Radiotherapy for Japanese elderly patients with cervical cancer: preliminary survival outcomes and evaluation of treatment-related toxicity

Geriatric Radiation Oncology: What We Know and What Can We Do Better?

Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.

Cervical cancer specific survival in Grande Cuiabá, Mato Grosso State, Brazil

OBJECTIVE

To estimate specific five-year survival in women diagnosed with cervical cancer living in the municipalities of Cuiabá and Várzea Grande, in the state of Mato Grosso, Brazil.

METHODS

This is a retrospective cohort study with information from the Cuiabá Population-based Cancer Registry and the Mortality Information System. To estimate the probability of specific survival in five years, the Kaplan-Meier estimator and the log-rank test were used aiming at verifying if there were statistical differences in the lifetime per groups. To verify the proportionality of the failure rates, the Schoenfeld residual test was used according to the statistical significance level of 0.05.

RESULTS

Specific five-year survival and median time were 90.0% and 50.3 months, respectively, for cervical cancer. When analyzing by age, the highest specific survival was among women aged 20 to 49 years (91.7%) and median time was 53.3 months. For the histological type, the highest specific survival was among women with adenocarcinoma (92.3%) and the mean survival time was 53.5 months.

CONCLUSION

This study showed that specific survival after five years of diagnosis remained about 90% in patients with cervical cancer. Patients aged 20 to 49 years had higher specific survival and there was statistically significant difference only between age groups.

Sobrevida específica do câncer do colo do útero na Grande Cuiabá, Mato Grosso, Brasil

RESUMO: Objetivo: Estimar a sobrevida específica em cinco anos de mulheres diagnosticadas com câncer do colo do útero que residem nos municípios de Cuiabá e Várzea Grande, Mato Grosso. Métodos: Estudo de coorte retrospectiva com informações provenientes do Registro de Câncer de Base Populacional de Cuiabá e do Sistema de Informação sobre Mortalidade. Para estimar a probabilidade de sobrevivência específica em cinco anos, foram utilizados o estimador de Kaplan-Meier e o teste de log-rank. Para verificar a proporcionalidade das taxas de falhas, usou-se o teste de resíduos de Schoenfeld, conforme o nível de significância estatística de 0,05. Resultados: A sobrevida específica em cinco anos e o tempo mediano de sobrevida foram de 90% e 50,3 meses, respectivamente, para o câncer do colo do útero. Quando se analisa por idade, a maior sobrevida específica foi entre as mulheres de 20 a 49 anos (91,7%) e o tempo mediano de sobrevida foi de 53,3 meses. Para o tipo histológico, a maior sobrevida específica foi entre as mulheres com adenocarcinoma (92,3%) e o tempo mediano de sobrevida foi de 53,5 meses. Conclusão: Este estudo mostrou que a sobrevida específica após cinco anos do diagnóstico se manteve em torno de 90% em pacientes com câncer de colo do útero. As pacientes entre 20 e 49 anos tiveram maiores sobrevidas específicas e houve diferença estatisticamente significativa somente entre as faixas etárias.

Differences in Treatment Outcomes and Prognosis between Elderly and Younger Patients Receiving Definitive Radiotherapy for Cervical Cancer

The aim was to compare the clinical outcomes and prognostic factors of cervical cancer between elderly and younger women, and to explore which treatment strategy is more appropriate for elderly patients. We retrospectively reviewed patients with cervical cancer receiving definitive radiotherapy (RT) between 2007 and 2016, and divided them into two age groups: age < 70 vs. age ≥ 70. The clinical outcomes were compared between the two age groups. The median follow-up was 32.2 months. A total of 123 patients were eligible, 83 patients in group 1 (age < 70), and 40 patients in group 2 (age ≥ 70). Patients in group 2 received less intracavitary brachytherapy (ICRT) application, less total RT dose, and less concurrent chemoradiotherapy (CCRT), and tended to have more limited external beam radiotherapy (EBRT) volume. The treatment outcomes between the age groups revealed significant differences in 5-year overall survival (OS), but no differences in 5-year cancer-specific survival (CSS), 66.2% vs. 64.5%, and other loco-regional control. In multivariate analyses for all patients, the performance status, pathology with squamous cell carcinoma (SCC), International Federation of Gynecology and Obstetrics (FIGO) stage, and ICRT application were prognostic factors of CSS. The elderly patients with cervical cancer had comparable CSS and loco-regional control rates, despite receiving less comprehensive treatment. Conservative treatment strategies with RT alone could be appropriate for patients aged ≥ 70 y/o, especially for those with favorable stages or histopathology.

Definitive Chemoradiotherapy in Elderly Cervical Cancer Patients: A Multiinstitutional Analysis

Objective

The aim of the study was to investigate the prognostic factors for survival and treatment-related toxicities in older (≥65 years) cervical cancer patients treated with definitive chemoradiotherapy. In addition, we sought to compare the outcomes between the older elderly (≥75 years) and their younger old counterparts (age, 65–74 years).

Materials and Methods

We retrospectively reviewed medical records from 269 biopsy-proven nonmetastatic cervical cancer patients treated with external radiotherapy and intracavitary brachytherapy at the departments of radiation oncology in 2 different universities. The prognostic factors for survival, local control, and distant metastasis (DM) were analyzed.

Results

The median follow-up time was 38.8 months (range, 1.5–175.5 months) for the entire cohort and 70.0 months (range, 6.1–175.7 months) for survivors. The 2- and 5-year overall survival (OS), disease-free survival (DFS), and cause-specific survival rates were 66% and 42%, 63% and 39%, and 72% and 55%, respectively. Patients 75 years or older showed significantly worse OS compared with patients aged 65 to 74 years but showed no significant difference in DFS. The 2- and 5-year local control rates were 86% and 71%, respectively. The incidences of DMs at 2 and 5 years were 22% and 30%, respectively. In multivariate analysis, vaginal infiltration and lymph node metastasis were predictive of OS, DFS, local recurrence, and DM. Concomitant chemotherapy was predictive of OS, DFS, and local recurrence, and larger tumor (>4 cm) was a significant prognostic factor for local recurrence. None of the patients had toxicity that necessitated the discontinuation of radiotherapy. All patients were evaluable for acute toxicity, and no grade higher than 3 adverse events occurred during external beam radiation therapy or brachytherapy.

Conclusions

Although age limited the delivery of aggressive treatment, concurrent chemoradiotherapy in elderly patients associated with improved outcomes similar as in younger counterparts without increasing serious acute and late toxicities.

Radiation Therapy for Very Elderly Patients Aged 80 Years and Older With Squamous Cell Carcinoma of the Uterine Cervix

OBJECTIVES

We carried out a retrospective review to determine the role played by radiation therapy in the treatment of very elderly patients with uterine cervical cancer.

MATERIALS AND METHODS

Thirty elderly patients aged 80 years and older with squamous cell carcinoma of the uterine cervix, at clinical stages IB-IVA, underwent radiation therapy. Of these 30 patients, 6 received external irradiation alone and 24 received external irradiation and intracavitary brachytherapy. A total median dose of 69.0 Gy (range, 45.6 to 75.4 Gy) was delivered to the cervical tumors. No patients underwent chemotherapy.

RESULTS

At a median follow-up time of 24 months, 7 patients had developed recurrences, including local recurrences in 3 and distant metastases in 5. The local control and distant metastasis-free rates were 88% and 79%, respectively, at 2 years. The disease-free, cause-specific, and overall survival rates were 69%, 77%, and 75%, respectively, at 2 years. Primary tumor size, T category, and clinical stage were found to be significant prognostic factors for distant metastasis. Age and primary tumor size were considered as being significant variables that affected survival. With the exception of a transient hematologic reaction, there were no therapy-related toxicities of grade ≥3.

CONCLUSIONS

Radiation therapy was safe and effective regarding local control of uterine cervical cancer in elderly patients aged 80 years and older, and appeared to contribute to their prolonged survival. Curative radiation therapy should be considered as a viable treatment option, even in very elderly patients.

Quality of life among survivors of early-stage cervical cancer in Taiwan: an exploration of treatment modality differences

PURPOSE

Women with early-stage cervical cancer may experience changes in their quality of life (QoL) due to treatment or to the effects of the cancer. In this study, we examined differences in QoL by treatment modality between women who underwent surgery only and those treated with concurrent chemoradiation (CCRT).

METHODS

The sample of 290 women had been diagnosed with stage I-II cervical cancer. Data were collected on these women's demographic and disease characteristics, general QoL, and cancer-specific QoL using an author-designed demographic-disease survey, the European Organization for Research and Treatment of Cancer QoL questionnaire, and the Taiwanese-version Cervical Cancer Module 24 questionnaire, respectively. Data were analyzed by descriptive statistics and analysis of covariance.

RESULTS

Women with cervical cancer who underwent surgery only had significantly worse constipation and body image than those treated with CCRT. Women who underwent CCRT had worse physical and role functioning than those who underwent surgery only. Women who had CCRT also reported worse symptoms, such as fatigue, appetite loss, diarrhea, financial difficulties, sexual enjoyment, and sexual/vaginal functioning, than those who had only surgery.

CONCLUSIONS

Our results add knowledge about QoL in women with early-stage cervical cancer who receive different treatment modalities. When suggesting treatment modalities for women with cervical cancer, health professionals should also consider changes in women's QoL after cancer treatment. To improve women's QoL after treatment, professionals should also offer timely and individualized interventions based on women's cervical cancer treatment.

[Radiotherapy in elderly patients, recommendations for the main localizations: Breast, prostate and gynaecological cancers]

Modifications of radiotherapy indications or schedules because of age could be discussed in view of a different evolution of the disease or because of specific toxicities. One important aim is to decrease the number of hospital transports. For breast cancer, the rate of local relapse after lumpectomy is lower in old patients; moreover, characteristics of the disease are often more favourable (hormonosensitivity, low grade). However, adjuvant irradiation decreases significantly the incidence of breast relapse and must be systematically proposed. Hypofractionnated schedules must be recommended; limited data are available for accelerated partial breast irradiation in old women and these techniques must not be used in routine. For low or intermediate risk prostate cancer, assessment of comorbidities is crucial before considering any invasive treatment. A life expectancy of at least 10 years is required if a curative approach, potentially toxic is proposed. In this case, radiotherapy is often the good choice, giving less sequelae than surgery. The indication of androgen deprivation must take into account cardiovascular and bone history. Management of gynaecological cancers must follow the same recommendations as in young women. Exclusive postoperative brachytherapy must be recommended in early stage endometrial carcinomas. Brachytherapy must be also systematically integrated in the radiotherapy program for cervix cancers, even in old women.

Major causes of impractical brachytherapy in elderly patients with uterine cervical cancer

AIM

Incomplete brachytherapy is a major risk factor for recurrence. However, high-dose-rate intracavitary brachytherapy has not been assessed adequately in elderly patients with invasive cervical cancer. The present study investigated the clinical importance of intracavitary brachytherapy and risk factors of incomplete intracavitary brachytherapy in elderly patients with cervical cancer.

MATERIAL AND METHODS

Subjects were 76 patients aged 70-89 years old with invasive cervical cancer. All subjects were recruited between January 1997 and September 2010, and were planning to receive external beam radiation therapy followed by high-dose-rate intracavitary brachytherapy. Survival rates and the incidence of complications were compared between the 70s and 80s age groups. Risk factors for recurrence in elderly patients were evaluated using multivariate analysis, and risk factors for impractical intracavitary brachytherapy were also estimated.

RESULTS

No significant differences were observed in 3-year progression-free survival rates or the incidence of complications in the two age groups. Cox multivariate analysis showed that histology (non-squamous cell carcinoma), incomplete intracavitary brachytherapy, and lymph node swelling were significant prognostic factors for recurrence. Impractical application was the major reason for incomplete treatment. Multiple logistic regression analysis revealed that a previous history without vaginal births (P = 0.016) was an independent risk factor for the impractical application, independent of tumor diameter ≥ 4 cm (P = 0.007).

CONCLUSIONS

Incomplete intracavitary brachytherapy decreased the survival rates of elderly patients. Larger tumors and patients without a history of vaginal births were the two major causes of impractical intracavitary brachytherapy, which may be fatal, especially in elderly patients with bulky tumors.