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BACKGROUND: The average age of patients with lung cancer is increasing and there are large numbers of elderly symptomatic patients with this common disease. However, there are few data on how the treatment of this group differs from that of younger patients. METHODS: From 1 January 1990 information was collected for the Southend Lung Cancer Registry on all patients with a diagnosis of lung cancer in a geographically well defined health district of the UK with a population of 325,000. Every effort was made to find new cases from all departments of the hospital, including all clinical diagnoses, histopathological and cytological reports, and necropsies. All death certificates in the district were examined, irrespective of age, for any diagnosis of lung cancer. This therefore included any patient not seen by the hospital services. The differences in initial treatment have been analysed for three age groups: under 65, 65-74 years, and over 75. RESULTS: The 563 cases of lung cancer diagnosed during a 30 month period were included in the study, of whom 240 (43%) were aged over 75 years. The overall mean age was 71 years (range 31-95). The incidence of lung cancer in the general population was 69 per 100,000, but in men over 75 years of age it rose to 751 per 100,000. For all patients the active treatment rate (chemotherapy, surgery, or radiotherapy) was 49%, but for patients not reviewed by a chest physician (n = 86) it was only 21%. There were large differences in initial treatment between age groups. For patients with non-small cell lung cancer (NSCLC) reviewed by a chest physician, surgery was undertaken in 18% of those under 65, 12% of the 65-74 age group, and 2.1% of those over 75. For patients with small cell lung cancer (SCLC) reviewed by a chest physician, 79% of those aged under 65, 64% of the 65-74 age group, and 41% of patients aged over 75 received chemotherapy. In patients with NSCLC reviewed by a chest physician, chemotherapy was given to 21% under 65, 6.4% in the 65-74 age group, and none over 75. If no histological diagnosis was made 37% of patients aged under 75 and only 5.4% of those over 75 received either surgery, radiotherapy, or chemotherapy. Patients not reviewed by a chest physician were less likely to have had a histological diagnosis. Differences in treatment rates with age persisted even after allowing for performance score status at presentation. CONCLUSIONS: Lung cancer is a common disease in the elderly and, in our district, 43% of patients were aged 75 or over at presentation. Age alone appeared to be a major factor in influencing treatment choices, and treatment was more likely if histological confirmation was obtained. Further detailed analysis of the reasons for the differences is needed. Patients referred to chest physicians were more likely to have both histological confirmation and active treatment. This study supports the contention that all patients with a diagnosis of lung cancer, irrespective of age or condition, should be assessed by an accredited chest physician.