Insight into the treatment of cancer in older patients: Developments in the last decade

Time trends in the use of curative treatment in men 70 years and older with nonmetastatic prostate cancer

BACKGROUND

Undertreatment of otherwise healthy men in their seventies with prostate cancer has been reported previously.

MATERIAL AND METHODS

Using information in a Swedish prostate cancer research database, patterns of management and cancer-specific mortality were compared across age groups in over 70,000 men diagnosed with intermediate- or high-risk nonmetastatic prostate cancer between 2008 and 2020. Crude probabilities of death were estimated non-parametrically. Staging procedures, primary treatment, and cancer death were compared using regression models, adjusting for patient and tumor characteristics.

RESULTS

During the study period, the proportion of men treated with curative intent increased in ages 70-74 (intermediate-risk from 45% to 72% and high-risk from 49% to 84%), 75-79 (intermediate-risk from 11% to 52% and high-risk from 12% to 70%), and 80-84 years (intermediate-risk from < 1% to 14% and high-risk from < 1% to 30%). Older age was associated with lower likelihoods of staging investigations and curative treatment, also after adjustment for tumor characteristics and comorbidity. Men treated with curative intent and those initially managed conservatively had lower crude risks of prostate cancer death than men receiving androgen deprivation treatment (ADT). In adjusted analyses, ADT was associated with higher prostate cancer mortality than curative treatment across ages and risk groups. Among men managed conservatively, prostate cancer mortality was higher in ages 70 and above.

INTERPRETATION

Use of curative treatment increased substantially in older men with prostate cancer between 2008 and 2020. Our findings suggest reduced age-bias and under-treatment, likely reflecting improved individualized decision-making and adherence to guidelines recommending more active management of older men.

Are older patients with non-small cell lung cancer receiving optimal care? A population-based study

BACKGROUND

Results from studies addressing age-related patterns of cancer care have found evidence of unjustified differences in management between younger and older patients.

METHODS

We examined associations between age and clinical presentation, management and mortality in patients diagnosed with non-small cell lung cancer (NSCLC) between 2002 and 2016. Analyses were adjusted for comorbidity and other factors that may have affected management decisions and outcomes.

RESULTS

The study population encompassed 40,026 patients with NSCLC. Stage at diagnosis did not differ between age groups ≤ 84. The diagnostic intensity was similar in age groups <80 years. In patients with stage IA-IIB disease and PS 0-2, surgery was more common in the youngest age groups and decreased with increasing age, and was rarely performed in those ≥ 85 years. The use of stereotactic body radiotherapy (SBRT) increased with age (≤69 years 5.4%; ≥85 years 35.8%). In patients with stage IIIA disease and PS 0-2, concurrent chemoradiotherapy was more common in younger patients (≤69 years 55.3%; ≥85 years 2.2%). In stage IA-IIIA disease, no major differences in treatment-related mortality was observed. In stage IIIB-IV and PS 0-2, chemotherapy was more common in patients <80 years. However, 58.1% of patients 80-84 years and 30.3% ≥ 85 years received treatment. In stage IA-IIIA, overall and cause-specific survival decreased with increasing age. No age-differences in survival were observed in patients with stage IIIB-IV NSCLC.

CONCLUSION

Treatments were readily given to older patients with metastatic disease, but to a lesser degree to those with early stage disease. Significant differences in cause specific survival were observed in early, but not late stage disease. Our findings underscore the importance of individualized assessment of health status and life expectancy. Our results indicate that older patients with early stage lung cancer to a higher extent should be considered for curative treatment.

Complete response to immunotherapy in a nonagenarian patient with metastatic melanoma

Despite the increasing incidence of metastatic melanoma in the older population, there are relatively limited data for those older than 75 years of age. Elderly patients are often under-represented in clinical trials. In addition, elderly patients in trials often have a lower Eastern Cooperative Oncology Group score and fewer comorbidities and may thus not truly reflect the realities of day-to-day clinical practice. We present a case of a 95-year-old woman who had extensive and unresectable subcutaneous and dermal deposits of metastatic melanoma of her right leg, which caused oedema and reduced mobility. She was treated concurrently with pembrolizumab and radiotherapy to her leg lesions of melanoma. She has had an excellent response to treatment, with complete resolution of the subcutaneous and dermal metastatic deposits and has not developed any immune-related toxicities. Our experience demonstrates that anti-programmed-death-receptor-1 therapy can be given safely and effectively even in very elderly metastatic melanoma patients.

Age-related differences in breast cancer mortality according to race/ethnicity, insurance, and socioeconomic status

BACKGROUND

We assessed breast cancer mortality in older versus younger women according to race/ethnicity, neighborhood socioeconomic status (nSES), and health insurance status.

METHODS

The study included female breast cancer cases 18 years of age and older, diagnosed between 2005 and 2015 in the California Cancer Registry. Multivariable Cox proportional hazards modeling was used to generate hazard ratios (HR) of breast cancer specific deaths and 95% confidence intervals (CI) for older (60+ years) versus younger (< 60 years) patients separately by race/ethnicity, nSES, and health insurance status.

RESULTS

Risk of dying from breast cancer was higher in older than younger patients after multivariable adjustment, which varied in magnitude by race/ethnicity (P-interaction< 0.0001). Comparing older to younger patients, higher mortality differences were shown for non-Hispanic White (HR = 1.43; 95% CI, 1.36-1.51) and Hispanic women (HR = 1.37; 95% CI, 1.26-1.50) and lower differences for non-Hispanic Blacks (HR = 1.17; 95% CI, 1.04-1.31) and Asians/Pacific Islanders (HR = 1.15; 95% CI, 1.02-1.31). HRs comparing older to younger patients varied by insurance status (P-interaction< 0.0001), with largest mortality differences observed for privately insured women (HR = 1.51; 95% CI, 1.43-1.59) and lowest in Medicaid/military/other public insurance (HR = 1.18; 95% CI, 1.10-1.26). No age differences were shown for uninsured women. HRs comparing older to younger patients were similar across nSES strata.

CONCLUSION

Our results provide evidence for the continued disparity in Black-White breast cancer mortality, which is magnified in younger women. Moreover, insurance status continues to play a role in breast cancer mortality, with uninsured women having the highest risk for breast cancer death, regardless of age.

Breast Cancer Mortality in Older and Younger Patients in California

BACKGROUND

Breast cancer in younger patients is reported to be more aggressive and associated with lower survival; however, factors associated with age-specific mortality differences have not been adequately assessed.

METHODS

We used data from the population-based California Cancer Registry for 38,509 younger (18-49 years) and 121,573 older (50 years and older) women diagnosed with stage I to III breast cancer, 2005-2014. Multivariable Cox regression models were used to estimate breast cancer-specific mortality rate ratios (MRR) and 95% confidence intervals (CI), stratified by tumor subtype, guideline treatment, and care at an NCI-designated cancer center (NCICC).

RESULTS

Older breast cancer patients at diagnosis experienced 17% higher disease-specific mortality than younger patients, after multivariable adjustment (MRR = 1.17; 95% CI, 1.11-1.23). Higher MRRs (95% CI) were observed for older versus younger patients with hormone receptor (HR)⁺/HER2^- (1.24; 1.14-1.35) and HR⁺/HER2⁺ (1.38; 1.17-1.62), but not for HR^-/HER2⁺ (HR = 0.94; 0.79-1.12) nor triple-negative breast cancers (1.01; 0.92-1.11). The higher mortality in older versus younger patients was diminished among patients who received guideline-concordant treatment (MRR = 1.06; 95% CI, 0.99-1.14) and reversed among those seen at an NCICC (MRR = 0.86; 95% CI, 0.73-1.01).

CONCLUSIONS

Although younger women tend to be diagnosed with more aggressive breast cancers, adjusting for these aggressive features results in older patients having higher mortality than younger patients, with variations by age, tumor subtype, receipt of guideline treatment, and being cared for at an NCICC.

IMPACT

Higher breast cancer mortality in older compared with younger women could partly be addressed by ensuring optimal treatment and comprehensive patient-centered care.

Trends in treatment and relative survival among Non-Small Cell Lung Cancer patients in the Netherlands (1990-2014): Disparities between younger and older patients

BACKGROUND

This study aimed to describe trends over time regarding disparities in treatment and relative survival (RS) between younger and older patients with non-small cell lung cancer (NSCLC).

METHODS

All patients diagnosed with pathologically verified NSCLC in 1990-2014 were included from the Netherlands Cancer Registry (n=187,315). Treatment and RS (adjusted for sex, histology and treatment) were analyzed according to age group (<70 years versus ≥70 years), stage and five-year period of diagnosis.

RESULTS

Between 1990 and 2014, five-year RS increased from 17 to 22% among younger patients and from 12 to 16% among elderly. The application of surgery increased over time for elderly with stage I NSCLC, decreased for elderly with stage II, and was stable but higher for younger patients. Disparities in RS between age groups with stage I became smaller since 2000-2004, but did not change over time for stage II. For stage III and IV, both age groups showed strong increases over time in chemoradiotherapy and chemotherapy from 2000 onwards, although considerably less among elderly. One-, three- and five-year RS increased more strongly over time for the younger group leading to larger disparities between age groups with stage III or IV NSCLC.

CONCLUSION

More curative-intent treatment and improved RS for NSCLC were seen over time, but were less profound among elderly. Disparities herein between age groups seemed to become smaller over time for stage I NSCLC, did not change for stage II, and were widening for stage III and IV at the expense of elderly. Future prospective studies should focus on optimizing treatment selection and outcomes for elderly.

Radioprotective Effects of Amifostine and Lycopene on Human Peripheral Blood Lymphocytes In Vitro

BACKGROUND

Radiation protection is a pivotal challenge for radiation workers employed in medical fields, industry, and also space professionals with an increasing role in medical diagnostic and therapeutic applications. Radioprotective effects of amifostine and lycopene and their ability to moderate the level of radiation-induced chromosomal aberrations were investigated using the dicentric chromosome assay.

METHODS

Parallel human whole blood samples, pretreated with amifostine (250 μg/mL), lycopene (5 μg/mL), and/or their combinations were irradiated for 30 minutes with ⁶⁰Co γ rays (1, 2, 3, and 4 Gy) with a dose rate of 98.46 cGy/min at SAD = 100 cm, in vitro and cocultured with control groups. The frequencies of chromosomal aberrations in the lymphocyte of the cells were analyzed.

RESULTS

There were no apparent chromosome aberrations in controls and also in the drug-treated groups in the absence of radiation. Radiodrug treatment significantly decreased frequency of the radiation-induced chromosome aberrations compared with radiation alone (P < .05). Amifostine reduced the frequency of radiation-induced dicentrics by 15.8%, 21.9%, 4.5%, and 11.6%, with dose protection factors (DPFs) of 1.2 ± 0.02, 1.3 ± 0.1, 1.05 ± 0.03, and 1.13 ± 0.02. Lycopene reduced the frequency by 17.2%, 3.07%, 1.63%, and 16.6%, with DPFs of 1.21 ± 0.12, 1.03±0.05, 1.02±0.03 and 1.12±0.03. The combination treatment reduced the frequency by 28%, 24.9%, 9%, and 31.2%, with DPFs of 1.38 ± 0.06, 1.33 ± 0.06, 1.09 ± 0.02, and 1.45 ± 0.03 with radiation doses of 1, 2, 3, and 4 Gy, respectively.

CONCLUSIONS

It can be suggested that pretreatment with combined amifostine and lycopene may reduce the extent of ionizing radiation damage in cells.

Trends in upper gastro-intestinal cancer among the elderly in Denmark, 1980-2012

BACKGROUND

Upper gastro-intestinal cancer (UGIC) includes malignancies in esophagus, stomach and small intestine, and represents some of the most frequent malignancies worldwide. The aim of the present analysis was to describe incidence, mortality and survival in UGIC patients in Denmark from 1980 to 2012 according to differences in age and time periods.

MATERIAL AND METHODS

UGIC was defined as ICD-10 codes C15-C17. Data derived from the NORDCAN database with comparable data on cancer incidence mortality, prevalence and relative survival in the Nordic countries, where the Danish data were delivered from the Danish Cancer Registry and the Danish Cause of Death Registry with follow-up for death or emigration until the end of 2013.

RESULTS

The proportion of male patients over the age of 70 years diagnosed with esophageal cancer was constant over time (around 42%) but increased in females to 49% in 2012. Incidence rates increased with time and continued to rise in all ages. Mortality rates were clearly separated by age groups with increasing mortality rates by increasing age group for both sexes. Relative survival increased slowly over time in all age groups. The proportion of older male and female patients with stomach cancer increased to 50% and 54%, respectively, in 2012. Incidence rates decreased steadily with time, especially from 1980 to 1990 but continued to decrease in all age groups. Mortality rates decreased considerably from 1980 to 90 and have been almost constant during the last decade for both women and men. Relative survival increased modest over time in both genders and all age groups. In 2012, only 1471 persons were alive after a diagnosis of stomach cancer.

CONCLUSION

There is a need for clinical trials focusing on patients over the age of 70 years with co-existing comorbidity.

Lycopene as a carotenoid provides radioprotectant and antioxidant effects by quenching radiation-induced free radical singlet oxygen: an overview

Radio-protectors are agents that protect human cells and tissues from undesirable effects of ionizing radiation by mainly scavenging radiation-induced free radicals. Although chemical radio-protectors diminish these deleterious side effects they induce a number of unwanted effects on humans such as blood pressure modifications, vomiting, nausea, and both local and generalized cutaneous reactions. These disadvantages have led to emphasis on the use of some botanical radio-protectants as alternatives. This review has collected and organized studies on a plant-derived radio-protector, lycopene. Lycopene protects normal tissues and cells by scavenging free radicals. Therefore, treatment of cells with lycopene prior to exposure to an oxidative stress, oxidative molecules or ionizing radiation may be an effective approach in diminishing undesirable effects of radiation byproducts. Studies have designated lycopene to be an effective radio-protector with negligible side effects.

Frailty is an independent predictor of survival in older patients with colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is prevalent in the older population. Geriatric assessment (GA) has previously been found to predict treatment tolerance and postoperative complications in older cancer patients. The aim of this study was to explore whether GA also predicts 1-year and 5-year survival after CRC surgery in older patients and to compare the predictive power of GA with that of established prognostic factors such as TNM classification of malignant tumors (TNM) stage and age.

MATERIALS AND METHODS

A cohort of 178 CRC patients aged 70 and older were followed prospectively. All patients went through elective surgery, and GA was performed presurgery. The GA resulted in patients being divided into two groups: frail or nonfrail. All patients were followed for 5 years or until death. Data were analyzed by Kaplan-Meier plots and the Cox proportional hazards model.

RESULTS

Seventy-six patients (43%) were frail, and one hundred and two (57%) were nonfrail. Twenty-three patients (13%) died during the first year after surgery. One-year survival was 80% in the frail group and 92% in the nonfrail group. Five-year survival was significantly lower in frail (24%) than nonfrail patients (66%), and this difference was apparent both within the stratums of TNM stages 0-II and TNM stage III. In multivariable analysis adjusting for TNM stage, age, and sex, frailty was an independent prognostic factor for survival.

CONCLUSION

A GA-based frailty assessment predicts 1-year and 5-year survival in older patients after surgery for CRC. In localized and regional disease, the impact of frailty upon 5-year survival is comparable with that of TNM stage.

Modulated chemotherapy according to modified comprehensive geriatric assessment in 100 consecutive elderly patients with diffuse large B-cell lymphoma

Chemotherapy is associated with toxicity in elderly patients with potentially curable malignancies, posing the dilemma of whether to intensify therapy, thereby improving the cure rate, or de-escalate therapy, thereby reducing toxicity, with consequent risks for under- or overtreatment. Adequate tools to define doses and combinations have not been identified for lymphoma patients. We conducted a prospective trial aimed to evaluate the feasibility and efficacy of chemotherapy modulated according to a modified comprehensive geriatric assessment (CGA) in elderly (aged ≥70 years) patients with diffuse large B-cell lymphoma (DLBCL). In June 2000 to March 2006, 100 patients were stratified using a CGA into three groups (fit, unfit, and frail), and they received a rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone modulated in dose and drugs according to comorbidities and activities of daily living (ADL) and instrumental ADL scores. Treatment was associated with a complete response rate of 81% and mild toxicity: grade 4 neutropenia in 14%, anemia in 1%, and neurological and cardiac toxicity in 2% of patients. At a median follow-up of 64 months, 51 patients were alive, with 5-year disease-free, overall, and cause-specific survival rates of 80%, 60%, and 74%, respectively. Chemoimmunotherapy adjustments based on a CGA are associated with manageable toxicity and excellent outcomes in elderly patients with DLBCL. Wide use of this CGA-driven treatment may result in better cure rates, especially in fit and unfit patients.

Impact of age on end-of-life care for adult Taiwanese cancer decedents, 2001-2006

BACKGROUND

With increasing patient age in Western countries, evidence indicates a pervasive pattern of decreasing healthcare expenditures and less aggressive medical care, including end-of-life (EOL) care. However, the impact of age on EOL care for Asian cancer patients has not been investigated.

PURPOSE

To explore how healthcare use at EOL varies by age among adult Taiwanese cancer patients.

METHODS

Retrospective cohort study using administrative data among 203,743 Taiwanese cancer decedents, 2001-2006. Age was categorized as 18-64, 65-74, 75-84, and ≥85 years.

RESULTS

Elderly (≥65 years) Taiwanese cancer patients were significantly less likely than those 18-64 years to receive aggressive treatment in their last month of life, including chemotherapy, >1 emergency room visits, >1 hospital admissions, >14 days of hospitalization, hospital death, intensive care unit admission, cardiopulmonary resuscitation, intubation, and mechanical ventilation. However, they were significantly more likely to receive hospice care in their last year of life.

CONCLUSION

Elderly Taiwanese cancer patients at EOL received less chemotherapy, less aggressive management of health crises associated with the dying process, and fewer life-extending treatments, but they were more likely to receive hospice care in their last year and to achieve the culturally highly valued goal of dying at home.

Repeated transfusions of autologous cytokine-induced killer cells for treatment of haematological malignancies in elderly patients: a pilot clinical trial

The elderly population is susceptible to haematological malignancies, and these elderly patients are intolerant to cytotoxic drugs. Therefore, the exploration of a safe and reliable strategy exclusive of chemotherapy is critical in improving the prognosis of elderly patients with haematological malignancies. We evaluated the safety and the efficacy of autologous cytokine-induced killer (CIK) cells combined with recombinant human interleukin 2 (rhIL-2) in the treatment of haematological malignancies in elderly patients. Peripheral blood mononuclear cells were isolated from 20 elderly patients with haematological malignancies, then augmented by priming with interferon gamma, rhIL-2 and CD3 monoclonal antibody. The autologous CIK cells (2-3 × 10(9)) were transfused back to patients, followed by a subcutaneous injection of IL-2 (1 mU/day) for 10 consecutive days. The regimen was repeated every 4 weeks. The host cellular immune function, tumour-related biological parameters, imaging characteristics, disease condition, quality of life and survival time were assessed. Fourteen patients received 8 cycles of transfusion and 6 received 4 cycles. No adverse effects were observed. The percentages of CD3(+), CD3(+) CD8(+) and CD3(+) CD56(+) cells were significantly increased (p < 0.05), and the levels of serum β2 microglobulin and lactate dehydrogenase (LDH) were markedly decreased (p < 0.05) after autologous CIK cell transfusion. Cancer-related symptoms were profoundly alleviated, as demonstrated by the improved quality of life (p < 0.01). Complete remission was observed in 11 patients, persistent partial remission in 7 patients and stable disease in 2 patients. At the end of follow-up, the mean survival time was 20 months. Transfusion with autologous CIK cells plus rhIL-2 treatment is safe and effective for treating haematological malignancies in elderly patients.

The cancer survival gap between elderly and middle-aged patients in Europe is widening

The present study is aimed to compare survival and prognostic changes over time between elderly (70-84 years) and middle-aged cancer patients (55-69 years). We considered seven cancer sites (stomach, colon, breast, cervix and corpus uteri, ovary and prostate) and all cancers combined (but excluding prostate and non-melanoma skin cancers). Five-year relative survival was estimated for cohorts of patients diagnosed in 1988-1999 in a pool of 51 European populations covered by cancer registries. Furthermore, we applied the period-analysis method to more recent incidence data from 32 cancer registries to provide 1- and 5-year relative survival estimates for the period of follow-up 2000-2002. A significant survival improvement was observed from 1988 to 1999 for all cancers combined and for every cancer site, except cervical cancer. However, survival increased at a slower rate in the elderly, so that the gap between younger and older patients widened, particularly for prostate cancer in men and for all considered cancers except cervical cancer in women. For breast and prostate cancers, the increasing gap was likely attributable to a larger use of, respectively, mammographic screening and PSA test in middle-aged with respect to the elderly. In the period analysis of the most recent data, relative survival was much higher in middle-aged patients than in the elderly. The differences were higher for breast and gynaecological cancers, and for prostate cancer. Most of this age gap was due to a very large difference in survival after the 1st year following the diagnosis. Differences were much smaller for conditional 5-year relative survival among patients who had already survived the first year. The increase of survival in elderly men is encouraging but the lesser improvement in women and, in particular, the widening gap for breast cancer suggest that many barriers still delay access to care and that enhanced prevention and clinical management remain major issues.

Lung cancer in New Zealand: patterns of secondary care and implications for survival

INTRODUCTION

The survival of patients with lung cancer in New Zealand is poor compared with Australia and the United States. To determine whether these poorer outcomes were related to secondary care management or to other factors, we documented stage of disease, comorbidities, and initial secondary care management for patients diagnosed with lung cancer in 2004, in Auckland and Northland (New Zealand). These data were compared with international data.

METHODS

Cases were identified from regional databases and the New Zealand Cancer Registry. Patient, tumor, and management details were collected from clinical records.

RESULTS

Five hundred sixty-five eligible cases were identified: 55% were male, the median age was 69 years, 9% were never-smokers, 81% had documented comorbidity, and 32% belonged to the most deprived socioeconomic quintile. Histopathology was non-small cell lung cancer (NSCLC) in 70%, small-cell lung cancer (SCLC) in 13%, 2% other types, and 15% clinicoradiological diagnoses. At presentation, 70% of NSCLC cases had locally advanced/metastatic disease, and 65% of SCLC cases had extensive disease. Overall, 70% of cases were referred to an anticancer service, and 50% received initial anticancer treatment. Potentially curative treatment was received by 20% of cases: 56% stage I/II, 10% stage III NSCLC, and 58% limited-stage SCLC.

CONCLUSIONS

This cohort was characterized by high comorbidity and advanced disease. Although similar to the United Kingdom, initial treatment rates were low in comparison with Australia and the United States, despite similar stage distributions. Overall, 50% of patients, including 30% with early-stage disease, did not receive initial anticancer treatment. Low anticancer treatment rates may contribute to poorer survival outcomes in New Zealand.

Older female cancer patients: importance, causes, and consequences of undertreatment

Despite increased interest in treatment of senior cancer patients, older patients are much too often undertreated. This review aims to present data on treatment practices of older women with breast and gynecologic cancers and on the consequences of undertreatment on patient outcome. We also discuss the reasons and validity of suboptimal care in older patients. Numerous studies have reported suboptimal treatment in older breast and gynecologic cancer patients. Undertreatment displays multiple aspects: from lowered doses of adjuvant chemotherapy to total therapeutic abstention. Undertreatment also concerns palliative care, treatment of pain, and reconstruction. Only few studies have evaluated the consequences of nonstandard approaches on cancer-specific mortality, taking into account other prognostic factors and comorbidities. These studies clearly showed that undertreatment increased disease-specific mortality for breast and ovarian cancers. For other gynecological cancers, data were insufficient to draw conclusions. Objective reasons at the origin of undertreatment were, notably, higher prevalence of comorbidity, lowered life expectancy, absence of data on treatment efficacy in clinical trials, and increased adverse effects of treatment. More subjective reasons were putative lowered benefits of treatment, less aggressive cancers, social marginalization, and physician's beliefs. Undertreatment in older cancer patients is a well-documented phenomenon responsible for preventable cancer deaths. Treatments are still influenced by unclear standards and have to be adapted to the older patient's general health status, but should also offer the best chance of cure.