What is the life expectancy and best management approach for a 90-year-old woman with squamous cell lung cancer and malignant pleural effusion, who has an indwelling pleural catheter and complains of lack of appetite?

From the Guidelines

For a 90-year-old woman with advanced squamous cell lung cancer, malignant pleural effusion, and poor appetite, the life expectancy is likely limited to weeks to a few months, and the best management approach should focus on palliative care and symptom management rather than aggressive cancer treatment. The patient's symptoms, including poor appetite, should be addressed with a focus on improving quality of life. For her appetite issues, I recommend starting with low-dose dexamethasone (2-4mg daily in the morning) or megestrol acetate (400-800mg daily), which can stimulate appetite and provide some energy, as suggested by the NCCN clinical practice guidelines in oncology: palliative care 1.

The indwelling pleural catheter should be maintained with regular drainage as needed for symptom relief, typically 500-1000mL every 2-3 days or when dyspnea worsens, as supported by the ERS/EACTS statement on the management of malignant pleural effusions 1. The use of indwelling pleural catheters has been shown to be effective in managing symptomatic malignant pleural effusions, with a study published in the European Respiratory Journal demonstrating its efficacy in reducing symptoms and improving quality of life 1.

Additionally, consider a palliative care consultation to address other symptoms and establish goals of care. Nutritional support should focus on small, frequent meals of preferred foods rather than forcing intake. Underlying causes of poor appetite should be addressed, including pain management with appropriate analgesics, treating constipation with a gentle regimen (such as senna 8.6mg 1-2 tablets daily plus docusate 100mg twice daily), and managing any nausea with medications like ondansetron 4-8mg every 8 hours as needed.

This approach prioritizes quality of life and comfort, recognizing that at this age and disease stage, aggressive cancer treatments often cause more harm than benefit while providing minimal survival advantage, as noted in the BTS guidelines for the management of malignant pleural effusions 1 and the American College of Chest Physicians evidence-based clinical practice guidelines 1.

From the Research

Life Expectancy and Management Approach

• The life expectancy of a 90-year-old woman with squamous cell lung cancer and malignant pleural effusion is generally poor, as the presence of malignant effusion indicates advanced disease and upstages the cancer to stage 4 2.
• The management approach for malignant pleural effusions focuses on palliation and relief of symptoms, with numerous interventions available, including drainage with thoracentesis or indwelling pleural catheter, and more definitive options such as pleurodesis 2.
• The use of an indwelling pleural catheter can provide significant symptom relief and improvement in quality of life, with a mean duration of catheter use of 2.3 months and mean fluid removal of 360 ml per 24 hours in the first weeks of treatment 3.

Indwelling Pleural Catheter Management

• The patient's indwelling pleural catheter drainage of 200 ml on the first day and 400 ml on the fourth day is within the expected range, with some studies reporting mean fluid removal of 360 ml per 24 hours 3.
• The prior thoracentesis initial draw of 1 liter and subsequent draw of 1.67 liters two weeks later indicates a significant amount of fluid accumulation, which can be managed with the indwelling pleural catheter 3.
• The patient's complaint of lack of appetite is a common symptom in patients with advanced cancer and malignant pleural effusions, and should be addressed as part of the overall management approach 2.

Treatment Options

• Pleurodesis may be an option for patients with malignant pleural effusions, but it may not be suitable for all patients, particularly those with trapped lung or significant comorbidities 4.
• The use of an indwelling pleural catheter can be an effective alternative to pleurodesis, providing outpatient intermittent drainage and relief of symptoms without significant complications 4, 5.
• The choice of treatment should be tailored to the patient's functional status, comorbidities, prognosis, and personal preferences, as well as local expertise 5.