Chronological Age Is Not an Independent Determinant of Survival or Treatment Access in Metastatic Non–Small Cell Lung Cancer: A Real-World Cohort Study

Background Older adults constitute a substantial proportion of patients with metastatic non–small cell lung cancer (NSCLC); however, the independent impact of chronological age on survival, treatment allocation, and toxicity remains controversial. This study aimed to evaluate whether age ≥ 70 years independently influences outcomes in patients with metastatic NSCLC in a real-world setting. Methods We conducted a single-center, retrospective cohort study including 268 patients with metastatic NSCLC diagnosed between January 2018 and December 2022. Patients were stratified into two age groups (< 70 vs ≥ 70 years). Clinical characteristics, treatment patterns, and outcomes were analyzed. Overall survival (OS) was assessed using Kaplan–Meier methods and Cox proportional hazards models. Logistic regression was used to identify determinants of treatment omission and toxicity-related hospitalization. Results The median OS for the entire cohort was 8.8 months. Patients aged ≥ 70 years had shorter unadjusted OS compared with younger patients (6.6 vs 10.3 months; p = 0.020); however, age was not an independent predictor of OS in multivariable analysis. Poor performance status, smoking exposure, and higher metastatic burden were independently associated with worse survival, whereas receipt of systemic therapy and the presence of any driver mutation were associated with improved outcomes. Chronological age did not independently predict access to systemic therapy; instead, poor performance status and cognitive impairment were the primary determinants of treatment omission. Among treated patients, older age was not associated with increased severe toxicity; notably, patients aged ≥ 70 years had lower odds of hospitalization due to treatment-related toxicity. Conclusions Chronological age alone should not guide treatment decisions in metastatic NSCLC. Functional status, disease burden, smoking exposure and access to effective systemic therapy are the principal determinants of survival and treatment outcomes. Appropriately selected older adults can safely receive systemic therapy without excess severe toxicity, underscoring the importance of individualized, geriatric-informed treatment strategies.