Age is not a limiting factor for radical radiotherapy in pelvic malignancies

Acute diarrhea during pelvic irradiation: is small-bowel volume effect different in gynecologic patients with prior abdomen operation or not?

OBJECTIVE

To evaluate volume effect of small bowel for diarrhea during pelvic irradiation in gynecologic patients with or without prior abdomen operation.

METHODS

From January 1996 through December 2003, 759 patients undergoing 4-field pelvic irradiation for cervical or uterine cancer were analyzed. Whole pelvic (WP), modified whole pelvic (MWP), or lower pelvic (LP) irradiation were delivered initially. According to contrast medium within small bowel in simulation films, we categorized the small-bowel volume of full dose related to WP fields as small-volume and large-volume groups. We recorded the severity of diarrhea until 39.6 Gy/22 fractions of pelvic irradiation. The actuarial rates of overall and moderate to severe diarrhea were compared among different groups.

RESULTS

Significantly more large-volume distribution (85%) was noted in patients >60 years without prior operation (P < 0.001). Large-volume distribution was 53%, 65%, and 82% in post-operative patients with no diarrhea, mild diarrhea, and moderate to severe diarrhea (P = 0.002), respectively. The corresponding rate was 79%, 77%, and 80% in patients without prior abdomen operation (P = 0.869). In multivariate analysis, prior operation with LP fields (P = 0.005) and prior operation with small volume (P = 0.031) were significantly protective factors for overall diarrhea. The latter was also a protective factor for moderate to severe diarrhea (P = 0.026). Prior operation could diminish overall diarrhea in patients without simultaneous large-field (WP or MWP) and large-volume. Large volume was a significant factor of overall (P = 0.014) and moderate to severe (P = 0.004) diarrhea in large-field patients with operation. The volume effect did not exist in those patients without operation.

CONCLUSION

Age and operation can change small-bowel distribution. Prior operation may attenuate diarrhea if irradiated volume of small bowel is small. There is a volume effect in post-operative rather than non-operative patients receiving large-field irradiation. More practical dose-volume evaluation of small bowel may be applied for volume effect in gynecologic patients without prior operation.

Pathologic stage I-II endometrial carcinoma in the elderly: Radiotherapy indications and outcome

PURPOSE

To assess the indications for, and the outcome of, adjuvant radiotherapy (RT) in elderly patients with pathologic Stage I-II endometrial carcinoma.

METHODS AND MATERIALS

Between 1980 and 2001, 79 elderly (age > or =75 years) patients with pathologic Stage I-II endometrial carcinoma were seen at our institution. All underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy with assessment of peritoneal cytology. Pelvic and paraaortic lymph node sampling was performed in 39 and 29 women, respectively. Patients with Stage IA and IB Grade 1-2 were designated as low risk; those with Stage IB Grade 3 and IC-IIB were designated as high risk. Thirty-four received adjuvant RT consisting of whole pelvic (n = 23) or vaginal brachytherapy (n = 3), or both (n = 8). Actuarial disease-free survival, cause-specific survival, and pelvic recurrence-free survival analyses were performed by the Kaplan-Meier method.

RESULTS

Adverse factors were common, including deep (>50%) myometrial invasion (47%), Grade 3 disease (28%), cervical involvement (15%), and unfavorable histologic features (15%). Overall, 46 patients (58%) had high-risk disease. Primarily because of concerns over toxicity, RT was administered in only 73%, 55%, and 67% of patients with deep myometrial invasion, Grade 3 disease, and cervical involvement, respectively. Thirty-one high-risk patients (67%) received adjuvant RT. At a median follow-up of 33.5 months, 19 patients had relapsed, for a 5-year actuarial disease-free survival rate of 67.7%. Ten patients (12%) had recurrence in the pelvis, 9 of whom had been patients treated with surgery alone. The 5-year pelvic recurrence-free survival rate of patients treated with and without RT was 97% and 73.1%, respectively (p = 0.02). The corresponding rates in the high-risk patients were 97% and 47% (p = 0.0001). High-risk patients treated with RT also had better 5-year actuarial disease-free survival (p = 0.0001) and cause-specific survival (p = 0.003) than those treated with surgery alone. RT was well tolerated, with all patients receiving their treatment as planned. Only 1 patient developed significant late toxicity.

CONCLUSIONS

Adverse features are common in pathologic Stage I-II elderly endometrial carcinoma patients, and pelvic recurrence is high after surgery alone. Given the improvement in outcome and low incidence of toxicity, our results support the use of adjuvant RT in elderly pathologic Stage I-II patients with high-risk disease.

Is endometrial carcinoma intrinsically more aggressive in elderly patients?

BACKGROUND

The current study was conducted to determine the influence of old age (age >/= 70 years) on outcome in a group of patients with endometrial carcinoma who were treated with simple hysterectomy followed by adjuvant radiation therapy (RT).

METHODS

Between November 1987 and May 2000, 405 patients with International Federation of Gynecology and Obstetrics (FIGO) Stage IB-II endometrial carcinoma were treated with postoperative RT. Intravaginal RT alone was given to 77% of patients (median dose, 21grays [Gy] given in 3 fractions). Additional postoperative external beam radiation therapy (EBRT) was given to 23% of patients (median dose, 45 Gy). Eighty-four patients were age >/= 70 years and 321 patients were age < 70 years. The two groups were well balanced with regard to race, comprehensive surgical staging, aggressive histology, lymphovascular invasion, lower uterine segment involvement, cervical involvement, and the use of postoperative EBRT. Significantly more patients in the age >/= 70 years group had other comorbidities such as obesity, diabetes mellitus, or hypertension (P = 0.02) and were found to have deep (> 50%) myometrial invasion (P = 0.008).

RESULTS

With a median follow-up time of 48 months, the 5-year locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) rates were 95%, 91%, and 90% respectively. On multivariate analysis, poor LRC was found to be correlated with age >/= 70 years (P = 0.019) and lymphovascular invasion (P = 0.001). Poor DFS was found to be correlated with age >/= 70 years (P = 0.03), lymphovascular invasion (P = 0.01), and aggressive histology (P = 0.001). Similarly, poor OS was found to correlate with age >/= 70 years (P = 0.001), lymphovascular invasion (P = 0.01), aggressive histology (P = 0.01), and cervical involvement (P = 0.02). The same factors that were found to correlate with OS (age >/= 70 years, lymphovascular involvement, aggressive histology, and cervical involvement) also appeared to correlate with disease-specific survival (P = 0.03, P = 0.008, P = 0.001, and P = 0.04, respectively). The 5-year actuarial rates of Radiation Therapy Oncology Group late complications that were >/= Grade 3 (gastrointestinal tract, genitourinary tract, or vagina) were 3% in both groups.

CONCLUSIONS

Even when treated in a similar fashion, endometrial carcinoma patients age >/= 70 years appear to fare worse than younger patients independent of other poor prognostic factors. The rate of complications from adjuvant RT, despite a higher rate of comorbidity in elderly patients, was found to be similar in both age groups. Endometrial carcinoma appears to be intrinsically more aggressive in older patients, thus mandating further improvement in their treatment strategies.

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.

Difference in stage and morphology-adjusted survival between young and elderly patients with a testicular germ cell tumor

OBJECTIVES

To compare the relative survival in men younger and older than 50 years with a testicular germ cell tumor.

METHODS

Data on patients with testicular cancer diagnosed between 1973 and 1997 and registered by one of the nine population-based Surveillance, Epidemiology, and End Results (SEER) cancer registries in the United States were obtained from the National Cancer Institute public domain SEER*Stat 3.0 package. Survival rates adjusted for mortality owing to other causes (ie, relative survival) were calculated for men within each category of the American Joint Committee on Cancer staging system.

RESULTS

Patients who developed a germ cell tumor before the age of 50 years had better 10-year relative survival (90.8%, 95% confidence interval 90.6% to 91.0%) than those who developed one after the age of 50 years (84.0%, 95% confidence interval 81.9% to 86.1%). This difference remained after stratification by histologic type and stage, except for patients with localized seminomatous disease (97.9% versus 98.0% for men younger and older than 50 years, respectively). The largest difference in 10-year relative survival was found in men with metastasized disease: seminomatous disease, 89.7% versus 69.6%, and nonseminomatous disease, 76.9% versus 57.0%, for men younger and older than 50 years, respectively.

CONCLUSIONS

Lower stage and morphology-adjusted relative survival rate was observed among patients older than 50 years of age with testicular cancer. This difference was more evident in metastasized disease. Whether the worse prognosis in testicular cancer can be explained by a lower tolerance to chemotherapy and/or to suboptimal treatment in the elderly has to be established.

Who gets adjuvant treatment for stage II and III rectal cancer? Insight from surveillance, epidemiology, and end results--Medicare

PURPOSE

To examine the relationship between patient characteristics and the use of adjuvant pelvic radiation with and without chemotherapy among patients aged 65 years and older with stage II and III rectal cancer.

PATIENTS AND METHODS

A retrospective cohort study using the Surveillance, Epidemiology, and End Results-Medicare linked database identified 1,411 patients aged 65 and older with resected stage II and III rectal cancers diagnosed between 1992 and 1996. From claims submitted to Medicare, we measured the use of pelvic radiation therapy with or without chemotherapy and pre- or postoperatively.

RESULTS

Fifty-seven percent of patients received radiation, 42% received chemotherapy and radiation, and 7% had treatment delivered preoperatively. Age was the strongest determinant of treatment: 73% of patients aged 65 to 69, 66% aged 70 to 75, 52% aged 75 to 79, 39% aged 80 to 84, and 21% aged 85 to 89 received radiation. The age trend remained strong after adjusting for other factors that predict receipt of treatment and after exclusion of patients with any evident comorbidity (P <.001). Patients were more likely to receive radiation treatment if they had an abdominal perineal resection, stage III disease, or a T4 tumor.

CONCLUSION

Because pelvic recurrences are a substantial cause of morbidity, further efforts are needed to ensure that elderly patients have the opportunity to make informed decisions regarding adjuvant treatment.

The role of radiotherapy in the management of elderly cancer patients in light of the GROG experience

60-70% of all cancers will develop in individuals aged 65 and over during this century. Radiation therapy will play a major role in the treatment of cancer, especially in the elderly. The Italian Geriatric Oncology Group (GROG) in 1994 started a number of prospective studies to assess the characteristics of each elderly cancer patient referred to the radiotherapy centers (age, gender, performance status, comorbidity, ADL, family status) and the main features of the tumor in that patient. Based on the obtained results, the role of radiotherapy is underlined and future perspectives are identified.

Do elderly cancer patients care about cure? Attitudes to radical gynecologic oncology surgery in the elderly

OBJECTIVE

The aim of this study was to address the hypothesis of no difference between elderly and younger patients' desire for optimal surgery and disease cure.

METHODS

The new ARGOSE questionnaire with established instruments was administered to 189 gynecologic cancer patients (95 aged <65, 57 aged 65-74, and 37 aged 75+ years).

RESULTS

Disease diagnosis differed between the <65 years and 65+ years cohorts (P < 0.001), but treatment modalities were similar (P = 0.28). Influences of family and friends and past experiences of cancer had little influence on treatment decisions. There was no difference between cohorts in desire for surgery offering a chance of disease cure (P = 0.75), except that the elderly desire cure more if treatment is associated with disfigurement than do the young. (P = 0.029). The elderly believe more strongly than the young that the elderly value cure (P < 0.001). Issues of sexuality and femininity associated with gynecologic cancer and treatment are more important to younger patients (P < 0.001). The elderly support equality of care with relation to age more strongly than the young. However, in a situation of resource limitation, inequality favoring the young is opposed less strongly by the elderly than by the young. Social desirability bias may have influenced this finding. All cohorts reported symptom palliation to be of secondary importance to treatments offering a possibility of cure (P = 0.26). The elderly believe more strongly that doctors should make management decisions (P < 0.001).

CONCLUSION

The elderly desire radical surgery and disease cure as strongly as the young. They are less likely to question their doctors' decisions and are therefore vulnerable to physicians' age bias. There is no justification for rationing care on the basis of chronological age.

Effect of age on radiation-induced early changes of rat rectum. A histological time sequence

BACKGROUND AND PURPOSE

Radiation treatment of the elderly (> 75 years) is often modified due to an assumed decrease in normal tissue tolerance in this age group. Since more radiobiological data concerning normal tissue toxicity as a function of age are needed, a histological study of age-related radiation changes of the rectum was performed.

MATERIALS AND METHODS

The rectum of young and old female Wistar rats (12 and 78 weeks, respectively) was irradiated with single doses of 22 and 39 Gy. The field size was 1.5 x 2.0 cm. The animals were sacrificed at 1, 2, 4 and 10 weeks after treatment. To evaluate radiation damage, 12 histological parameters were scored in four areas of the rectum. A total radiation injury score was calculated. The number of proliferative epithelial cells was evaluated by 5-bromo-2'-deoxyuridine labeling.

RESULTS

Some age-related histological differences were observed; especially, the incidence of ulceration and vascular occlusion was higher in the older group. In the low dose group of the older animals, 60% showed ulceration, which was 0% for the young low dose animals. Severe vascular changes occurred early and were more extensive in older animals (4 weeks) than in the younger group (10 weeks). In the area adjacent to the treatment field, cell proliferation increased significantly in older rats at 1 week after 22 Gy, which did not occur in the young group.

CONCLUSIONS

Discrete radiation-induced histological differences were observed between the rectum of young and old Wistar rats, especially in the development of ulceration and vascular changes. Although the survival of these Wistar rats in earlier studies was not affected by age, the impact of the observed histological differences for their importance in the long-term is currently being investigated.

Age as a prognostic factor for recurrence in patients with endometrial carcinoma

PURPOSE

The aim of this study was to evaluate age as a prognostic factor for recurrence in endometrial cancer patients treated with primary surgery.

METHODS

Between 1983 and 1998, 455 endometrial cancer patients underwent primary surgery at our institution. Patients were divided into three age groups based on age at diagnosis: Group A (age <60, n = 156), B (age 60-69, n = 147), and C (age >/=70, n = 152). Clinicopathologic, treatment factors, and outcome were compared among the three groups. Prognostic factors were evaluated by univariate and multivariate analysis.

RESULTS

The three age groups had a similar distribution of most pathologic features including stage, histology, cervical involvement, positive cytology, adnexal involvement, nodal metastases, serosal involvement, and lymphovascular invasion (LVI). Older women had a higher rate, however, of deep (>1/2) myometrial invasion (P < 0.0001) and grade 3 tumors (P < 0.0001). The extent of surgical staging and use of adjuvant radiation therapy were similar. Five-year disease-free survivals (DFS) of Groups A, B, and C were 74.3, 70.2, and 60.3%, respectively (P = 0.08). A significant difference in DFS was seen when Groups A and B were combined and compared with Group C (72.0 vs 60.3%, P = 0.03). Multivariate analysis confirmed the significance of race, stage, grade, and LVI. Age was not found to be associated with recurrence (HR 1.1, 95% C.I. 0.91-1.5, P = 0.21).

CONCLUSION

Our results reveal that, in a large cohort of comparably staged and treated endometrial carcinoma patients, age is not a prognostic factor for recurrence.

[Cancer and the elderly. Management. Decision aspects]

INTRODUCTION

Age is the major risk factor for the majority of patients with cancer. More than 50% of cancers occurs after the age of 60. Cancer in the elderly is therefore a public health issue at stake. However, in daily clinical practice the elderly presenting cancer are not listened to with great interest and treatment is often not proper or suboptimal.

CURRENT KNOWLEDGE AND KEY POINTS

Diagnosis in the elderly is established at a more advanced stage of cancer than in younger people; diagnostic workup is reduced and suboptimal treatments are implemented. Therefore, barriers exist that prevent the elderly from accessing the healthcare system as easily as their younger counterpart. Misconceptions about cancer also lead them to delay their first visit. As well, although treatment with curative intent and without major side-effect is feasible, physicians have misconceptions regarding therapeutic possibilities. Due to the heterogeneity of the so-called "ageing population", difficulties are related to patients' selection.

FUTURE PROSPECTS AND PROJECTS

Decision in oncology for the elderly must walk a fine line in attempting to deliver the best treatment under the best conditions. Age per se must not be the only criterion for medical decision. Providing accurate information adapted to the elderly, with large circulation among healthcare professionals, should lead to the same quality of care as that in young people. Comprehensive multimodal geriatric assessments should help to further differentiate patients who may benefit from curative treatment from those for whom only palliative treatment is necessary.

Impact on treatment outcome and late effects of customized treatment planning in cervix carcinomas: baseline results to compare new strategies

PURPOSE

The aim of the study was to determine the predictive factors of complications, to evaluate the impact of customized treatment planning on late normal tissue effects per stage, and to report disease-free survival (DFS) and local control (LC) rates.

METHODS AND MATERIALS

From 1970 to 1994, 642 patients were treated with radiotherapy alone for carcinoma of the intact uterine cervix. According to the International Federation of Gynecology and Obstetrics (FIGO) substaging, 34% were Stage I, 39% Stage II, and 27% Stage III. The analysis was divided into three periods: 1970-1978 (use of standard prescriptions),1979-1984 (implementation of individual adjustments), 1985-1994 (systematic individual adjustments). Five-year DFS, LC, and complications rates were calculated using the Kaplan-Meier method. Predictive factors of complications were determined by univariate analysis using frequency tables and nonparametric t-tests. Multivariate analysis consisted of a polychotomous stepwise regression.

RESULTS

The comparison of the three time periods showed a significant reduction of the external radiation dose (dose above 40 Gy in 47% of patients before 1979 vs. 36% after 1984), of the use of parametrial boost (55% vs. 39%), of the use of vaginal cylinder (28% vs. 11.5%), and of the HWT volume (combined intracavitary and external irradiation) (842 cc vs. 503 cc on average). The total sequelae/complications rate, all toxicity grades, all stages, all organs was 51%. Five-year actuarial rate per toxicity grade was: G1, 42%; G2, 23.5%; G3, 10%; G4, 3%. The three main predictive factors for rectal and bladder sequelae/complications (all toxicity grades) taking into account time period were: the increase of external radiation dose, the high dose rate at reference points, and the whole vagina brachytherapy. No G4 occurred in the third period. The rate of G3 complications dropped from 16% to 6% over time: from 5% during the first period to 0% during the third period in Stage I, from 8% to 6% in Stage II, and from 23% to 12% in Stage III. G3 currently describes a variety of clinical situations with a different impact on quality of life which justifies further refinements of definitions of late effects. In our experience the severity of G3 markedly decreased: less than one-third of G3 had a real impact on quality of life in the last period compared to more than two-thirds in the first period. Meanwhile, 5-year LC rates remained stable in Stages I and II, 91% and 85% respectively. Conversely they fell from 75% to 55% in Stage III, thus raising the problem of underdosage and/or more accurate staging with time.

CONCLUSIONS

Customized treatment planning eradicated lethal complications and provided a significant decrease of G3 in all stages while maintaining high cure rates in early stages. Dose reduction should be considered with caution in Stage III.

[Complications of treatments of invasive cancers of the uterine cervix with intact uterus: results and prevention]

The prospective record of acute and late toxicity after treatment of cervix carcinomas is a part of the description of treatment outcome as well as local control and survival. Due to the large number of scales and glossaries used, the comparison of the results from one study to another is often difficult. The French-Italian syllabus seems to be the most reliable scale, providing implementation of quality of life assessments. The main predictive factor of complications, which is not related to the treatment type, is the previous history of abdominal or pelvic surgery. The incidence and severity of complications occurring after surgery are related to the surgical procedure and to the amount of peri-uterine tissues removed. The increase in dose and volume of external irradiation and brachytherapy and the increase in dose rate of the low-dose rate brachytherapy are responsible for the radiotherapeutic morbidity. The significant decrease of severe complication rates during the last 15 years was obtained by the implementation of individual adjustments in treatment planning. The treatment strategies of early bulky and advanced carcinomas are changing. Concurrent radiotherapy and chemotherapy is becoming a standard, but its late toxicity needs to be documented by a longer follow-up. The optimisation of radiation therapy should remain a reference to evaluate the outcome and morbidity of the new combined strategies: the addition of chemotherapy will never compensate for less than optimal radiotherapy/brachytherapy planning.

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.

Assessment of the older cancer patient

The correct assessment of a cancer patient is a key step in the treatment process. In older people, this assessment entails not only the patient's basic medical history and the standard cancer staging, but also much more comprehensive evaluation of the various facets of the patient's health and environment that may interfere with his or her therapy. Patient fitness for elective surgery, radiation therapy, and chemotherapy must be considered. Geriatricians have defined the relevant aspects of the general evaluation of the older person, and now this work is being adapted to cancer patients. This article reviews the various aspects of a comprehensive assessment applicable to the cancer patient in settings such as academic oncology programs, cooperative group studies, and private oncology practice.

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 of the elderly patient. Radiotherapy tolerance and results in older patients]

BACKGROUND

Despite a growing number of elderly patients receiving radiation therapy little is known about side effects and outcome of irradiation in this section of the population.

METHODS

In a review article epidemiologic data, aspects of radiation-biology as well as side effects and outcome of radiation therapy of elderly patients are discussed.

RESULTS

Cancer incidence rises with age (Figure 1) and is exceeding 3.5% for males older than 85 years. With a life expectancy of more than 4 years, curative therapy is indicated even at this age. Furthermore several retrospective studies indicate that local control and disease-Specific survival after radiation therapy of elderly patients is comparable with that of younger persons (Tables 3 and 4). The exception contains elderly patients with Grade-III to IV gliomas or with rectal carcinoma who show a reduced survival which is perhaps caused by less aggressive combined treatment (tumor resection). Although some biological and molecular data indicate a rise in radiation sensitivity with growing age like the reduction of the capacity of some DNA-repair enzymes, there is no convincing evidence in animal studies or in retrospective clinical studies that radiation therapy is generally less well tolerated by older individuals (Tables 1 and 2). Some age-depending differences in organ toxicities are described in 3 large studies, which evaluate the data of patients who were enrolled in different EORTC-trials: Older patients suffer more of functional mucositis in case of radiation therapy to the head and neck, they have an increased weight loss and a higher frequency of late esophageal damage when irradiated in the thorax, and they show a higher prevalence of sexual dysfunction when treated with radiation therapy to the pelvis. On the other hand younger patients suffer more from acute toxicity like skin damage, nausea, and deterioration of the performance status during pelvic radiotherapy. When discussing the dose intensity of radiation therapy concomitant disease which leads to extensive atherosclerotic vessel damage should be kept in mind. Old patients should be monitored closely during therapy, since the loss of electrolytes or fluid is often not very well tolerated.

CONCLUSION

The indication to radiation therapy of elderly cancer patients should take into account their performance status as well as the extent and the severity of comorbidity. Age per se is seldom a contraindication for radiation therapy. Regarding the available data in literature there is no indication for a dose reduction in radiation therapy only because of age, especially in the curative setting.

Treatment of anal carcinoma in the elderly: feasibility and outcome of radical radiotherapy with or without concomitant chemotherapy

BACKGROUND

For most cancers, information on treatment tolerance and results for elderly patients is quite limited. This study was conducted to investigate the feasibility and results of curative nonsurgical treatment of patients age 75 years or older with anal carcinoma.

METHODS

From January 1976 through June 1996, invasive anal squamous cell carcinoma was diagnosed in 58 patients age > or = 75 years. Curative treatment was administered to 47 patients (81%), of whom 42 received radiotherapy (RT), either used alone (21) or associated with concomitant chemotherapy (CT). RT was administered in two sequences, the first in which a median dose of 39.6 gray (Gy) was delivered with megavoltage photon beams, followed (after a median interval of 43 days) by a boost with either brachytherapy or external beam (median dose, 20 Gy). CT started on Day 1 and generally consisted of 1 cycle of mitomycin C (MMC; median dose, 9.5 mg/m2) and a 96-hour infusion of 5-fluorouracil (5-FU; median dose, 600 mg/m2/day). The median follow-up for all patients was 48 months (range, 5-163 months).

RESULTS

Of 40 patients (95%) who completed curative treatment, acute toxicity resulted in shortening of the planned first irradiation sequence in 2 patients (1 in each group) and an unplanned treatment break in 11 patients (4 in the RT group and 7 in the RT-CT group). Grade 2 and 3 acute reactions (RTOG) were observed in 43% and 54% of patients, respectively. Among all Grade 3 reactions, 32% occurred in the RT group and 68% in the RT-CT group. In patients receiving RT-CT, Grade 2-3 leukopenia was observed in 25% of patients, Grade 2-3 fatigue was observed in 58% of patients, and Grade 2 cardiac toxicity related to 5-FU occurred in 1 patient. At 5 years, the overall survival was 54% (49% and 59% for the RT and RT-CT groups, respectively, P = 0.28), and the actuarial local control rate was 78.5% (73% and 83% for the RT and RT-CT groups, respectively, P=0.36). Five patients presented with Grade 3-4 late complications, all of them in the RT-CT group.

CONCLUSIONS

The current series confirms the feasibility of sphincter-conserving treatment for elderly patients who present with anal carcinoma. Rates of acute or late complications appeared similar to those observed in younger patients, and the oncologic results were at least as favorable as those commonly reported.

Cervical cancer in the elderly treated with radiation therapy

OBJECTIVES

The aim of this study was to evaluate the tolerance and outcome of elderly cervical carcinoma patients treated with radiation therapy (RT).

METHODS

Three hundred ninety-eight patients with stage I-III cervical carcinoma treated with definitive RT were analyzed. Patients were divided into nonelderly (ages 35-69) (n = 338) and elderly (ages >/= 70) (n = 60) groups. A comparison of patient, tumor and treatment factors, morbidity, and outcome was performed. Median follow-up was 81 months.

RESULTS

Elderly patients had a higher rate of comorbid conditions including diabetes (P = 0. 02), coronary artery disease (P = 0.003), and hypertension (P = 0. 001) than younger patients. Comorbid conditions in the elderly resulted in more frequent treatment breaks and less ability to undergo definitive treatment with intracavitary RT (ICRT). While the 5-year actuarial disease-free (DFS) and cause-specific (CSS) survival rates were comparable between the two groups, disease recurrence and death from cervical cancer were more common beyond 5 years in the elderly group. When patients not undergoing ICRT and those with treatment protraction were excluded, differences in the DFS and CSS curves were no longer evident. The frequency and severity of acute and chronic sequelae were similar.

CONCLUSIONS

Elderly cervical carcinoma patients have an equivalent overall outcome following radiation therapy to younger patients when comparable treatment is delivered. Age per se is not associated with a higher rate of acute or chronic sequelae. Comorbid conditions adversely impacted on the quality and delivery of RT in the elderly group and help explain observed differences in outcome based on age.

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.

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

PURPOSE

To present 23 patients > or = 90 years old treated with radiotherapy, and to retrospectively evaluate the results of radiotherapy and tolerance in these patients.

METHODS AND MATERIALS

The clinical records of 27 patients over 90 years of age who were treated with radiotherapy at the Department of Radiology, Shinshu University Hospital, and eight affiliated general hospitals from 1990 until 1995 were reviewed. The strategy of radiotherapy was individually planned depending on the stage of the disease and performance status (PS) of the patient; however, it was not modified, based solely on chronologic age. The overall survival rate and disease-free survival rate were determined using the Kaplan-Meier method. The Radiation Therapy Oncology Group scoring criteria of acute and late reactions of radiation therapy were used.

RESULTS

This group of patients accounted for 0.37% of all patients treated with radiotherapy in these hospitals. Of these, 23 patients in whom cancer was pathologically confirmed and whose follow-up data were available for retrospective analysis were included in the final evaluation of data. The age of the 23 patients ranged from 90 to 96 years (median 93). Tumor was untreated and in the early stage in five patients, locoregionally advanced in 13, recurrent in four, and systemic in one. Definitive radiation therapy was administered in 12 patients (13 sites), preoperative intent in one, and palliative intent in 10. The period of observation ranged from 2.5 to 6 years (median 18 months). Seven patients were alive for 15-67 months. Fourteen patients died because of intercurrent diseases or senility associated with active cancer, and two because of senility without evidence of cancer. The overall and relapse-free survival rates were 65% and 30% at 1 year and 30% and 21% at 2 years, respectively. Definitive radiation therapy was completed in 13 of 13 patients (100%), and local control was attained in 9 of 13 patients at 6 months (62%). Palliative radiation therapy was completed as intended in 7 of 11 (64%), and effects of palliation were observed in 9 of 11 patients (81%). Acute dermatitis, mucositis, pharyngitis, esophagitis, and cystitis of grade 2-3 related to the definitive radiation therapy were tolerable for the patients with good PS. It took 3-7 weeks (median 5) for acute moist desquamation of six lesions of skin cancer to heal. Depending on the radiation doses, grade 1-2 atrophy of skin and telangiectasia were documented for eight patients followed up for more than 1 year. A brief description of representative case is presented.

CONCLUSION

Patients older than 90 years with good PS may tolerate the acute effects of radiotherapy administered according to conventional fractionation schedules. Definitive radiation therapy should be considered, when applicable, even for patients older than 90 years.