our department were aged 70 years ; yet only about 25% of them received chemotherapy . elderly patients require an additional degree of consideration because of the increasing prevalence of comorbidities and reduction in physiological reserve , which may influence the possibility of administering chemotherapy safely , especially doublet regimens [ 8 , 9 ] . little data exist , however , regarding the outcome of chemotherapy in nsclc patients aged 80 years , which is a rapidly expanding , potentially vulnerable population cohort . most standard definitions for  frailty  in geriatric texts define people aged > 85 years as frail ; by definition , this group has insufficient physiological reserve to tolerate standard chemotherapy . hesketh and colleagues   analysed the effect of either sequential vinorelbine followed by docetaxel or weekly , single agent docetaxel in the 21.5% of patients aged > 80 years in their elderly - specific studies . compared to the younger group ( aged < 80 years ) , the response rate was lower ( 8% versus 17% ) , as was the overall survival in the more elderly group when patients with poor ps were excluded ( 7 versus 11 months ) . the survival of patients who were treated was 310 days in those aged 7079 years and 285 days in patients aged 80 years ( p = 0.9 ) . treatment guidelines for stage iv nsclc of the american college of chest physicians recommend chemotherapy for patients aged 7079 years ( grade 1a ) and for select patients aged 80 years on a case by case basis ( grade 2c ) . a number of prospective trials in advanced elderly nsclc patients have established clearly the efficacy of single agent chemotherapy compared to best supportive care ( bsc ) in patients aged 70 years [ 1921 ] . in a phase iii trial specifically designed for elderly lc patients in france , carboplatin and paclitaxel both conferred significant improvement in overall survival ( os ) compared with single agent vinorelbine or gemcitabine . the standard first - line treatment for fit , elderly patients with advanced nsclc is , therefore , chemotherapy . unfortunately , the proportion of elderly patients receiving this treatment is still low [ 2325 ] , primarily due to concern about drug - related , toxic side effects . a survey from the seer showed that only a minority of patients aged > 65 years received chemotherapy for an advanced nsclc ( 25.8% of 21.2% patients aged 66 years ) , while in france , 61.5% of 1627 patients aged 70 years received chemotherapy . response rates and survival are reported to be lower in the more elderly population despite similar toxicities [ 3 , 23 , 28 ] . age per se is not the determinant factor of poor prognosis in advanced cancer [ 2931 ] but rather the physiological status , daily living capacity , and other factors . this is consistent with our study , which showed ps to be more important than age as regards prognosis . a retrospective analysis of cisplatin - based chemotherapy in nsclc patients revealed a significant increase in mortality within 30 days of starting chemotherapy with increasing age , while other studies have shown good tolerance and benefit even in patients aged 80 years . schedule and dose of chemotherapy treatments in the elderly both require further investigation ; consequently , special care is required when using cisplatin - based therapy in elderly patients . in our study , most patients received carboplatin - based chemotherapy because this is probably less nephrotoxic than cisplatin . generally , it is accepted that nsclc patients who either are female or have never smoked live longer than men [ 33 , 35 , 36 ] . the influence of gender and smoking status was very limited in our patients . in conclusion , our retrospective study supports the concept that chemotherapy that includes platinum is feasible in elderly lc patients . the use of carboplatin appears to be more suitable for this population , with less toxicity than cisplatin , and can be used in association with new drugs in fit , elderly patients with good ps . larger , prospective studies in elderly patients with advanced - stage nsclc are needed to both guide clinical management and therapeutic decisions and improve treatment outcomes in such patients .
an increasing proportion of cancer patients are aged > 65 years and many are aged > 70 years . 
 treatment of the elderly with lung cancer has , therefore , become an important issue ; so we performed a retrospective study of our patients to demonstrate how elderly patients with nsclc are treated in real - life , clinical practice . 
 all patients aged 70 years with nsclc at our department were reviewed retrospectively . in total , 1059 patients ( 50.8% of all nsclc patients ) . of these patients , 
 243 ( 22.9% ) received chemotherapy , 164 ( 70.4% ) of whom were treated with a platinum doublet using carboplatin . 
 second- and third - line chemotherapy were given to 31.4% and 13.9% of patients , respectively . 
 median overall survival was 289 and 320 days for male and female patients , respectively . 
 patients with performance status ( ps ) 0 experienced significantly better survival than patients with ps1 or ps 2 : 410 , 314 , and 204 days , respectively . 
 age was of less importance , with patients aged 7079 years versus those aged 80 years . 
 treatment of elderly nsclc patients with chemotherapy is feasible if they have a good ps and appears to prolong survival . in this study 
 , we found no significant differences in survival either between age groups or genders .