Cancer in the elderly: why so badly treated?

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.

Individualized Dosing Patterns in the Treatment of Older Patients with Gastrointestinal Stromal Tumors: Results of a Registry-Based Observational National Cohort Study Including 871 Patients

BACKGROUND

While the effectiveness of tyrosine kinase inhibitors (TKIs) seems similar in older patients with gastrointestinal stromal tumors (GIST) compared with younger patients, toxicities in older patients treated with TKIs more often lead to discontinuation of treatment.

OBJECTIVE

To better understand the age-related pharmacology and pharmacodynamic differences in patients with GIST treated with TKIs, the primary aim of this study was to evaluate TKI dosing patterns in older patients with GIST, while the secondary aims were to evaluate differences in imatinib trough plasma concentrations between age groups and to compare the overall survival (OS) in patients with and without dose reductions in all treatment lines in a palliative setting.

METHODS

Patients (18 years of age or older) with histologically proven GIST diagnosed between January 2009 and June 2021 and treated with one or more lines of TKIs were selected from the Dutch GIST Registry (DGR) database. Age groups were divided into younger patients (age <70 years) and older patients (age ≥70 years). All imatinib trough plasma concentrations of blood withdrawals taken from initiation of imatinib until a maximum of 1 year of treatment with imatinib were collected. Reasons for first adjustment of treatment were classified as adverse event, dose modification, progressive disease and other reasons. The next treatment steps after first adjustment of treatment were defined as dose escalation, dose reduction, dose interruption, or end of treatment. The association of dose reduction and OS was analyzed using the landmark approach.

RESULTS

Overall, 871 patients were included in this study, including 577 younger patients and 294 older patients. Older patients more often had an adverse event as the reason for first adjustment of treatment with both imatinib (45.6%; p < 0.001) and sunitinib (58.6%; p = 0.224) compared with younger patients (19.5% and 42.7%, respectively). Adjustment of imatinib and sunitinib after starting on a standard dose because of an adverse event most often resulted in dose reduction in both age groups. Median trough plasma concentrations of all samples taken within the first year after initiation of imatinib were higher in older patients (1228 ng/mL, interquartile range [IQR] 959-1687) compared with younger patients (1035 ng/mL [IQR 773-1377]; p < 0.001). No significant differences were seen between OS in patients with or without dose reduction in all treatment lines (imatinib: p = 0.270; sunitinib: p = 0.547; and regorafenib: p = 0.784).

CONCLUSION

Older patients showed higher imatinib trough plasma concentrations compared with younger patients and also had earlier and more often adverse events as the reason for first adjustment of treatment with imatinib followed by dose reduction. However, in a landmark analysis, patients with imatinib dose reductions had no poorer outcomes compared with patients not requiring a dose reduction.

Survival and prognosis of surgical head and neck cancer patients aged 80 years and older

Introduction

Elderly patients (≥80 years of age) with head and neck cancer (HNC) can prove a management challenge due to concerns regarding their suitability for surgery. This study aims to describe the characteristics and outcomes of elderly patients undergoing HNC surgery.

Methods

A retrospective review of elderly patients undergoing HNC surgery was conducted. Demographics, comorbidities, tumor characteristics, surgical procedure type, postoperative complications, and disposition were reviewed. Overall survival (OS) in the elderly cohort was compared against younger patients (<80 years).

Results

A total of 595 patients were included, of whom 86 were aged >80 years (71% male; mean age 84.8, range 80.0-98.8 years). The overall complication rate was 43%. When compared with younger patients (n = 509), elderly patients had reduced OS (risk ratio: 2.0, 95% CI: 1.3-3.2), higher 90-day mortality (8.1% vs. 2.3%, p = .005), and lower 5-year survival (43.5% vs. 64.1%, p < .001). However, survival was comparable to age-specific life expectancy. There was no difference in OS, 90-day mortality, and 5-year survival when comparing >85 (n = 33) and 80-85 (n = 53) age groups.

Conclusions

Chronological age alone should not negatively influence decision-making in HNC surgery the elderly. With careful preoperative selection and optimization, surgery can be performed at acceptable risk with good outcomes in elderly patients.

Level of evidence

IV.

The Gut-Prostate Axis: A New Perspective of Prostate Cancer Biology through the Gut Microbiome

Obesity and a high-fat diet are risk factors associated with prostate cancer, and lifestyle, especially diet, impacts the gut microbiome. The gut microbiome plays important roles in the development of several diseases, such as Alzheimer's disease, rheumatoid arthritis, and colon cancer. The analysis of feces from patients with prostate cancer by 16S rRNA sequencing has uncovered various associations between altered gut microbiomes and prostate cancer. Gut dysbiosis caused by the leakage of gut bacterial metabolites, such as short-chain fatty acids and lipopolysaccharide results in prostate cancer growth. Gut microbiota also play a role in the metabolism of androgen which could affect castration-resistant prostate cancer. Moreover, men with high-risk prostate cancer share a specific gut microbiome and treatments such as androgen-deprivation therapy alter the gut microbiome in a manner that favors prostate cancer growth. Thus, implementing interventions aiming to modify lifestyle or altering the gut microbiome with prebiotics or probiotics may curtail the development of prostate cancer. From this perspective, the "Gut-Prostate Axis" plays a fundamental bidirectional role in prostate cancer biology and should be considered when screening and treating prostate cancer patients.

Frailty in Very Elderly Patients is Not Associated with Adverse Surgical or Oncological Outcomes in Extremity Surgery for Soft Tissue Sarcoma

Background

While surgery remains the mainstay of treatment for limb sarcoma, extreme old age is a relative contraindication to oncological surgery.

Methods

Patients >80 years referred with primary extremity soft-tissue sarcoma (ESTS) between 2007 and 2016 were retrospectively reviewed. Prognostic variables, including ASA status and Clinical Frailty Scores, were collected. Endpoints were perioperative morbidity, locoregional (LRR) and distant recurrence (DR), disease-specific survival (DSS) adjusted using competing risk modelling, and overall survival (OS).

Results

A total of 141 primary tumours were identified, with 116 undergoing resections. Main motives for nonoperative management were severe frailty or significant comorbidity (56.0%). The operative group had a median age of 84 (range 80-96) years and median follow-up of 16 months (range 0-95). 45.7% of patients received radiotherapy. Median hospital stay was 7 (range 0-40) days, with frailty (p = 0.25) and ASA (p = 0.28) not associated with prolonged admission. 12.9% developed significant complications, with one perioperative mortality.

24.1% had LRR, occurring at a median of 14.5 months. All patients with reported DR (28.4%), except one, died of their disease. Frailty did not confer a significant difference in adjusted LRFS (p = 0.95) and DMFS (p = 0.84). One- and 5-year adjusted DSS and OS was 87.0% versus 74.9% and 62.3% versus 27.4%, respectively. Frailty (CFS ≥4) was associated with worse OS (hazard ratio [HR] 2.49; 95% confidence interval [CI] 1.51-4.12; p < 0.001), however not with adjusted DSS (p = 0.16). Nonoperative management conferred a 1- and 5-year adjusted DSS was 58.3% and 44.4%, respectively.

Conclusions

Extremity surgery for sarcoma is well tolerated in the frail very elderly population with low morbidity and comparable oncological outcomes.

Outcomes of soft-tissue sarcoma in nonagenarians

AIMS

Current literature suggests that survival outcomes and local recurrence rates of primary soft-tissue sarcoma diagnosed in the very elderly age range, (over 90 years), are comparable with those in patients diagnosed under the age of 75 years. Our aim is to quantify these outcomes with a view to rationalizing management and follow-up for very elderly patients.

METHODS

Retrospective access to our prospectively maintained oncology database yielded a cohort of 48 patients across 23 years with a median follow-up of 12 months (0 to 78) and mean age at diagnosis of 92 years (90 to 99). Overall, 42 of 48 of 48 patients (87.5%) were managed surgically with either limb salvage or amputation.

RESULTS

A lower overall local recurrence rate (LRR) was seen with primary amputations compared with limb salvage (p > 0.050). The LRR was comparable between free (R0), microscopically (R1), and macroscopically positive (R2) resection margins in the limb salvage group. Amputation was also associated with longer survival times (p < 0.050). Overall median survival time was limited to 20 months (0 to 80).

CONCLUSION

Early and aggressive treatment with appropriate oncological surgery confers the lowest LRR and a survival advantage versus conservative treatment in this cohort of patients. With limited survival, follow-up can be rationalized on a patient-by-patient basis using alternative means, such as GP, local oncology, and/or patient-led follow-up. Cite this article: Bone Joint J 2022;104-B(1):177-182.

Multimodality treatment of undifferentiated pleomorphic soft tissue sarcoma of the extremity (eUPS) in the elderly

INTRODUCTION

This subgroup analysis of undifferentiated pleomorphic soft tissue sarcoma of the extremity (eUPS) from the PERSARC collaborative group aimed to achieve a more personalized multimodality treatment approach for primary eUPS in elderly patients.

MATERIAL AND METHODS

A multicenter retrospective study including primary high-grade eUPS surgically treated with curative intent between 2000 and 2016. Overall survival (OS), local recurrence (LR) and distant metastasis (DM) curves were calculated by Kaplan Meier analysis. Cox proportional hazard models were used to determine the effect of radiotherapy.

RESULTS

From a total of 2511 patients with extremity soft tissue sarcoma (eSTS) of the PERSARC study collaborative; 703 patients with eUPS were included in this study. In elderly patients with eUPS 5-year OS, LR and DM were 35.4 (95%CI 29.3-42.8), 17.7 (95%CI 12.7-22.6) and 24.6 (95%CI 19.1-30.1). eUPS was significantly less treated with radiotherapy compared with other eSTS, especially in elderly patients. Patients with R1-R2 margins treated with radiotherapy had about half the risk of developing LR compared with patients treated without radiotherapy (HR = 0.454, p = 0.033).

CONCLUSION

Elderly patients with eUPS were less often treated with radiotherapy and showed higher LR. Nowadays, given an increasing life expectancy in elderly patients, multimodality treatment should be considered.

Functional decline after surgery in older patients with head and neck cancer

INTRODUCTION

In addition to classical endpoints such as survival and complication rates, other outcomes such as quality of life and functional status are increasingly recognized as important endpoints, especially for elderly patients. However, little is known about the long-term effect of surgery with regard to these other outcomes. Our aim is to investigate the functional status and self-reported health status of patients ≥ 70 years one year after surgery for head and neck cancer.

METHODS

We present one-year follow-up data of patients ≥ 70 year who underwent surgery for HNC. During an interview by telephone, functional status was evaluated by using the Katz-15 Index of Independence questionnaire including six items covering basic Activities of Daily Living (ADL) and nine items covering Instrumental Activities of Daily Living (IADL). Measurements were compared with those obtained preoperatively.

RESULTS

In total, 126 patients were included and eventually we collected follow-up data of 68 patients. There was a statistically significant decrease in functional status on the total Katz-15 and on the IADL questionnaire scores one year after surgery (mean 1.34 versus 2.42,p-value 0.00 and mean 1.21 versus 1.94,p-value 0.00). There was no significant change concerning ADL dependence (p-value 0.18) and cognitive status (p-value 0.11). The self-reported health status improved postoperatively, although not statistically significantly so (mean 67.36 versus 71.25,p-value 0.12).

CONCLUSION

Approximately-one year after surgery for HNC, there is a significant decline in functional status indicating a higher level of dependency.

Safe Free Tissue Transfer in Patients Older than 90 Years

Objective This study aimed to evaluate the safety of microvascular free tissue transfer in the elderly patient population.

Methods We performed a 20-year retrospective review at a tertiary care private practice of patients of ≥ 90 years of age who underwent microvascular free tissue transfer and had at least 6 months of follow-up. Similarly, we reviewed patients aged 70 to 89 years who underwent free tissue transfer between 2018 and 2020 as a control group. Records were examined for type of flap, defect site, pathology, and occurrence of complications.

Results Overall 77 patients of 90 years or older met the inclusion criteria and 77 sequential patients aged 70 to 89 years were identified to serve as a control group. The overall complication rate among patients of ≥ 90 years of age was 18%, with flap-related complications in 4% (two partial flap loss and one total loss). The mortality rate was 1.3%. All patients of ≥ 90 years of age undergoing osteocutaneous reconstruction for osteoradionecrosis experienced complications, but only one was a flap complication (partial loss). Among patients aged 70 to 89 years, the overall complication rate was also 18%, with flap-related complications in 4% (two complete flap failures and one partial loss). The mortality rate in the control group was 2.6%.

Conclusion Soft tissue free flaps are a safe option in the elderly patient population and should be offered to patients who are medically optimized prior to surgery, regardless of age. Osteocutaneous reconstruction for osteoradionecrosis must be undertaken with caution. This study reflects level of evidence 4.

Major head and neck surgeries in the elderly population, a match-control study

BACKGROUND AND OBJECTIVES

To investigate complication rates in elderly cancer patients undergoing major head and neck surgeries.

METHODS

A retrospective, matched-control, analysis. For each elderly (≥70 years) patient, a younger, (<70 years) patients were matched based on sex, tumor location, disease stage, and operation time. Post-operative complication and survival analyses were performed.

RESULTS

Of 225 patients, 75 (33.3%) were elderly (mean age 76.2 (70-88) years) and compared with a match control group (53.2 (23-69) years). A higher rate of cardio-vascular comorbidity was noted in the elderly group (70.6% vs. 34%, respectively, P < 0.001). The majority (62.7%) of elderly patients required reconstruction with 24% receiving vascularized flap reconstruction. Total postoperative complication rate was 49.9% in the study versus 42.3% in the control group, with a major complication rate of 22.5% in the elderly versus 11.9% in the control group (P = 0.154). Mean follow-up was 41 (0-144) months. Five-year disease-specific (67.1% vs. 80.7%, P < 0.001) and overall survival rates (48.6% vs. 75.4%, P < 0.001) were significantly lower among elderly patients.

CONCLUSIONS

Major head and neck surgery in the elderly population does not entail higher complication rate, compared with younger patients, and should be allowed when curative intent is feasible and patient's general condition allows.

Oncologic Outcomes Following Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Carcinoma in Older Patients

Importance

While early epidemiologic studies ascribed increases in the incidence of human papillomavirus-associated oropharyngeal cancers to middle-aged patients, recent analyses have demonstrated an increasing median age of diagnosis. Treatment of patients older than 70 years is controversial as their inclusion in the practice-defining clinical trials has been limited and the survival benefit conferred by chemotherapy may be outweighed by treatment toxic effects.

Objective

To assess the oncologic outcomes of older adults with human papillomavirus-associated oropharyngeal cancer who underwent upfront transoral robotic surgery and pathologic characteristics-guided adjuvant therapy in a large cohort of patients with close follow-up.

Design, Setting, and Participants

A retrospective cohort analysis was conducted in a tertiary care academic medical center between January 1, 2010, and December 30, 2017. Patients aged 70 years or older at time of diagnosis with biopsy-proven and surgically resectable p16-positive oropharyngeal cancers were included. Data analysis was conducted from March 1 to June 1, 2020.

Exposures

Transoral robotic surgery oropharyngeal resection and neck dissection with pathologic characteristic-guided adjuvant therapy.

Main Outcomes and Measures

Three-year estimates of disease-specific survival, overall survival, and disease-free survival, as well as rates of adjuvant therapy (radiotherapy and chemoradiotherapy) and perioperative complications.

Results

Seventy-seven patients were included (median age, 73.0; interquartile range, 71.0-76.0; range, 70-89 years); of these, 58 were men (75.3%). Perioperative mortality was 1.3% and the rate of oropharyngeal hemorrhage was 2.6%. Twenty-seven patients (35.1%) underwent postoperative radiotherapy and 20 patients (26.0%) underwent postoperative chemoradiotherapy. The median length of follow-up was 39.6 (range, 0.1-96.2) months, and the 3-year estimates of survival were 92.4% (95% CI, 82.4%-96.9%) for disease-specific survival, 90.0% (95% CI, 79.4%-95.0%) for overall survival, and 84.3% (95% CI, 73.4%-91.0%) for disease-free survival.

Conclusions and Relevance

The findings of this cohort study suggest that transoral robotic surgery and pathologic characteristic-guided adjuvant therapy can provide beneficial survival outcomes, infrequent perioperative mortality, and, for most carefully selected older adults, obviate the need for chemotherapy.

Male breast cancer: a closer look at patient and tumor characteristics and factors that affect survival using the National Cancer Database

OBJECTIVE

To comprehensively describe the tumor and clinical characteristics of breast cancer in a cohort of male patients and to assess the factors that affect survival.

BACKGROUND

Much of the standard care of male breast cancer is based on the diagnosis and treatment strategies of female breast cancer. However, important clinical differences between the two have been elucidated, which suggests the need for unique attention to male breast cancer.

METHODS

We evaluated the records of male patients who were diagnosed with breast cancer between 2004 and 2015 using the National Cancer Database (NCDB). Data obtained were demographic characteristics, clinical and tumor data, type of therapy, as well as survival data. We used descriptive statistics to characterize our study population. We then performed a survival and Cox proportional hazards analysis.

RESULTS

We identified 16,498 patients (median age: 63 years). Several treatment modalities were used, of which surgery was the most common (14,882 [90.4%]). The total follow-up time was 13 years (156 months). Five-year survival was 77.7% (95% CI 76.9-78.4) and 10-year survival was 60.7%. In a Cox proportional hazards model, mastectomy was associated with the greatest survival (hazard ratio [HR] 0.49; p < 0.001).

CONCLUSION

We report what is to our knowledge the largest national population-based cohort of male breast cancer patients. Importantly, our data suggests that similar to female patients, several treatment modalities are significantly associated with improved survival in male patients, particularly surgery. Increasing age, black race, government insurance, more comorbidities, and higher tumor stages are associated with decreased survival.

Survival outcomes with concomitant chemoradiotherapy in older adults with oropharyngeal carcinoma in an era of increasing human papillomavirus (HPV) prevalence

BACKGROUND

Human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has dramatically increased in incidence and prevalence among patients aged 70 and older. There are virtually no data regarding outcomes in this population, and thus optimal therapy, including the role of chemotherapy for those undergoing radiotherapy (RT), remains unclear.

METHODS

The National Cancer Database was queried for older adults (defined as age 70 years and older) with locally advanced OPSCC (cT1-2N1-3, cT3-4N0-3) diagnosed from 2010 to 2014 with known HPV-status undergoing definitive RT alone or chemoradiation (CRT).

RESULTS

Overall, 1,965 older adults with locally advanced OPSCC met inclusion criteria, including 1,141 HPV-positive (58%) and 824 HPV-negative (42%) patients. 1,211 patients (62%) received CRT. In multivariable analysis, CRT was associated with improved survival in older patients when compared to RT alone (hazard ratio [HR] = 0.74, 95% confidence interval [CI] 0.64-0.86, P < 0.001). CRT was associated with improved survival in both HPV-positive (HR = 0.80, 95% CI: 0.64-1.00, P = 0.05) and HPV-negative (HR = 0.69, 95% CI: 0.56-0.85, P < 0.001) subgroups. There was no significant interaction between HPV status and the impact of CRT on survival (P interaction = 0.57).

CONCLUSIONS

Despite the radiosensitivity of HPV-positive OPSCC and the challenges in delivering CRT to older adults, CRT was associated with improved survival in older patients with HPV-positive OPSCC, similar in magnitude to the benefit in HPV-negative patients. As the incidence of HPV-positive OPSCC in older patients continues to increase, further studies are needed to investigate optimal therapeutic strategies in this population.

Rising to the medication's requirements: The experience of elderly cancer patients receiving palliative chemotherapy in the elective oncogeriatrics field

A new subfield of oncology has emerged in the last twenty years to raise awareness and address the specific needs of elderly cancer patients, a population that was long neglected in oncology. We sought to understand the individual experiences, as well as moral and social implications of considering elderly cancer patients as "treatable". Following an anthropological critical interpretative approach focusing on practical and symbolic effects of chemotherapy in a rapidly evolving medical field, we conducted 20 semi-structured interviews and observations of medicine storage places at home among elderly cancer patients aged 70 and over in a clearly incurable situation receiving palliative chemotherapy. We used photographs representing paths as triggers in interviews, and compared the patients' views with those of 12 health professionals in oncology during a brief open-ended interview. Elderly cancer patients consider themselves to be survivors and fighters. Their long trajectory is a result of their successful struggle and tolerance of the treatments allowing them to carry on. They continually observe their physical ability and test their resistance, they resist complaining and are grateful to have cancer at a late stage of life. By highlighting their active life rather than the treatment inconveniences, they show they are "young elderly" persons, capable of keeping active physically. They are treated precisely because they demonstrated that they had the physical and moral capacity to take the hit of the chemotherapy to their bodies and had the will to fight. The development of oncogeriatrics has enabled the treatment of the fittest cancer patients over 70, but the ethical debate to treat some elderly patients and not others, and decisions of therapeutic abstention facing frail elderly cancer patients remains an issue rarely discussed. This aspect should not be eluded by the important progress achieved in medicine facing cancer.

The Impact of Epidemiological Factors and Treatment Interventions on Survival in Patients With Signet Ring Cell Carcinoma of the Pancreas

OBJECTIVES

Primary pancreatic signet ring cell carcinoma (SRCC) is a rare histologic variant of pancreatic carcinoma. A population-based analysis of pancreatic SRCC was performed to determine the predictive effects of epidemiological factors and treatment interventions on overall survival (OS) and disease-specific survival (DSS).

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results registry was searched for pancreatic SRCC cases diagnosed between January 1, 1973 and December 31, 2013. Statistical analysis was performed using the Fisher exact test, χ(2) analysis, Kaplan-Meier method, log-rank test, and Cox proportional hazards regression.

RESULTS

The mean age among 497 patients was 66.6 years (SD, 11.9). Most patients were white (82.7%) and male (54.5%). The 1-, 2-, and 5-year OS rates were 17%, 9%, and 4%, respectively, while the corresponding 1-, 2-, and 5-year rates for DSS were 18%, 10%, and 5%, respectively. On univariable analysis; age, site, grade, stage, and treatment were predictive of OS and DSS (P<0.05). On multivariable analysis; radiation improved OS and DSS (adjusted hazard ratio [aHR], 0.592 and 0.589, respectively), pancreatectomy improved OS and DSS (aHR, 0.360 and 0.355, respectively), and combination therapy improved OS and DSS (aHR, 0.295 and 0.286, respectively). Age, site, and stage were also independent predictors of OS and DSS. Subgroup analysis demonstrated treatment to be an independent predictor of OS and DSS in localized/regional disease, in distant disease, and in patients diagnosed between 2000 and 2013.

CONCLUSIONS

Age, site, stage, and treatment independently predict OS and DSS in pancreatic SRCC.

Free Flaps for Advanced Oral Cancer in the "Older Old" and "Oldest Old": A Retrospective Multi-Institutional Study

Introduction: Surgery followed by adjuvant therapy represents the most adequate treatment for advanced oral squamous cell carcinoma (OSCC). Free flaps are considered the best reconstructive option after major oral surgery. In the last decades, OSCC has increased in the elderly due to an augmented life span. The aim of this work is to evaluate the feasibility of microvascular surgery in patients older than 75 years, focusing on clinical and surgical prognosticators.

Methods: “Older old” (aged ≥ 75) and “oldest old” (>85) patients who underwent microvascular reconstruction for OSCC from 2002 to 2018 were retrospectively evaluated in three referral Head and Neck Departments. Demographic, clinical, and surgical data were collected and analyzed. Pre-operative assessment was performed by ASA and ACE-27 scores. Complications were grouped as medical or surgical, and major or minor according to the Clavien-Dindo scale.

Results: Eighty-four patients (72 “older old” and 12 “oldest old”) were treated with a free flap success rate of 94.1%. Thirty-seven (44.7%) and nine (10.7%) patients had minor and major medical complications, respectively; 18 (21.4%) and 17 (20.2%) had minor and major surgical complications, respectively. Twenty-one (25%) patients had both medical and surgical complications (with a statistically significant association, p = 0.018). Overall, 52 (61.9%) patients had at least one complication: ASA score, diabetes mellitus, and duration of general anesthesia (DGA) significantly impacted the complication rate at multivariate analysis.

Conclusion: Our data confirm the feasibility of free flaps for OSCC reconstruction in appropriately selected elderly patients. Pre-operative assessment and aggressive management of glycemia in patients with diabetes is mandatory. DGA should be reduced as much as possible to prevent post-surgical complications. Comprehensive geriatric assessment is of paramount importance in this subset of patients.

Elderly Patients with Advanced Head and Neck Carcinoma: Does Aggressive Treatment Result in Better Outcomes?

OBJECTIVE

There are no well-defined treatment recommendations for elderly patients with advanced head and neck squamous cell carcinoma. This study aimed to investigate whether aggressive treatment among the elderly translated into better survival outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary institution.

SUBJECTS AND METHODS

Elderly patients (≥60 years) with advanced-stage head and neck squamous cell carcinoma (stage III and IV) treated between January 1991 and May 2014 were reviewed. According to current National Comprehensive Cancer Network guidelines, they were classified to have received standard or substandard treatment. Overall survival (OS), locoregional recurrence-free survival, and distant recurrence-free survival were evaluated.

RESULTS

A total of 355 patients were treated curatively: 194 with up-front surgery and 161 with radiotherapy or concurrent chemotherapy and radiotherapy. Median OS was higher among patients who received standard treatment (42.0 vs 16.0 months, P < .001). On multivariate analysis, standard treatment showed superior OS ( P < .001). Use of substandard treatment showed a hazard ratio of 2.09 (95% CI, 1.59-2.74) for poorer OS.

CONCLUSION

Aggressive standard treatment protocols should be advocated for elderly patients, where comorbidities permit, as they confer better outcomes.

Limited resection in clinical stage I non-small cell lung cancer patients aged 75 years old or more: a meta-analysis

Background

This study aims to compare perioperative and oncologic efficacy of limited resection with lobectomy in clinical stage I non-small cell lung cancer (NSCLC) patients ≥75 years old.

Methods

A systemic search of database including PubMed, OVID and Cochrane was carried out to identify the potential relevant studies published. Data extracted were analyzed with Revman 5.1.

Results

5,304 citations were identified by the electronically search. A total of 3,461 patients were included, of whom 1,323 received limited resection and 2,139 received lobectomy. There was higher postoperative complication ratio after lobectomy (32.93% vs. 23.87%, RR =0.71; 95% CI, 0.54-0.93; P=0.01). There were similar total recurrent (18.56%, RR =1.15; 95% CI, 0.82-1.61; P=0.43), and distant recurrent ratio (16.17%, RR =0.67; 95% CI, 0.43-1.05; P=0.08) between groups. Lower local-regional recurrent ratio (2.40%, RR =4.31; 95% CI, 1.98-9.39; P<0.001) was observed after lobectomy. Compared with lobectomy, patients received limited resection showed poorer overall survival (HR =1.24; 95% CI, 1.07-1.44; P=0.004) and lung cancer specific survival (HR =1.37; 95% CI, 1.14-1.64; P<0.001).

Conclusions

This analysis showed superior lung cancer specific survival, and overall survival after lobectomy over limited resection for clinical stage I NSCLC patients aged ≥75 years old. Our results confirmed that lobectomy should be considered in aged patients if tolerable.

Clinician-observed and patient-reported toxicities and their association with poor tolerance to therapy in older patients with head and neck or lung cancer treated with curative radiotherapy

OBJECTIVES

The agreement between clinician- and patient-reported toxicities and their association with poor tolerance to therapy were assessed in an older population receiving curative radiotherapy (RT).

MATERIALS AND METHODS

Patients ≥ 65 years old with newly-diagnosed head and neck or lung cancer receiving curative RT ± chemotherapy were enrolled on a prospective, observational study. Agreement between clinician (CTCAEv4.02) and patient (PRO-CTCAE, EORTC QLQ-C30) report of toxicities were assessed at baseline, during treatment, and post-treatment. The association of clinician- and patient-reported symptoms with poor tolerance to therapy (defined as hospitalization, >3-day treatment delay, change in treatment regimen, or death) was assessed.

RESULTS

Among 45 patients, median age was 71, 60% had head and neck cancer, and 47% received concurrent chemotherapy with RT. In comparing CTCAE vs PRO-CTCAE, there was good agreement at baseline except for fatigue, anorexia, and pain, where clinicians under-reported the severity. The discrepancy increased during treatment with clinicians reporting lower severity in ≥50% of matched pairs for 4/10 symptoms assessed. At follow-up, clinicians under-reported severity in ≥50% of pairs for 7/10 symptoms. CTCAE vs EORTC QLQ-C30 mirrored these findings. Patient-reported symptoms of nausea and dysphagia at 2 weeks and clinician-observed symptoms of nausea and dysphagia at 4 weeks were associated with poor tolerance to therapy.

CONCLUSION

Clinicians under-report toxicities during and after curative RT in older patients with head and neck or lung cancer. Select toxicities reported by patients early in treatment and clinicians later in treatment were associated with poor tolerance to cancer therapy, providing valuable complementary information.

Pattern and Determinants of Diagnostic Interval in Cancers of the Prostate, Bladder and Kidney

The present study examined the pattern of presentation and diagnostic interval, i.e. number of months between first cancer symptom or sign and first medical visit, in 444 cases of urological cancer (122 of prostate cancer, 187 of bladder cancer and 135 of kidney cancer). The mean diagnostic interval was 7.6 months for prostate, 5.6 for bladder and 4.5 kidney cancer. A chance diagnosis, i.e. in absence of any symptom or sign, was reported by 16%, 8% and 18% of patients with cancer of the prostate, bladder and kidney respectively. We observed on significant differences in diagnostic intervals according to patients’ demographic, sociocultural, and lifestyle characteristics, or tumor stage. Better quantitative and qualitative data on the pattern and determinants of delay in cancer diagnosis are clearly warranted, and the present study, although largely negative, shows the possibility of using large-scale epidemiological Investigations for this purpose.

Single-Agent Irinotecan as Second-Line Weekly Chemotherapy in Elderly Patients with Advanced Colorectal Cancer

Aims and background

Irinotecan is a standard option for relapsed/refractory advanced colorectal cancer. Although in a recently reported, randomized trial it was found that a regimen of irinotecan once every 3 weeks was associated with a lower incidence of severe diarrhea than with weekly treatment with similar efficacy, there is no evidence in the literature that suggests the optimal dosing strategy for the drug, along with treatment efficacy and safety, following 5-fluorouracil/oxaliplatin-based chemotherapy in elderly patients. A phase II study has reported significantly reduced toxicity when irinotecan was administered once a week for 2 weeks, followed by a week rest.

Patients and methods

From January 2004 to April 2005, we analyzed, retrospectively, our data on single-agent irinotecan as a second-line chemotherapy in elderly patients (≥70 years) with advanced colorectal cancer. Twenty-three patients were evaluated. CPT-11 (80 mg/m2) was given as a 60-min intravenous infusion in repeated 21-day courses comprising weekly treatment for 2 consecutive weeks followed by a 1-week rest. Tumor measurements were obtained after every third course of therapy. Toxicity was assessed weekly using the National Cancer Institute Common Toxicity Criteria, version 2.

Results

The median number of treatment courses received per patient was 4 (range, 1–8). All patients were assessable for toxicity and 21 for response. The most frequently observed severe toxicities were diarrhea (grade 3, 13%) and neutropenia (grade 3, 30.4%; grade 4, 8.6%). Only 1 case of neutropenic fever occurred. Other hematological and non-hematological toxicities were mild and manageable. Objective partial responses were observed in 3 patients (13%). An additional 10 patients (43%) had stable disease as their best response. To date, 12 patients have progressed with a median time-to-progression of 4.3 months and a median survival of 8.3 months.

Conclusions

A weekly irinotecan administration can induce tumor control in elderly patients with advanced colorectal cancer that has progressed during or shortly after 5-fluorouracil/oxaliplatin-based chemotherapy. However, a careful monitoring of hematological toxicity and special instructions to prevent and manage diarrhea are mandatory in this setting of patients.

Cancer Patient Survival in the Elderly in Italy

Aims and background

Italy, like most western populations, is sharply aging and changing its age structure with a striking increase in the oldest segment of the elderly. Since age is related to an exponential growth of cancer incidence rates and to a worsening of prognosis, the progressive aging of the population will constitute, in the future, an issue increasingly more important for public health. The present study is the first effort to present and analyze survival rates in Italian elderly cancer patients in order to provide a starting point for the development of better clinical strategies addressed to the aged.

Materials and methods

The presented data come from a large data set consisting of survival data relating to 25,798 men and 20,479 women, aged 65–84 years at diagnosis, collected by Italian cancer registries participating in the ITACARE project. Relative survival rates of patients have been calculated by sex, quinquennial age classes and the considered entire age class for overall malignant neoplasms and the 10 most frequent cancer sites in the elderly.

Results

When all Italian data for all cancers in the 65–84 year age group were pooled, survival rates at 5 years from the diagnosis was 27% and 39% in men and women, respectively. As regards specific sites, survival rates below 50% were observed for lung, stomach and ovary cancer at 1 year from diagnosis. At 5 years from diagnosis, the rates were less than 50% for colon, prostate, cervix, multiple myeloma, non-Hodgkin's lymphoma and melanoma (only in men). The best survival at 5 years from diagnosis (above 50%) was in women for melanoma and corpus uteri and breast cancer. For all cancers, the prognosis for women was better in each considered age group even though a dramatic decrease in survival with age was observed in both sexes. In general, a similar decline in survival with increasing age characterized all considered specific sites. However, at closer observation, the patterns of a decrease revealed some differences. The ratio between the survival rates of 55–64 vs 65–84 year age class indicated that the sites with the greatest advantage of survival for younger patients (ratio >1.5) were ovary, lung and melanoma (only in men), whereas the least advantage was observed for colon, corpus uteri, breast and prostate. By calendar periods, excluding non-Hodgkin's lymphoma for women, an increase in survival was observed for all considered sites, improving an encouraging successful trend in diagnostic and therapeutic progresses.

Age-related Differences in Patients Admitted to a Palliative Home Care Service

Aims

The aim of the study was to investigate possible differences in access to the service, symptomatology and therapy in relation to age among terminal cancer patients admitted to a home care program. We examined prospectively all 116 terminal cancer patients enrolled in a home care program in 1998, comparing those up to 70 years of age (48 patients) with those above 70 (68 patients). We also compared the age-related characteristics of this population with those of all 348 patients enrolled in the program in 1989-1991. There were no significant differences between the two age groups of the 1998 population in terms of symptoms, tumor site or medication, although NSAID use tended to be greater in older patients, and opioid and anti-emetic use greater in younger patients. Patients up to 70 years of age had significantly shorter survival from admission to home care than those over 70, and a greater proportion had metastases. There were no such significant age-related differences as regards survival and the presence of metastases in patients enrolled 10 years before. In conclusion, among terminally ill cancer patients referred to a palliative home care service in Milan, mostly treated at the National Cancer Institute, the 10-year admission trend showed that palliative care is made available increasingly later, particularly to those up to 70 years of age, in contrast to current recommendations.

Management of head and neck cancer in older patients

OBJECTIVE

A progressive increase in the number of older patients with head and neck cancer has been observed in the last few years. The aim of this study was to assess our experience in the management of older patients with head and neck cancer (HNC) in comparison with younger patients.

STUDY DESIGN

A retrospective review was conducted for all patients admitted and treated for newly diagnosed HNC between January 2008 and December 2012. The clinical characteristics, management approaches, and outcome data were recorded.

RESULTS

In total, 316 patients with HNC (232 males, 84 females) were enrolled: 203 (64%) were in the young group, whereas 113 patients (36%) were in the older group. Comorbidities (P < .000005) and stage IV tumors (P < .0005) were more frequently observed in the older group. Treatment options were uniformly distributed within the 2 groups; only radiotherapy alone was more frequently administered in older patients (P < .0005).

CONCLUSIONS

Chronologic age should not be a reason to deny appropriate treatments that could prevent death in older patients. A careful pretreatment assessment should always be performed.

Outcomes of Craniofacial Open Surgery in Octogenarians

Introduction  The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods  We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results  A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80-89), and the male-to-female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions  Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Prediction of mortality and morbidity in head and neck cancer patients 80 years of age and older undergoing surgery

OBJECTIVES

To determine postoperative complications and mortality rates in octogenarian and older head and neck cancer patients undergoing ablative surgical resections and to identify factors associated with postoperative morbidity and mortality.

METHODS

Retrospective cohort study investigating risk factors for 30-day serious complication risk and 90-day mortality risk for patients aged 80 years and older who underwent ablative head and neck oncologic surgical procedures at an academic tertiary care center between 2005 and 2015.

RESULTS

Of the 219 patients who underwent 241 surgeries, 74 patients experienced serious complications within 30 days and 25 died within 90 days of surgery. American Society of Anesthesiologists (ASA) score of 4 or greater, and operating room (OR) time ≥6 hours were independently associated with serious complications, whereas age ≥90 years, overall severe comorbidity score, presence of preoperative dysphagia, and large extent of resection were associated with increased risk of death in 90 days. Models to predict risk of 30-day serious complications and 90-day mortality were then developed.

CONCLUSION

Patient and surgical treatment factors predict risk of serious complications and mortality in patients aged 80 years and older undergoing ablative head and neck surgery. Predictive models may guide preoperative discussion with patients.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:871-877, 2018.

Free flap reconstruction for patients aged 85 years and over with head and neck cancer: clinical considerations for comprehensive care

We aimed to identify and evaluate the clinical challenges involved in microvascular flap reconstructions of defects caused by resection of head and neck cancer among patients aged 85 and over. We designed a retrospective study of patients who were treated in the head and neck department of a tertiary referral centre from 2005 to 2015, and all patients aged 85 years and over who had reconstructions with microvascular flaps for head and neck cancer were entered into the study. A total of 24 patients fulfilled the criteria, of whom 15 were men and nine were women. The median (range) duration of stay in hospital was 23 (14-59) days. Eighteen patients had an American Society of Anesthesiologists (ASA) score grade II and six patients grade III. The median (range) operating time was 420 (310-705)minutes, and operative blood loss 550 (200-1500)ml. Sixteen patients had prophylactic tracheostomies, nine of whom developed postoperative surgical complications, seven associated with the tracheostomy (p=0.005). Resections of head and neck cancer and microvascular reconstructions in patients aged 85 and over are associated with a high incidence of postoperative complications. Medical complications tend to be associated with the tracheostomy while surgical complications are potentially associated with the ASA score. Although the morbidity is high, complex resections and microvascular reconstructions are successful with optimum recovery, and age did not seem to influence the outcome. However, it is necessary to avoid prophylactic tracheostomy if possible in these patients.

External-beam radiation therapy combined with limb-sparing surgery in elderly patients (>70 years) with primary soft tissue sarcomas of the extremities : A retrospective analysis

PURPOSE

To report our experience with EBRT combined with limb-sparing surgery in elderly patients (>70 years) with primary extremity soft tissue sarcomas (STS).

METHODS

Retrospectively analyzed were 35 patients (m:f 18:17, median 78 years) who all presented in primary situation without nodal/distant metastases (Charlson score 0/1 in 18 patients; ≥2 in 17 patients). Median tumor size was 10 cm, mainly located in lower limb (83%). Stage at presentation (UICC7th) was Ib:3%, 2a:20%, 2b:20%, and 3:57%. Most lesions were high grade (97%), predominantly leiomyosarcoma (26%) and undifferentiated pleomorphic/malignant fibrous histiocytoma (23%). Limb-sparing surgery was preceded (median 50 Gy) or followed (median 66 Gy) by EBRT.

RESULTS

Median follow-up was 37 months (range 1-128 months). Margins were free in 26 patients (74%) and microscopically positive in 9 (26%). Actuarial 3‑ and 5‑year local control rates were 88 and 81% (4 local recurrences). Corresponding rates for distant control, disease-specific survival, and overall survival were 57/52%, 76/60%, and 72/41%. The 30-day mortality was 0%. Severe postoperative complications were scored in 8 patients (23%). Severe acute radiation-related toxicity was observed in 2 patients (6%). Patients with Charlson score ≥2 had a significantly increased risk for severe postoperative complications and acute radiation-related side effects. Severe late toxicities were found in 7 patients (20%), including fractures in 3 (8.6%). Final limb preservation rate was 97%.

CONCLUSION

Combination of EBRT and limb-sparing surgery is feasible in elderly patients with acceptable toxicities and encouraging but slightly inferior outcome compared to younger patients. Comorbidity correlated with postoperative complications and acute toxicities. Late fracture risk seems slightly increased.

Prognostic Factors in Stage III Non-Small-Cell Lung Cancer Patients

Aim: The objective of this study is to investigate prognostic factors affecting survival of patients undergoing concurrent or sequential chemoradiotherapy (CRT) for stage III non-small-cell lung cancer (NSCL). Methods and materials: We retrospectively reviewed the clinical records of 148 patients with advanced, inoperable stage III NSCLC, who were treated between 2007 and 2015. Results: The median survival was found to be 19 months and 3-year overall survival was 27%. Age (<65 vs ≥65 years, p=0.026), stage (IIIA vs IIIB, p=0.033), dose of radiotherapy (RT) (<60 vs ≥60 Gy, p=0.024) and treatment method (sequential chemotherapy+RT vs concurrent CRT , p=0.023) were found to be factors affecting survival in univariate analyses. Gender, histological subtype, weight loss during CRT, performance status, induction/consolidation chemotherapy and presence of comorbidities did not affect survival (p>0.050). Conclusion: Young age, stage IIIA, radiotherapy dose and concurrent chemoradiotherapy may positively affect survival in stage III NSCL cases.

Older patients' experiences of pre-treatment discussions: An analysis of qualitative data from a study of colorectal cancer

It has been suggested that cancer in the elderly is badly treated and that criteria other than chronological age should form the basis for treatment decisions. A study was conducted to discover whether there were age-related differences in the treatment received by a sample of older people with colorectal cancer, and to determine whether any differences were related to patterns of functional status. It was recognised that involvement in treatment decisions may be influenced by contextual factors, therefore additional qualitative data were collected from patients themselves.

Responses to semi-structured questions from 337 patients aged 58-95 years were analysed in the light of previous research, which suggests that only a minority want to share equally in medical decision-making with clinicians. Our aim was to determine whether a similar pattern was apparent in patients' responses, and to develop understanding of the determinants of involvement in treatment decision-making.

The analysis suggests that patients often lack a sense of agency in the face of disease- and treatment-related events, and that many do not believe they possess the relevant knowledge or authority to act positively in these circumstances. Concerns remain about the losses involved in taking a dependent approach and about the extent to which resisting dependency is possible.

Worse Survival in Elderly Patients with Extremity Soft-Tissue Sarcoma

BACKGROUND

Nearly half of soft-tissue sarcoma (STS) patients are over the age of 65, and the behavior of cancer in these elderly patients is poorly understood. The aim of this study was to assess the impact of age, sarcoma histotype, grade, stage, and treatment modalities on survival of extremity STS (ESTS) patients.

METHODS

Patients ≥18 years diagnosed with ESTS between 1989 and 2008 were selected from the Netherlands Cancer Registry. Survival rates and patient and treatment characteristics were analyzed for all patients. Relative survival and relative excess risk of death were estimated for young (<65 years) and older (>65 years) patients.

RESULTS

Overall, 3066 patients were included in this study. Histotype was different between young (<65 years) and elderly (>65 years) patients (p < 0.001). Patients over the age of 65 were more often diagnosed with high-stage ESTS and an increasing proportion of high-grade ESTS (p < 0.001). The proportion of patients who received no treatment increased with age, and the elderly received fewer combined-modality treatments. Age was significantly associated with relative 5-year survival [72.7 % for younger patients and 43.8 % for the oldest elderly (>85 years)]. In multivariable analysis, age still remained a significant prognostic factor.

CONCLUSIONS

Different distribution of sarcoma histotypes, more high-stage and high-grade sarcomas at diagnosis, less aggressive treatment, and worse survival rates emphasize the need for optimizing sarcoma research and care of the elderly.

Trends in chemoradiation use in elderly patients with head and neck cancer: Changing treatment patterns with cetuximab

BACKGROUND

Cetuximab was approved for use in chemoradiation therapy (CRT) for locally advanced head and neck squamous cell carcinoma (HNSCC) in 2006.

METHODS

Among 3705 patients with locally advanced HNSCC identified in the linked Surveillance Epidemiology and End Results (SEER) Medicare database, we assessed treatment trends, including surgery, radiation therapy (RT), CRT, and specific agents used in CRT. We examined the influence of demographic and clinical characteristics on the likelihood of receiving CRT before and after 2006.

RESULTS

Chemoradiation use increased from 29% of patients diagnosed in 2001 to 61% in 2009 (p < .0001). Compared to before 2006, neither age nor comorbidity score was associated with receipt of CRT after 2006. Platinum combinations were the most commonly used concurrent chemotherapies before 2006, but, since then, cetuximab has become the most commonly used agent.

CONCLUSION

The use of CRT has increased substantially and cetuximab may have increased CRT use, especially in older and sicker patients. © 2015 Wiley Periodicals, Inc. Head Neck 38: E165-E171, 2016.

Management of hepatocellular carcinoma in the elderly

Mean age of hepatocellular carcinoma (HCC) patients has been progressively increasing over the last decades and ageing of these patients is becoming a real challenge in every day clinical practice. Unfortunately, international guidelines on HCC management do not address this problem exhaustively and do not provide any specific recommendation. We carried out a literature search in MEDLINE database for studies reporting on epidemiology, clinical characteristics and treatment outcome of HCC in elderly patients. Available data seem to indicate that in elderly patients the outcome of HCC is mostly influenced by liver function and tumor stage rather than by age and the latter should not influence treatment allocation. Age is not a risk for resection and older patients with resectable HCC and good liver function could gain benefit from surgery. Mild comorbidities do not seem a contraindication for surgery in aged patients. Conversely, major resection in elderly, even when performed in experienced high-volume centres, should be avoided. Both percutaneous ablation and transarterial chemoembolization are not contraindicated in aged patients and safety profile of these procedures is acceptable. Sorafenib is a viable option for advanced HCC in elderly provided that a careful evaluation of concomitant comorbidities, particularly cardiovascular ones, is taken into account. Available data seem to suggest that in either elderly and younger, treatment is a main predictor of outcome. Consequently, a nihilistic attitude of physicians towards under- or no-treatment of aged patients should not be longer justified.

First-line treatment of newly diagnosed elderly patients with chronic myeloid leukemia: current and emerging strategies

Chronic myeloid leukemia (CML) is a disease of the hematopoietic stem cell characterized by a median age at diagnosis of 60-65 years according to most epidemiologic registries. Prior to the tyrosine kinase inhibitor (TKI) era, older age was considered an adverse prognostic factor and was included in two of the most used scoring systems for CML, the Sokal score and the Euro score. Moreover, older age was generally considered a limitation for the use of allogeneic stem-cell transplantation, given the higher toxicity observed. After the introduction of TKIs, age lost much of its prognostic impact in patients in chronic phase (CP), and the EUTOS score, developed in patients treated with imatinib, did not identify age as a risk variable. However, most CML patients require life-long treatment; therefore, as patients age while taking a TKI, the complexity of the management of elderly patients may increase over time. To date, imatinib, the first TKI introduced, and two second-generation TKIs, nilotinib and dasatinib, have been approved in most Western countries for the first-line treatment of CML. These drugs differ in terms of efficacy, safety, and costs; therefore, knowledge of their characteristics is extremely relevant for optimal management of elderly CML patients. We reviewed the impact of age on the first-line treatment of CP CML patients in the TKI era, considering the epidemiology of the disease, the role of comorbidities, and analyzing data from population-based studies and clinical trials.

The Combination of 80 Years of Age and Metastatic Castration-Resistant Prostate Cancer Remain an Uphill Battle: A Case Report with Cabazitaxel as a Double-Edged Sword

We report the case of an 80-year-old patient who presented with a progressive prostate metastatic cancer with poor performance status. The patient had already benefitted from docetaxel and abiraterone. A new line of chemotherapy by cabazitaxel was started with good response, and there was a dramatic improvement in general status and pain symptoms. Age and performance status alone should not be limiting decision factors for elderly cancer patients.

Free flaps in head and neck reconstruction after oncologic surgery: expected outcomes in the elderly

OBJECTIVE

To provide surgeons and clinicians with a critical review of microvascular reconstructive options and their expected outcomes after head and neck cancer resection in the elderly.

DATA SOURCES

Medline, Isiweb, and Cochrane databases.

REVIEW METHODS

A literature search was performed in May 2014 and included studies published between 2000 and 2014. Keywords were used for articles identification, and inclusion criteria were defined for consideration in the present review.

CONCLUSIONS

Evaluation of the pertinent literature is hampered by a number of biases, such as a lack of general consensus of a definition of "elderly," differences among scales used to quantify comorbidities, and subjective evaluation of flap-related and systemic complications. However, our findings showed no differences in terms of free flap success, surgical complications, or mortality rate between older and younger patients. Moreover, recipient site complications do not seem to be affected by age.

IMPLICATION FOR PRACTICE

Microvascular reconstruction in the elderly can be performed with high success rates, even though medical complications can occur more frequently compared to younger patients. Minor and major surgical complications in the elderly appear to be comparable to those in the younger population and do not affect final outcome or the perioperative mortality rate. Flap outcome does not seem to be significantly affected by age. Careful preoperative assessment and postoperative monitoring are mandatory to prevent adverse events, and prompt management is warranted whenever present.

Optimal management of the elderly patient with head and neck cancer: Issues regarding surgery, irradiation and chemotherapy

Head and neck cancer (HNC) represents the sixth most common malignancy and accounts for approximately 6% of new cancer cases annually worldwide. As life expectancy constantly increases, the onset of HNC in patients older than 65 years of age at diagnosis is not rare and up to one fourth of cases occurs in patients older that 70 years at age. Because elderly cancer patients are severely under-represented in clinical trials, there is a clear need to address the particular aspects of this specific patient group, especially in the context of novel multidisciplinary therapeutic approaches. The frailty of elderly patients with HNC is attributed to the high incidence of smoking and alcohol abuse in this malignancy and the presence of substantial cardiovascular, respiratory or metabolic comorbidities. In the current work, I provide an overview of current and emerging treatment approaches, in elderly patients with HNC. In particular, I discuss modern surgical approaches that improve radical excision rates while preserving functionality, the incorporation of modern radiotherapeutic techniques and the introduction of novel chemotherapeutic combinations and molecular targeted agents in an effort to reduce toxicity without compromising efficacy. Finally, there is an urgent need to increase accrual and active participation of elderly patients with HNC in clinical trials, including biomarker evaluation in biopsy specimens towards an individualized therapeutic approach.

Targeted therapy for advanced hepatocellular cancer in the elderly: focus on sorafenib

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related deaths worldwide. Worldwide progressive population aging demands consensus development for decision making when treating elderly patients. Age itself might not be a critical determinant for the selection of a therapeutic option. In the past few years, the mechanisms of hepato-carcinogenesis have been elucidated, and the involvement of a number of pathways, including angiogenesis, aberrant signal transduction, and dysregulated cell cycle control, have been demonstrated, leading to evaluation of the activity and toxicity of some of the new molecularly targeted agents. Sorafenib was demonstrated to significantly increase the survival of patients with advanced HCC in two prospective, randomized, placebo-controlled trials. Subsequently, a number of retrospective or prospective studies have indicated that the effectiveness of sorafenib therapy in the treatment of HCC is similar in elderly and non-elderly patients. The aim of this review is to describe the impact of age on the effects of sorafenib-targeted therapy in patients with HCC, and the next treatment options with new targeted agents (everolimus, tivantinib, linifanib, etc.).

Evaluation of results of linac-based radiosurgery for brain metastases from primary lung cancer

AIM

The purpose of our review was to evaluate results of radiosurgery for patients with brain metastases from lung cancer.

BACKGROUND

Lung cancer is the leading cause of death from cancer and the most common source of brain metastases. Radiosurgery allows the precise focal delivery of a high single radiation dose to brain metastases and results in high rates of local control.

MATERIALS AND METHODS

83 patients were treated between 2006 and 2008. We evaluated local control and outcome after radiosurgery and identified prognostic factors.

RESULTS

Median survival in the whole group was 7.8 months from radiosurgery and 11 months from diagnosis. Median survival in classes I, II and III was 13.2, 8.2 and 2.2 months. For 94% of patients symptoms improved or stabilised at the first follow-up visit and this status did not change during 7.1 months. According to the univariate analysis, factors associated with improved survival included: RPA class 1 compared with RPA 2 and 3, RPA class 2 compared with RPA 3, KPS > 70, control of the primary disease, radiosurgery performed more than once, level of haemoglobin >7 mmol/1, absence of extracranial metastases, volume of the biggest lesion <11 cm(3). The multivariate analysis confirmed a significant influence on survival for the following factors: RPA class 1 as compared with RPA 3, KPS > 70, absence of extracranial metastases, multiplicity of radiosurgery.

CONCLUSIONS

Stereotactic radiosurgery is a safe and effective treatment. It proved to be effective and safe in older patients. Selection of patients who are likely to benefit most should be based on prognostic factors. KPS proved to be the most important prognostic factor. In the RPA III group (patients with KPS < 70) survival time was similar to that achieved after symptomatic medical management.

Sorafenib Therapy for BCLC Stage B/C Hepatocellular Carcinoma; Clinical Outcome and Safety in Aged Patients: A Multicenter Study in Japan

Background and aims: We aimed to compare clinical outcomes and safety after sorafenib therapy between patients with Barcelona Clinic Liver Cancer (BCLC) stage B or C hepatocellular carcinoma (HCC) aged ≥75 years (aged group, n=179) and those with BCLC stage B or C HCC aged <75 years (control group, n=279).

Patients and methods: We compared overall survival (OS), progression free survival (PFS), best treatment response and sorafenib related serious adverse events (SAEs) of grade 3 or more in the two groups. Furthermore, for reducing the selection bias, we compared clinical outcome of these two groups using propensity score matching analysis.

Results: The median OS and PFS intervals were 9.7 and 3.8 months in the aged group and 8.2 and 3.3 months in the control group (P=0.641 for OS and P=0.068 for PFS). Disease control rates were 49.2% (88/179) in the aged group and 49.1% (137/279) in the control group (P>0.999). Objective response rates were 15.1% (27/179) in the aged group and 14.3% (40/279) in the control group (P=0.892). Treatment related SAEs of grade 3 or more were observed in 51 patients (28.5%) in the aged group and in 69 patients (24.7%) in the control group (P=0.385). In the propensity score matched cohort (132 pairs), no significant difference in the two groups was observed in terms of OS (P=0.898) and PFS (P=0.407).

Conclusion: In BCLC stage B or C HCC patients treated with sorafenib, life expectancy, disease progression, treatment efficacy and SAEs are unaffected by age over 75 years.