Cancer in the Elderly: Moving the Needle Toward Evidence-Based Personalized Oncology

Physicians’ Opinion on Intraoperative Radiotherapy as a Therapeutic De-Escalation Option in Older Women with Early Breast Cancer

Background: Intraoperative radiotherapy (IORT) is a therapeutic de-escalation option in older women with low-risk early breast cancer (EBC). A qualitative study was implemented to describe EBC physicians’ points of view on IORT as a de-escalation option. Methods: Recorded face-to-face and telephone semi-structured interviews were conducted among diverse physicians from seven French comprehensive cancer centers. Interview transcripts were grouped as corpus to construct a typology. Thematic analysis was performed. Results: Positions toward IORT were contrasted between the 16 participating physicians. Five fully supported IORT as a de-escalation option, four were not in favor, and seven had a more reserved or neutral opinion. Points of divergence concerned treatment efficacy, treatment duration, side effects and sequelae, psychological impact, compliance with adjuvant endocrine therapy, logistical constraints, financial cost, and availability of other techniques of partial breast irradiation. Physicians in favor of IORT emphasized direct benefits for the patient, and those against pointed the lack of specific guidelines, risk of lost opportunity in older women with long life expectancy, and challenges of shared decision making. Conclusions: Despite national policies to preserve cancer patients’ quality of life and increase their participation in medical decision making, therapeutic de-escalation using IORT is not consensual among physicians. Further efforts are needed to promote patient-centered care.

Frailty-the missing constraint in radiotherapy treatment planning for older adults

Current demographic changes translate into an increased frequency of cancer in older adults. Available data show that about 45-55% of the new cancer patients will need RT treatments, with an expected increase of 20-30% in the future. To provide the best cancer care it is mandatory to assess frailty, offer appropriate curative treatments to patients and personalise them for the frail. Based on published data, the median prevalence of frailty in older population is about 42%. Recently, the free radical theory of frailty has been proposed stating that oxidative damage is more prevalent in frail patients. In parallel, RT is one of the most frequent cancer treatments offered to older adults and is a source of external free radicals. RT dose constraints correlate with toxicity rates, so we open the question whether frailty should be considered when defining these constraints. Thus, for this paper, we will highlight the importance of frailty evaluation for RT treatment decisions and outcomes.