Experiences of 23 patients > or = 90 years of age treated with radiation therapy

Outcome of radiotherapy for the treatment of laryngeal squamous cell carcinoma in the very elderly population

BACKGROUND

Treatment selection for squamous cell carcinoma patients aged over 84 years is controversial. This retrospective chart review examined and compared characteristics of laryngeal squamous cell carcinoma in very elderly (over 84 years) and younger patients (approximately 65 years). The secondary objective was to further evaluate the outcome of radiotherapy as a treatment modality in this patient population.

METHODS

Of all 23 very elderly patients with laryngeal squamous cell carcinoma treated with radiotherapy, with or without surgery, in the Davidoff Cancer Center, from 1992 to 2012, 19 had sufficient data for analysis, and comprised the study group.

RESULTS

Median age at diagnosis was 86 years. Disease stage at diagnosis was I, II, III and IVA in 53 per cent, 21 per cent, 21 per cent and 5 per cent, respectively. Median radiotherapy dose was 60 Gy given in 25 fractions. Three patients had recurrence. No patient discontinued treatment because of toxicity. Median overall survival was 3.6 years (range, 0-10 years).

CONCLUSION

Very elderly laryngeal squamous cell carcinoma patients may derive a similar survival advantage as younger counterparts. Modern radiotherapy is effective and safe for treating laryngeal squamous cell carcinoma in this study population. Further, large-scale studies are needed.

Stereotactic body radiotherapy as primary treatment for elderly and medically inoperable patients with head and neck cancer

BACKGROUND

Patients with head and neck cancer (HNC) who are not candidates for definitive treatment represent an increasing challenge, with limited data to guide management. Conventional local therapies such as surgery and chemoradiation can significantly impact quality of life (QoL). There has been limited data published using stereotactic body radiotherapy (SBRT) as primary treatment in previously unirradiated patients. We hypothesize that SBRT provides high rates of control while limiting toxicity.

METHODS

A total of 66 medically unfit previously unirradiated patients with HNC were treated with SBRT, consisting of 35-40 Gy to gross tumor volume and 30 Gy to clinical target volume in five fractions.

RESULTS

Median age was 80 years. Local control (LC) and overall survival (OS) at 1 year were 73% and 64%. Two patients experienced grade 3 toxicity.

CONCLUSION

SBRT shows acceptable outcomes with relatively low toxicity in previously unirradiated patients with HNC who are medically unfit for conventional treatment. SBRT may provide an aggressive local therapy with high rates of LC and OS while maintaining QoL.

Radiotherapy for nonagenarians: the value of biological versus chronological age

Background

The number of nonagenarian cancer patients (≥ 90 years) is continuously increasing, and radiotherapy is performed in a relevant proportion of patients, as surgery and chemotherapy are often not feasible for these patients. However, the evidence regarding the feasibility and treatment outcomes after radiotherapy for this patient group is very limited.

Methods

All nonagenarian patients receiving (chemo) radiotherapy between 2009 and 2019 at the University of Freiburg - Medical Center were analyzed for patterns of care, overall survival (OS) and therapy-associated toxicities according to the Common Terminology Criteria for Adverse Events. Uni- and multivariate Cox regression analyses were conducted to assess the influence of patient- and treatment-related factors on patient outcomes.

Results

One hundred nineteen patients with a total of 137 irradiated lesions were included in this analysis. After a median follow-up of 27 months, median OS was 10 months with a 3-year OS amounting to 11.1%. Univariate analyses demonstrated that a reduced performance status (HR = 1.56, 95% CI 1.00–2.45, p < 0.05), a higher burden of comorbidities (HR = 2.00, 95% CI 1.00–4.10, p < 0.05) and higher UICC tumor stages (HR = 2.21, 95% CI 1.14–4.26, p < 0.05) were associated with impaired survival rates. Split-course treatments (HR = 2.05, 95% CI 1.07–3.94, p < 0.05), non-completion of radiotherapy (HR = 7.17, 95% CI 3.88–13.26, p < 0.001) and palliative treatments (HR = 2.84, 95% CI 1.68–4.81, p < 0.05) were found to result in significantly reduced OS. In the multivariate analysis, split-course concepts (HR = 2.21, 95% CI 1.10–4.37, p < 0.05) and palliative treatments (HR = 3.19, 95% CI 1.77–5.75, p < 0.001) significantly deteriorated outcomes, while impaired ECOG status (HR = 1.49, 95% CI 0.91–2.43, p = 0.11) did not. The vast majority of patients reported either no (n = 40; 33.6%) or grade 1–2 acute toxicities (n = 66; 55.5%), and only very few higher-grade toxicities were observed in our study.

Conclusion

Radiotherapy for nonagenarian patients is generally feasible and associated with a low toxicity profile. Given the relatively poor OS rates and the importance of the quality of life for this patient group, individualized treatment regimens including hypofractionation concepts should be considered.

Individualized treatment of head neck squamous cell carcinoma patients aged 70 or older with radiotherapy alone or associated to cisplatin or cetuximab: impact of weekly radiation dose on loco-regional control

The purpose of this study is to evaluate if, in elderly HNC patients, loco-regional control (LRC) is influenced by average weekly radiation dose (AWD). From 2009 to 2017, 150 consecutive HNC elderly patients were analyzed. AWD was calculated by dividing total dose in Gray by overall treatment time in weeks. Patients were divided in 2 groups: Group 1 (70-75 years) and Group 2 (> 75 years). Primary endpoint was LRC; secondary endpoints were overall survival (OS) and compliance to treatment. The median age was 76 years (range 70-92), the distribution of patients by age was 72 and 78 patients in Group 1 and in Group 2, respectively; overall median follow-up was 23 months. Optimal cut-off of AWD for LRC was 9.236 (p = 0.018). Median OS was 73 months. In univariate survival analysis low PS (p = 0.005), T3-T4 (p = 0.021), Stage III-IV (p = 0.046) and AWD^Low (< 9.236) (p = 0.018) were significantly associated with lower LRC; low PS (p < 0.001) and Group 2 (p = 0.006) were also associated with lower OS. Considering patients treated with radiotherapy alone AWD^Low was significantly associated with lower LRC (p = 0.04) whereas among patient treated with chemoradiotherapy AWD did not affected LRC (p = 0.18). The multivariate analysis confirmed the significant value of PS for the prediction of LRC and OS (p = 0.035 and p < 0.001, respectively). In elderly patients an AWD of > 9.236 Gy was found to be beneficial for RT alone regimen. When radiotherapy alone is indicated in elderly patients an effort should be made to maintain an increased AWD in order to improve LRC.

Feasibility of radiotherapy in nonagenarian patients: a retrospective study

PURPOSE

Specific information about radiation therapy in nonagenarians is limited. In order to shed more light on the feasibility of radiotherapy in this challenging subgroup, a retrospective study was performed.

METHODS

The data of 93 consecutive patients receiving irradiation treatment at the Department of Radiation Oncology, Ordensklinikum Linz Barmherzige Schwestern between June 2005 and December 2016 were analyzed. Patient- and treatment-related factors were extracted from the patient records. Overall survival (OS) was defined as time from irradiation to death or last follow-up. The survival rates were analyzed using the Kaplan-Meier method and log-rank test.

RESULTS

The study population of 93 patients was between 90 and 99 years old (median 91 years). It included 59 women (63%) and 34 men (37%). Of these, 38 (41%) received definitive radiotherapy, 14 (15%) received neoadjuvant or adjuvant radiotherapy, whereas a palliative regimen was prescribed in 44% of the cases (n = 41). In all, 79 patients (85%) were able to complete their prescribed course of radiotherapy. While 16 (17%) patients reported grade 2 toxicities or higher, 4 had ≥grade 3 side effects (4%). The median survival was significantly higher in patients treated with adjuvant, neoadjuvant or definitive radiotherapy (13.8 months) compared to patients treated with palliative radiotherapy (3.6 months; p < 0.001).

CONCLUSION

Even in patients managed without preradiotherapy comprehensive geriatric assessment, carefully planned fractionated radiotherapy was feasible and resulted in acceptable rates of acute toxicities.

Carcinoma of the cervix in elderly patients treated with radiotherapy: patterns of care and treatment outcomes

OBJECTIVE

The aim of this analysis was to examine the management of cervix cancer in elderly patients referred for radiotherapy and the results of treatment in terms of overall survival (OS), relapse-free survival (RFS), and treatment-related toxicities.

METHODS

Patients were eligible if they were aged ≥75 years, newly diagnosed with cervix cancer and referred for radiotherapy as part of their treatment. Patient details were retrieved from the gynaecology service database where clinical, histopathological treatment and follow-up data were prospectively collected.

RESULTS

From 1998 to 2010, 126 patients aged ≥75 years, met selection criteria. Median age was 81.5 years. Eighty-one patients had definitive radiotherapy, 10 received adjuvant radiotherapy and 35 had palliative radiotherapy. Seventy-one percent of patients had the International Federation of Gynecology and Obstetrics stage 1b-2b disease. Median follow-up was 37 months. OS and RFS at 3 years among those treated with curative intent were 66.6% and 75.9% respectively with majority of patients dying without any evidence of cervix cancer. Grade 2 or more late toxicities were: bladder 5%, bowel 11%, and vagina 27%. Eastern Cooperative Oncology Group (ECOG) status was a significant predictor of OS and RFS with each unit increment in ECOG score increased the risk of death by 1.69 times (p<0.001).

CONCLUSION

Following appropriate patient selection, elderly patients treated curatively with radiotherapy for cervix cancer have good disease control. Palliative hypofractionated regimens are well tolerated in patients unsuitable for radical treatment.

[Radiation therapy for elderly patients]

Cancer is a disease that predominantly occurs in older patients who represent a quarter of the population in western countries. Numerous types of cancer are observed in elderly people. Radiotherapy is one of the most powerful treatments against cancer. Most of published studies have demonstrated feasibility of radiotherapy in curative or palliative intent whatever cancer types are considered. Complete geriatric assessment and a multidisciplinary approach are the key points. The purpose of this review is to highlight sights of radiation oncology specifically related to aging. Particular emphasis is placed on logistic and technical aspects of radiation, as dose, irradiated volume, fractionation and the potential usefulness of new technologies.

Tolerability and outcomes of curative radiotherapy in patients aged 85 or more years

OBJECTIVES

To assess the tolerability and survival outcome of curative radiotherapy in patients over the age of 85 years.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of all patients aged over 85 years who received radiotherapy as part of curative treatment for any cancer (excluding insignificant skin cancers) at the Peter MacCallum Cancer Centre between 1 January 2000 and 1 January 2010.

MAIN OUTCOME MEASURES

Poor treatment tolerability (defined as hospital admission during radiotherapy, treatment break, or early treatment cessation); predictors for poor treatment tolerability, overall survival and cancer-specific survival.

RESULTS

327 treatment courses met eligibility criteria. The median age of patients was 87 years. The most common treatment sites were pelvis (30%), head and neck (25%), and breast (18%). The Eastern Cooperative Oncology Group performance status (ECOG PS) score was 0 or 1 for 70% of patients. Overall, 79% of patients completed the prescribed treatment without poor treatment tolerability, and 95% of patients completed all treatment. Only unfavourable ECOG PS score (odds ratio [OR], 1.80; P = 0.005) and increasing age (OR, 1.18; P = 0.018) predicted poor treatment tolerability. ECOG PS score predicted overall survival (hazard ratio, 1.53; P = 0.001).

CONCLUSION

Age should not be the sole discriminator in decisions to prescribe aggressive loco-regional radiotherapy. ECOG PS score predicts for treatment tolerability, and also overall survival. The risk of cancer death was higher than non-cancer death for more than 5 years after treatment.

Local control rates of metastatic renal cell carcinoma (RCC) to the bone using stereotactic body radiation therapy: Is RCC truly radioresistant?

PURPOSE

We report the radiographic and clinical response rate of stereotactic body radiation therapy (SBRT) compared with conventional fractionated external beam radiation therapy (CF-EBRT) for renal cell carcinoma (RCC) bone lesions treated at our institution.

METHODS AND MATERIALS

Forty-six consecutive patients were included in the study, with 95 total lesions treated (50 SBRT, 45 CF-EBRT). We included patients who had histologic confirmation of primary RCC and radiographic evidence of metastatic bone lesions. The most common SBRT regimen used was 27 Gy in 3 fractions.

RESULTS

Median follow-up was 10 months (range, 1-64 months). Median time to symptom control between SBRT and CF-EBRT were 2 (range, 0-6 weeks) and 4 weeks (range, 0-7 weeks), respectively. Symptom control rates with SBRT and CF-EBRT were significantly different (P = .020) with control rates at 10, 12, and 24 months of 74.9% versus 44.1%, 74.9% versus 39.9%, and 74.9% versus 35.7%, respectively. The median time to radiographic failure and unadjusted pain progression was 7 months in both groups. When controlling for gross tumor volume, dose per fraction, smoking, and the use of systemic therapy, biologically effective dose ≥80 Gy was significant for clinical response (hazard ratio [HR], 0.204; 95% confidence interval [CI], 0.043-0.963; P = .046) and radiographic (HR, 0.075; 95% CI, 0.013-0.430; P = .004). When controlling for gross tumor volume and total dose, biologically effective dose ≥80 Gy was again predictive of clinical local control (HR, 0.140; 95% CI, 0.025-0.787; P = .026). Toxicity rates were low and equivalent in both groups, with no grade 4 or 5 toxicity reported.

CONCLUSIONS

SBRT is both safe and effective for treating RCC bone metastases, with rapid improvement in symptoms after treatment and more durable clinical and radiographic response rate. Future prospective trials are needed to further define efficacy and toxicity of treatment, especially in the setting of targeted agents.

Stereotactic body radiotherapy as primary therapy for head and neck cancer in the elderly or patients with poor performance

OBJECTIVE

Stereotactic body radiotherapy (SBRT) is increasingly used to treat a variety of tumors, including head and neck squamous cell carcinoma (HNSCC) in the recurrent setting. While there are published data for re-irradiation using SBRT for HNSCC, there are limited data supporting its use as upfront treatment for locally advanced disease.

STUDY DESIGN/METHODS

Here, we describe three patients who received SBRT as the primary treatment for their HNSCC along with a review of the current literature and discussion of future pathways.

RESULTS

The three cases discussed tolerated treatment well with manageable acute toxicities and had either a clinical or radiographic complete response to therapy.

CONCLUSION

Head and neck squamous cell carcinoma presents a unique challenge in the elderly, where medical comorbidities make it difficult to tolerate conventional radiation, often given with a systemic sensitizer. For these individuals, providing a shortened course using SBRT may offer an effective alternative.

Age and comorbidity considerations related to radiotherapy and chemotherapy administration

Oncological treatment decision-making is a highly complex enterprise integrating multiple patient, tumor, treatment, and professional factors with the available medical evidence. This management complexity can be exacerbated by the interplay of patient age and comorbid non-cancer conditions that can affect patient quality of life, treatment tolerance, and survival outcomes. Given the expected increase in median age (and associated comorbidity burden) of Western populations over the next few decades, the use of evidence-based therapies that appropriately balance treatment intensity and tolerability to achieve the desired goal of treatment (radical, adjuvant, salvage, or palliative) will be increasingly important to health care systems, providers, and patients. In this review, we highlight the evidence related to age and comorbidity, as it relates to radiotherapy and chemotherapy decision making. We will address evidence as it relates to age and comorbidity considerations separately and also the interplay between the factors. Clinical considerations to adapt radiation and/or chemotherapy treatment to deal with comorbidity challenges will be discussed. Knowledge gaps, future research, and clinical recommendation in this increasingly important field are highlighted as well.

The added challenges of bone metastases treatment in elderly patients

Most cancers occur in those older than the age of 65 years. As the population of the world ages and life expectancies continue to increase, it is important to address treatment challenges for elderly patients. This narrative review details the challenges of palliative radiotherapy treatment for elderly patients with bone metastases. We begin with the definition of elderly and its appropriateness, outlining recent demographic data of patients with cancer. The current status of elderly participation in clinical trials is discussed by reviewing the recent literature and clinical trial data. Factors affecting enrolment of the elderly are assessed, with a focus on palliative radiotherapy trials, and what we can do to improve accrual in this data-driven setting. At present, there is a lack of level 1 evidence that evaluates the optimal treatment for elderly patients with bone metastases. Therefore, a review of safety and efficacy is given based on previously published reports. Palliative radiotherapy for elderly patients is a worthwhile treatment and should be recommended regardless of age, as supported by available evidence. Patient, family and physician concerns about physical burden may be reduced as single treatments (that often can be done in a single visit) are as beneficial as multiple treatments for painful bone metastases. In elderly patients, radiotherapy may even be the best treatment for these cases as opioid-related adverse events are amplified in this group and often dosages are more difficult to titrate. Clinicians should continue to encourage the enrolment of elderly patients on to clinical trials as these data form the basis of optimal treatment guidelines. Radiation oncologists are encouraged to reduce the physical burden for elderly patients by offering single treatments where appropriate and completing consultation, treatment simulation and treatment in a single clinical visit.

Squamous cell carcinoma of the head and neck in the elderly

The incidence of head and neck squamous cell carcinoma (HNSCC) peaks between the fifth and seventh decades of life. With prolongation of life expectancy, however, the proportion of elderly HNSCC patients is also increasing, which makes HNSCC in this life period an important issue for healthcare providers. With features characteristic to the older patient groups coupled with the inherent complexity of the disease, HNSCC in the elderly represents a considerable challenge to clinicians. Indeed, to expedite the progress and improve the healthcare system to meet the needs of this unique population of patients, several essential issues related to the clinical profile, diagnostics, optimal treatment and support are of concern and should be addressed in properly conducted clinical trials. In the present review, we analyzed a literature series comparing different age groups with regard to their clinical characteristics, therapy, outcome and quality of life in an attempt to determine their implications on treatment-decision-making for elderly patients with HNSCC.

Is advanced age a barrier to effective cancer treatment? The experience of nonagenarians receiving radiation therapy

AIM

Decision-making about elderly patients is difficult due to the absence of clinical experience or evidence-based results to develop optimal treatment plans. This study aims to determine the tolerability and impact of radiation therapy (RT) when delivered to patients aged >89 years.

METHODS

A retrospective review was conducted on all nonagenarian patients (defined as aged 90 years or over) managed with RT between 2005 and 2007. Patients' records were reviewed in regard to their characteristics, the presence of significant medical comorbidities, performance status, management intent, cancer diagnosis and RT modality. Outcome end-points were overall survival and the tolerability of RT (presence of grade 3 or 4 morbidity, hospital admission or treatment interruption).

RESULTS

Between 2005 and 2007, 2762 new courses of RT were delivered to patients at the Northern Sydney Cancer Centre, of whom 55, or 2%, were nonagenarians. Median age at treatment was 92 years, with range 90-104 years. A total of 56% were managed with radical intent, 31% had significant comorbidities, 55% had non-skin primary tumors and 78% received linac-based treatment. The mean follow up for survivors was 19.8 months (10.2-41.8 months). RT was well tolerated, with 89% completing planned RT and only 18% requiring interruption. One patient was hospitalized due to RT toxicity. Median survival post-RT was 13.0 months, with 56% of patients alive at 12 months. Survival duration was associated with radical management intent (P= 0.001), cutaneous primary site (P= 0.001) and female gender (P= 0.043).

CONCLUSION

Nonagenarian patients receiving treatment had satisfactory tolerability and achieved expected survival rates post-RT.

Principles of surgical oncology in the elderly

Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.

Age is not a limiting factor for brachytherapy for carcinoma of the node negative oral tongue in patients aged eighty or older

BACKGROUND

To examine the role of brachytherapy for aged patients 80 or more in the trend of rapidly increasing number.

METHODS

We examined the outcomes for elderly patients with node negative oral tongue cancer (T1-3N0M0) treated with brachytherapy. The 21 patients (2 T1, 14 T2, and 5 T3 cases) ranged in age from 80 to 89 years (median 81), and their cancer was pathologically confirmed. All patients underwent definitive radiation therapy, with low dose rate (LDR) Ra-226 brachytherapy (n = 4; median 70Gy), with Ir-192 (n = 12; 70Gy), with Au-198 (n = 1) or with high dose rate (HDR) Ir-192 brachytherapy (n = 4; 60 Gy). Eight patients also underwent external radiotherapy (median 30 Gy). The period of observation ranged from 13 months to 14 years (median 2.5 years). We selected 226 population matched younger counterpart from our medical chart.

RESULTS

Definitive radiation therapy was completed for all 21 patients (100%), and acute grade 2-3 mucositis related to the therapy was tolerable. Local control (initial complete response) was attained in 19 of 21 patients (90%). The 2-year and 5-year local control rates were 91%, (100% for T1, 83% for T2 and 80% for T3 tumors after 2 years). These figures was not inferior to that of younger counterpart (82% at 5-year, n.s.). The cause-specific survival rate was 83% and the regional control rate 84% at the 2-years follow-up. However, 12 patients died because of intercurrent diseases or senility, resulting in overall survival rates of 55% at 2 years and 34% at 5 years.

CONCLUSION

Age is not a limiting factor for brachytherapy for appropriately selected elderly patients, and brachytherapy achieved good local control with acceptable morbidity.

Patterns of care in elderly head-and-neck cancer radiation oncology patients: a single-center cohort study

PURPOSE

To compare the patterns of care for elderly head-and-neck cancer patients with those of younger patients.

METHODS AND MATERIALS

A retrospective review was conducted of all new mucosal head-and-neck cancer referrals to radiation oncology between July 1, 2003 and December 31, 2007 at our institution. The clinical characteristics, treatment pattern, tolerance, and outcomes were compared between the elderly (aged ≥75 years) and younger (aged <75 years) cohorts.

RESULTS

A total of 2,312 patients, including 452 (20%) elderly and 1,860 (80%) younger patients, were studied. The elderly patients were more likely to be women (36% vs. 27%, p <.01) and to have other malignancies (23% vs. 13%, p <.01), Stage I or II disease (38% vs. 32%, p <.01), and N0 status (56% vs. 42%, p <.01). Treatment was less often curative in intent (79% vs. 93%, p <.01). For the 1,487 patients who received definitive radiotherapy (RT), no differences were found between the elderly (n = 238) and younger (n = 1,249) patients in treatment interruption, completion, or treatment-related death. Within the subset of 760 patients who received intensified treatment (concurrent chemoradiotherapy or hyperfractionated accelerated RT), no difference was seen between the elderly (n = 46) and younger (n = 714) patients in treatment interruption, completion, or treatment-related death. After a median follow-up of 2.5 years, the 2-year cause-specific survival rate after definitive RT was 72% (range, 65-78%) for the elderly vs. 86% (range, 84-88%) for the younger patients (p <.01).

CONCLUSION

Elderly head-and-neck cancer patients exhibited different clinical characteristics and experienced different patterns of care from younger patients. Although age itself was an adverse predictor of cause-specific survival, its effect was modest. Elderly patients selected for definitive RT or intensified RT showed no evidence of impaired treatment tolerance.

[Radiation therapy in elderly patients]

Cancer is a disease that predominantly occurs in older patients who represent a quarter of the population in western countries. Numerous types of cancer are observed in elderly people. Radiotherapy is one of the most powerful treatment against cancer. Most of published studies have demonstrated feasibility of radiotherapy in curative or palliative intent whatever cancer types are considered. Complete geriatric assessment and a multidisciplinary approach are the key points. The purpose of this review is to highlight sights of radiation oncology specifically related to aging. Particular emphasis is placed on logistic and technical aspects of radiation, as dose, irradiated volume and fractionation.

Elderly patients with painful bone metastases should be offered palliative radiotherapy

PURPOSE

To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients.

METHODS AND MATERIALS

The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed.

RESULTS

No significant difference was found in the response rate in patients aged >or=65, >or=70, and >or=75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status.

CONCLUSION

Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.

[Radiation therapy in elderly patients]

Cancer is a disease that predominantly occurs in older patients who represent a quarter of the population in western countries. Numerous types of cancer are observed in elderly people. Radiotherapy is one of the most powerful treatment against cancer. Most of published studies have demonstrated feasibility of radiotherapy in curative or palliative intent whatever cancer types are considered. Complete geriatric assessment and a multidisciplinary approach are the key points. The purpose of this review is to highlight sights of radiation oncology specifically related to aging. Particular emphasis is placed on logistic and technical aspects of radiation. Special techniques are also reviewed that have particular relevance to the treatment of the elderly.

The influence of age and comorbidity on receiving radiotherapy as part of primary treatment for cancer in South Netherlands, 1995 to 2002

BACKGROUND

The objective of this study was to study the influence of age and comorbidity on receiving radiotherapy (RT) in primary treatment of cancer.

METHODS

In a population-based setting, the authors calculated the proportion of irradiated patients within 6 months after they received a diagnosis of lung, rectal, breast, or prostate cancer or non-Hodgkin lymphoma (n = 33,369 patients) according to age and comorbidity between 1995 and 2002. Logistic regression analysis was used to adjust for age, comorbidity, gender, and stage.

RESULTS

Patients with localized nonsmall cell lung cancer (NSCLC) ages 65 years to > or = 80 years or with comorbid conditions received RT alone significantly more often compared with younger patients (ages 65-79 years: odds ratio [OR], 3.4; age > or = 80: OR, 12.0) and patients without comorbidities (1 comorbid condition: OR, 2.1; > or = 2 comorbid conditions: OR, 2.4). This also applied to patients with nonlocalized NSCLC ages 65 years to 79 years compared with younger patients (OR, 1.4). RT was administered significantly less often to elderly patients with resected rectal cancers (ages 65-79 years: OR, 0.7; age > or = 80 years: OR, 0.4), patients age > or = 80 years with breast cancer after undergoing conserving surgery (OR, 0.1), and patients age > or = 80 years with clinical T1-T3,N0,M0 prostate cancer age (OR, 0.1) compared with younger patients. Patients with breast cancer who underwent breast-conserving surgery received RT significantly less often in the presence of comorbidities (1 comorbid condition: OR, 0.6; > or = 2 comorbid conditions: OR, 0.4). Older patients with aggressive non-Hodgkin lymphoma received only RT as treatment significantly more often compared with younger patients (OR, 3.4).

CONCLUSIONS

Comorbidity and age did have influence over whether patients received RT, although, for most tumor types, age appeared to be a stronger predicting factor. Under treatment was observed among patients with breast cancer and rectal cancer.

The opinion of general practitioners on the treatment of prostate and breast cancer in elderly people: results of a survey based on clinical models

AIMS

Several publications have reported age-related differences in the management of people with cancer. Most data have been derived retrospectively from hospital or cancer-centre databases. The aim of the present study was to identify major decisional factors observed in general practitioner (GP) practices, outside the hospital setting, regarding the clinical management of patients with prostate and breast cancer.

MATERIALS AND METHODS

During three national GP meetings in Belgium, questionnaires presenting two simulated patient cases were presented to GPs who were asked two questions: one regarding further staging and referral of the case and the second regarding the treatment of the case. A total of 678 questionnaires were distributed. GPs received two randomly selected cases each: a breast cancer history and a prostate cancer history. Three variables were assessed simultaneously: age, performance status and medical history (comorbidity).

RESULTS

The analysis indicated that elderly patients were more likely to be referred for non-curative treatment (OR 13.71; 95% CI 5.67-33.12; P < 0.0001 for prostate cancer and OR 17.67; 95% CI 4.04-77.31; P < 0.0001 for breast cancer). The other variables (performance status and medical history) did not affect treatment orientation. However, GPs were prepared to seek assistance from oncologists in both cases, irrespective of the patient's age.

CONCLUSION

Age seems to be more important among GPs in deciding how to manage cancer patients than performance status and comorbidity. This is a very common prejudice. They are, nevertheless, inclined to refer people with cancer to oncologists independently of the patient's age.

Radiation-induced rectal complications are not influenced by age: a dose fractionation study in the rat

Radiation-induced complications of the rectum are an important dose-limiting factor in radiotherapy of pelvic malignancies. In general, animal studies demonstrated no differences in acute and late normal tissue toxicity with age, but little is known about rectal complications in relation to age. For this purpose, an extensive histological and dose fractionation study was carried out on the rectum of young (12 weeks) and older (77-80 weeks) rats. In this paper, the results of dose fractionation are presented in relation to age at the time of irradiation. Young and older animals were irradiated with single and fractionated doses. After irradiation, rectal complications could lead to occlusion and stenosis, eventually resulting in the clinical symptoms of a megacolon and a possible fistula. For each dose group, cumulative survival rates were obtained with Kaplan-Meier analysis, from which dose-effect curves and the associated LD(50) values for a megacolon/fistula were calculated. The majority of responders died between 8 and 24 weeks after irradiation, irrespective of age. For both age groups, only the fractionation data showed a reduction in the mean latency with increasing dose. In the older age group, 39% of the responders developed a fistula compared to 26% for the younger animals. The LD(50) values increased from around 30 Gy after single doses to nearly 65 Gy after 10 fractions. The increases in LD(50) values with the number of fractions were independent of the age of the rats. For each of the dose fractionation schedules, log-rank testing indicated no significant differences in cumulative survival rates between younger and older animals (P > 0.10). The high alpha/beta ratios obtained for both the young and older animals strongly suggested that the late rectal complications were a consequence of early epithelial injury. Associated histological findings indicated that blood vessel damage, which was already evident at a high incidence at 4 weeks after irradiation, could also play a significant role in the occurrence of consequential late injuries. In conclusion, data obtained for the latent period of rectal occlusion, for the dose-effect curves, for the log-rank testing of cumulative survival rates, and for the alpha/beta ratios strongly support the hypothesis that the incidence of radiation-induced rectal complications is independent of age. Late rectal complications could be a consequence of radiation-induced acute injury.

Radiation therapy of the older patient

Radiotherapy has a major role in the multidisciplinary approach to cancer therapy. It is widely used for curative and palliative treatment of cancer involving various sites. Radiotherapy is of particular benefit to older and frail cancer patients as an alternative to surgery and to systemic therapy. The available data on the sensitivity of normal tissues to radiotherapy in elderly patients strongly suggest that older patients with good functional status tolerate radiotherapy as well as younger patients and have comparable tumor response and survival rates. Aggressive radiotherapy should not be withheld from older patients because of chronological age alone.

Analysis of 57 nonagenarian cancer patients treated by radical radiotherapy: a survey of eight institutions

BACKGROUND

As the human society grows more aged, it is considered important to elucidate factors essential in applying radical radiotherapy (RT) to the elderly, with ages as high as 90 years and greater.

METHODS

A retrospective survey was conducted for patients 90 years of age or older who received radiotherapy with radical intent in eight leading institutions in Japan from 1990 through 1995.

RESULTS

Fifty-seven nonagenarian patients were studied. Their ages ranged up to 98 (median 91) and there was a strong female preponderance (M/F: 16/41). The distribution by site was as follows: head and neck, 16; skin and adnexae, 11; uterine cervix, 7; esophagus, 6. The prevailing histopathological diagnosis was squamous cell carcinoma (34), followed by adenocarcinomas (8). The highest age at RT was 98 years [female, skin cancer, died of senility 2.5 years after treatment, with no evidence of disease (NED)] and the longest survivor is 102 years old (female, glottic cancer T2, age at RT 93, alive NED for 8 years, uses wheel-chair). The rate of completion of treatment was 75% (43/57), if the treatment field was limited to the gross primary tumor volume only and if the cumulative dose was above 80% of the tolerable adult dose. Familial escort was necessary for most of the patients in completing the day-to-day RT.

CONCLUSION

Radiotherapy is feasible with radical intent even in the elderly, if the treatment field is limited to the gross primary tumor volume only, if the cumulative dose is above 80% of the tolerable adult dose and if familial support is adequate.

Cancer in patients aged 90 years or older: radiation therapy

PURPOSE

To investigate the clinical efficacy of radiation therapy for cancer in patients aged 90 years or older.

MATERIALS AND METHODS

Cancer cases in 32 patients (11 men, 21 women) aged 90 years or older who underwent radiation therapy in 1970-1997 were retrospectively analyzed. The mean patient age was 92.2 years, with a range of 90-98 years. Head and neck cancer (n = 14 [44%]) and skin cancer (n = 6 [19%]) were the most common.

RESULTS

Eleven (79%) of the 14 patients with head and neck cancer were treated with curative intent. Radiation response without any severe complication was observed in nine (90%) of the 10 patients with head and neck cancer treated with curative intent who finished treatment. The median survival time was 8 months (range, 3-55 months) in the 10 patients with head and neck cancer who completed treatment with curative intent. Complete response was achieved in all of the patients with skin cancer without any major sequelae. Complete response was also observed in all three of the patients with non-Hodgkin lymphoma, but two patients treated with adjuvant chemotherapy died of drug-induced pneumonitis. Palliation was achieved in all nine of the patients treated with palliative intent.

CONCLUSION

Age of 90 years or older is not a limiting factor for radiation therapy.

Radiotherapy in the elderly

Older patients with cancer are frequently victims of discriminatory treatment strategies according to parameters unrelated to the tumour itself. The general approach is influenced by the belief that good tolerance to radiotherapy might be compromised in older patients and that the course of cancer might be less aggressive in this age group. Substandard treatment is therefore often offered to older patients, although this attitude is supported neither by clinical nor by scientific evidence, but rather stems from a lack of specific knowledge of the actual cancer prognosis and the tolerance to radiotherapy in the elderly. In clinical practice advanced age may result in undertreatment, even though patients may have no other medical illness and no functional impairment. Some comorbid conditions which are more frequent in older patients may complicate the outcome of treatment. However, these impaired vital functions are not an intrinsic feature of the elderly. Overall, noncompliance in radiotherapy, related to comorbidity or technical condition, is rare. Short-term radiotherapy using a large daily fraction is often advocated in elderly patients; however, this should only be considered if a palliative treatment option has previously been selected due to the high risk of late side-effects. Acute side-effects often result in decreasing doses of radiotherapy. Data on acute tolerance of radiotherapy for different types of tumours did not demonstrate a radical difference in occurrence of toxicities. 'Reducing' radiotherapy is never a solution, unless the life expectancy of the patient is obviously so short that the tumour recurrence is unlikely to occur or at least to produce substantial morbidity before the patient has died from other causes.