MANAGEMENT OF ADVANCED BLADDER CANCER IN THE ELDERLY

Radical cystectomy in the elderly

BACKGROUND

The authors reported their experience with radical cystectomy for transitional cell carcinoma (TCC) of the bladder. They compared pathologic features and survival rates between older and younger patients.

METHODS

The authors retrospectively reviewed the records of 1054 patients who underwent radical cystectomy for bladder TCC between 1971 and 1997. Four age groups were compared: < 60 years old at the time of cystectomy (n = 310), 60-69 years old (n = 381), 70-79 years old (n = 313), and >/= 80 years old (n = 50).

RESULTS

There were no significant differences in pathologic features among the groups regarding frequency of carcinoma in situ, high-grade disease, p53 status, and lymph node positivity. However, in the age groups < 60, 60-69, 70-79, and >/= 80, 45%, 49%, 51%, and 72% of patients, respectively, had extravesical TCC (P=0.004). Significant differences also were seen in the proportion of patients who received adjuvant chemotherapy (26%, 26%, 15%, and 6%, respectively; P < 0.001). The 5-year overall survival rates for patients < 60, 60-69, 70-79, and >/= 80 years old were 72%, 58%, 54%, and 33%, respectively (P < 0.001). The 5-year disease recurrence-free survival rates were 75%, 65%, 68%, and 45%, respectively (P = 0.003). The elderly had a lower probability of receiving adjuvant chemotherapy.

CONCLUSIONS

Elderly patients undergoing cystectomy for TCC had similar pathologic features (except for disease stage) as younger patients. In the current series, elderly patients undergoing cystectomy had a higher pathologic stage and were less likely to receive adjuvant chemotherapy. The elderly had worse disease recurrence-free survival rates. Further work is needed to identify the causes for this and to develop strategies to improve cancer control in elderly patients.

La cistectomia nell'anziano: Radical cystectomy in the elderly patient

It is certainly true that an increase in the average life span has caused a greater percentage of elderly people to visit urological departments. From April 1989 to December 1996, 52 patients over 75 years underwent radical cystectomy and urinary diversion. The numerical analysis of our experience has highlighted the fact that in operated patients the incidence and mortality caused by cardiovascular diseases were no higher than those found in other people of the same age.

Treatment outcome following radiotherapy in elderly patients with bladder cancer

BACKGROUND AND PURPOSE

The optimal treatment of elderly patients with bladder cancer is not established. This study aimed to evaluate prognostic variables for survival and morbidity, which may be important for treatment strategy.

MATERIAL AND METHODS

The medical records of 94 patients aged > or = 75 years receiving curatively intended radiotherapy for bladder cancer were reviewed retrospectively.

RESULTS

Median age was 78 years (range 75-93 years). Fifty patients had T1-2 tumors, and 42 patients had T3-4 tumors. The total planned dose was 57.6-62.6 Gy in 24-30 fractions in 6 weeks. In 76 patients, a 2 week rest period was planned after 16 fractions (split course). Half of the patients were hospitalized during or after the treatment because of gastrointestinal or urogenital side effects. Median survival was 13.9 months (range 0.6-150.0 + months), 29% survived for 2 years and 7% survived for 5 years. Patients aged > 78 years survived for a shorter period than patients aged 75-78 years (13.4 versus 16.1 months). Univariate survival analysis revealed that low stage (T1-2), good performance status (PS < or = 1), split course treatment, no treatment interruption due to side effects, and no hospitalization during treatment were associated with long survival. In multivariate analyses, T-stage, split course treatment, and performance status were independent prognostic factors.

CONCLUSION

The results confirm that curative intended radiotherapy is feasible in elderly patients, but patients with stage T3-4 and PS > 1 have a short survival. These patients should be offered palliative treatment.

Clinical aspects of cancer in the elderly. Treatment decisions, treatment choices, and follow-up

Fifty-five percent of human cancer occurs in individuals 65 years of age and older; the most common sites are the stomach, colon, rectum, prostate, and breast. Patient delay in seeking care for symptoms may result in diagnosis at a more advanced stage than that seen in younger individuals. Treatment decisions may be impacted by comorbid illness and by physician reluctance to treat the elderly patient as they do the younger. Age alone never should be the factor that modifies a cancer treatment plan. Clinical trials rarely are available to the elderly; it is time that such treatment bias ceased. Adequate informed consent is as important in the elderly as it is in other age groups. Quality of life after cancer treatment is most important to the elderly cancer patient. Surgery and/or radiotherapy may be used for cancer treatment in the elderly when comorbid conditions are treated appropriately. Chemotherapy schedules may need modification when renal or hepatic function is impaired. Compliance with treatment is usually good if transportation is available. Pain management is important in this age group and requires individualization. Home health care is of great benefit to the elderly patient with cancer. Oncologic nursing for the elderly requires multiple skills. The literature on cancer treatment for the elderly is limited and, at times, negative. Cancer treatment in the elderly is remarkably safe when the comorbid conditions also are treated. Treatment choices are just as important to the elderly as they are to all cancer patients. Quality-of-life issues are critical in selecting treatment choices. Cancer follow-up is performed most appropriately by the oncologist.

Clinical aspects of cancer in the elderly. Treatment decisions, treatment choices, and follow-up

Fifty-five percent of human cancer occurs in individuals 65 years of age and older; the most common sites are the stomach, colon, rectum, prostate, and breast. Patient delay in seeking care for symptoms may result in diagnosis at a more advanced stage than that seen in younger individuals. Treatment decisions may be impacted by comorbid illness and by physician reluctance to treat the elderly patient as they do the younger. Age alone never should be the factor that modifies a cancer treatment plan. Clinical trials rarely are available to the elderly; it is time that such treatment bias ceased. Adequate informed consent is as important in the elderly as it is in other age groups. Quality of life after cancer treatment is most important to the elderly cancer patient. Surgery and/or radiotherapy may be used for cancer treatment in the elderly when comorbid conditions are treated appropriately. Chemotherapy schedules may need modification when renal or hepatic function is impaired. Compliance with treatment is usually good if transportation is available. Pain management is important in this age group and requires individualization. Home health care is of great benefit to the elderly patient with cancer. Oncologic nursing for the elderly requires multiple skills. The literature on cancer treatment for the elderly is limited and, at times, negative. Cancer treatment in the elderly is remarkably safe when the comorbid conditions also are treated. Treatment choices are just as important to the elderly as they are to all cancer patients. Quality-of-life issues are critical in selecting treatment choices. Cancer follow-up is performed most appropriately by the oncologist.