Assessment and management of radiotherapy induced toxicity in older patients

Geriatric assessment with management for older patients with cancer receiving radiotherapy: a cluster-randomised controlled pilot study

BACKGROUND

Geriatric assessment and management (GAM) improve outcomes in older patients with cancer treated with surgery or chemotherapy. It is unclear whether GAM may provide better function and quality of life (QoL), or be cost-effective, in a radiotherapy (RT) setting.

METHODS

In this Norwegian cluster-randomised controlled pilot study, we assessed the impact of a GAM intervention involving specialist and primary health services. It was initiated in-hospital at the start of RT by assessing somatic and mental health, function, and social situation, followed by individually adapted management plans and systematic follow-up in the municipalities until 8 weeks after the end of RT, managed by municipal nurses as patients' care coordinators. Thirty-two municipal/city districts were 1:1 randomised to intervention or conventional care. Patients with cancer ≥ 65 years, referred for RT, were enrolled irrespective of cancer type, treatment intent, and frailty status, and followed the allocation of their residential district. The primary outcome was physical function measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (QLQ-C30). Secondary outcomes were overall quality of life (QoL), physical performance, use and costs of health services. Analyses followed the intention-to-treat principle. Study registration at ClinicalTrials.gov ID NCT03881137.

RESULTS

We included 178 patients, 89 in each group with comparable age (mean 74.1), sex (female 38.2%), and Edmonton Frail Scale scores (mean 3.4 [scale 0-17], scores 0-3 [fit] in 57%). More intervention patients received curative RT (76.4 vs 61.8%), had higher irradiation doses (mean 54.1 vs 45.5 Gy), and longer lasting RT (mean 4.4 vs 3.6 weeks). The primary outcome was completed by 91% (intervention) vs 88% (control) of patients. No significant differences between groups on predefined outcomes were observed. GAM costs represented 3% of health service costs for the intervention group during the study period.

CONCLUSIONS

In this heterogeneous cohort of older patients receiving RT, the majority was fit. We found no impact of the intervention on patient-centred outcomes or the cost of health services. Targeting a more homogeneous group of only pre-frail and frail patients is strongly recommended in future studies needed to clarify the role and organisation of GAM in RT settings.

Molecular mechanisms and therapeutic applications of huaier in breast cancer treatment

Breast cancer is one of the most common female malignant tumors today and represents a serious health risk for women. Although the survival rate and quality of life of patients with breast cancer are improving with the continuous development of medical technology, metastasis, recurrence, and drug resistance of breast cancer remain a significant problem. Huaier, a traditional Chinese medicine (TCM) fungus, is a type of Sophora embolism fungus growing on old Sophora stems. The polysaccharides of Trametes robiniophila Murr (PS-T) are the main active ingredient of Huaier. There is increasing evidence that Huaier has great potential in breast cancer treatment, and its anti-cancer mechanism may be related to a variety of biological activities, such as the inhibition of cell proliferation, metastasis, tumor angiogenesis, the promotion of cancer cell death, and regulation of tumor-specific immunity. There is growing evidence that Huaier may be effective in the clinical treatment of breast cancer. This review systematically summarizes the basic and clinical studies on the use of Huaier in the treatment of breast cancer, providing useful information to guide the clinical application of Huaier and future clinical studies.

Patient-Reported Experiences and Associated Factors in a Norwegian Radiotherapy Setting: An Explorative Cross-Sectional Study

Introduction

Radiotherapy is the main treatment modality in cancer. There is sparse knowledge on how patients with cancer experience their radiotherapy trajectory, and which factors might be associated with patients' experiences.

Objectives

The aim of the present study was to explore how adults with cancer receiving radiotherapy evaluate the quality of their care, utilizing a patient-reported experience measure, and how patient- and service-related characteristics are associated with their evaluation.

Methods

An explorative cross-sectional study using a self-completed questionnaire to assess patients' radiotherapy experiences was performed. Participants were recruited consecutively, within their last week of treatment, from two different hospitals in Norway from January 2021 to January 2022. Four hundred and eighty paper questionnaires were distributed to recruited patients, 240 at each hospital. Questionnaires were self-completed at home and returned by mail. The instrument person-centered coordinated care experience questionnaire (P3CEQ) was used. In addition to this, participants completed the European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) and The Sense of Coherence 13 scale (SOC-13). Data were analyzed using descriptive statistics, parametric tests, and unadjusted/adjusted linear regression models were estimated.

Results

The study included 373 patients. Patients evaluated quality of care in terms of P3CEQ scores, with a mean score of 19.5 (standard deviation = 5.4). Lowest scores were identified in areas concerning person-centeredness and service coordination. There were no significant differences in P3CEQ scores between the younger and older groups. Having a partner and better SOC-13 scores were independently associated with the overall patient-reported experience score, whereas age was not.

Conclusion

Patient-reported experience scores indicate that improvements are needed in some areas, such as informing and involving patients in the planning and coordination of their care. Findings suggest paying special attention to patients without a partner to offer patients the best possible care.

Equity in adjuvant radiotherapy utilization in locally advanced head and neck cancer: A SEER-data based study

BACKGROUND

Not all patients with locally advanced head and neck cancer (HNC) who are eligible for adjuvant radiotherapy (RT) following upfront surgery appear to receive it.

METHODS

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Selected patients from 2009 to 2018 had locally advanced HNC, underwent upfront surgery, and were eligible for adjuvant RT. Multivariable logistic regression and chi-squared test were used to analyze available patient and tumor characteristics.

RESULTS

Of 12 549 patients, 84.5% underwent adjuvant RT, 15.5% did not. Characteristics associated with lowest adjuvant RT utilization included cancers of the larynx (p < 0.0001) and gingivae (p < 0.0001), age 80 and above (p < 0.0001), unpartnered status (p < 0.0001), and residence within a nonmetropolitan area (p < 0.0024).

CONCLUSIONS

Tumor subsite, age, partnered status, and rural/urban residence correlate with omission of adjuvant RT in locally advanced HNC.

Geriatric impairments are associated with reduced quality of life and physical function in older patients with cancer receiving radiotherapy - A prospective observational study

INTRODUCTION

Quality of life (QoL) and function are important outcomes for older adults with cancer. We aimed to assess differences in trends in patient-reported outcomes (PROs) during radiotherapy (RT) between (1) groups with curative or palliative treatment intent and (2) groups defined according to the number of geriatric impairments.

MATERIALS AND METHODS

A prospective observational study including patients aged ≥65 years receiving curative or palliative RT was conducted. Geriatric assessment (GA) was performed before RT, and cut-offs for impairments within each domain were defined. Patients were grouped according to the number of geriatric impairments: 0, 1, 2, 3, and ≥ 4. Our primary outcomes, global QoL and physical function (PF), were assessed by The European Organisation for Research and Treatment of Cancer Quality-of-Life Core Questionnaire (EORTC) (QLQ-C30) at baseline, RT completion, and two, eight, and sixteen weeks later. Differences in trends in outcomes between the groups were assessed by linear mixed models.

RESULTS

301 patients were enrolled, mean age was 73.6 years, 53.8% received curative RT. Patients receiving palliative RT reported significantly worse global QoL and PF compared to the curative group. The prevalence of 0, 1, 2, 3 and ≥ 4 geriatric impairments was 16.6%, 22.7%, 16.9%, 16.3% and 27.5%, respectively. Global QoL and PF gradually decreased with an increasing number of impairments. These group differences remained stable from baseline throughout follow-up without any clinically significant changes for any of the outcomes.

DISCUSSION

Increasing number of geriatric impairments had a profound negative impact on global QoL and PF, but no further decline was observed for any group or outcome, indicating that RT was mainly well tolerated. Thus, geriatric impairments per se should not be reasons for withholding RT. GA is key to identifying vulnerable patients in need of supportive measures, which may have the potential to improve treatment tolerance. Registered at clinicaltrials.gov (NCT03071640).

Older adults and the unique role of the radiation therapist: Future directions for improving geriatric oncology training and education

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This article reviews the status quo of the available evidence and guidance for geriatric oncology clinical practice, training and education for radiation therapists worldwide.

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We explore the unique clinical role that radiation therapists play in the management of older adults undergoing radiation therapy.

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We define multiple clinical care points in which the radiation therapists role could potentially expand or specialise into geriatric screening, assessment and intervention to optimise the care of older adults.

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Current GO educational offerings and future directions to improve RTT knowledge and skills around caring for older adults are outlined.

There is widespread recognition that the provision of high quality, appropriate and equitable care to older adults with cancer is a growing challenge in oncology practice. Radiation therapy (RT) is an effective and localised treatment that represents an attractive curative or palliative option for many older adults, and radiation therapists (RTT) play an important role in the delivery, support and quality of care for people during RT. The need to develop an evidence-based, global approach to improving all radiation oncology (RO) professionals’ knowledge and clinical practice in geriatric oncology (GO) has been previously identified. This article specifically focusses on the status quo of GO clinical practice and education for RTT worldwide. We explore the unique clinical role that RTT play in the management of older adults with cancer and define multiple clinical care points in which RTT could potentially participate in geriatric screening, geriatric assessment and intervention to optimise the care of older adults, with a focus on dementia. Directions for future efforts to improve the knowledge and clinical skills of RTT in caring for older adults are discussed.

Characteristics and Assessment of Frailty as Risk Factor of Therapy-Related Acute Toxicities and Delayed Overall Treatment Time in Elderly Patients Treating with External Beam Radiation Therapy at Indonesia Top Referral Hospital

BACKGROUND: Older patients are at a higher risk of being frail. Frailty implies that even a minor stressor can have major negative implications on physical, psychological domains. Geriatric-8 (G-8) screening tool shows good screening properties for identifying vulnerable elderly patients with cancer. AIM: We, therefore, decided to investigate the utility of G-8 associated with acute toxicity and prolonged overall treatment time (OTT) in elderly cancer patients treated with radiotherapy (RT). MATERIALS AND METHODS: A prospective observational cohort study is performed. Eligible subjects are patients aged ≥60 years and were referred for curative or palliative RT. We use the G-8 questionnaire for consecutive patients before starting RT. We recorded acute toxicity and OTT and identified potential predictors. RESULTS: A total of 52 consecutive geriatric patients were included with an average age of 67 years. Of all those subjects, 21% had head-and-neck cancers, 29% gynecology cancers, 23% breast cancers, and 27% other cancers. According to the G-8, 65% of the patients were potentially frail. Toxicity Grade ≥3 was observed among 32% of subjects who were potentially frail according to the G-8 and 0% of the subject who was fit (p = 0.007). Prolonged OTT was observed in 61.8% of potentially frail and 27.8% of the subjects who were fit (p = 0.020). On multivariate analysis, only chemoradiation was strongly associated with acute toxicity Grade ≥3 odds ratio 11.1 (95% confidence interval 1.4–83.6; p = 0.019). CONCLUSION: The utility of G-8 in daily practice seems to be limited. Only concurrent chemoradiation was associated with acute toxicity. Future prospective studies should investigate whether the G-8 is a good predictor for other relevant clinical outcomes and survival in our local settings.

Cognitive Trajectories in Older Patients with Cancer Undergoing Radiotherapy—A Prospective Observational Study

Cognitive function can be affected by cancer and/or its treatment, and older patients are at a particular risk. In a prospective observational study including patients ≥65 years referred for radiotherapy (RT), we aimed to investigate the association between patient- and cancer-related factors and cognitive function, as evaluated by the Montreal Cognitive Assessment (MoCA), and sought to identify groups with distinct MoCA trajectories. The MoCA was performed at baseline (T0), RT completion (T1), and 8 (T2) and 16 (T3) weeks later, with scores ranging between 0 and 30 and higher scores indicating better function. Linear regression and growth mixture models were estimated to assess associations and to identify groups with distinct MoCA trajectories, respectively. Among 298 patients with a mean age of 73.6 years (SD 6.3), the baseline mean MoCA score was 24.0 (SD 3.7). Compared to Norwegian norm data, 37.9% had cognitive impairment. Compromised cognition was independently associated with older age, lower education, and physical impairments. Four groups with distinct trajectories were identified: the very poor (6.4%), poor (8.1%), fair (37.9%), and good (47.7%) groups. The MoCA trajectories were mainly stable. We conclude that cognitive impairment was frequent but, for most patients, was not affected by RT. For older patients with cancer, and in particular for those with physical impairments, we recommend an assessment of cognitive function.

Replication Stress: A Review of Novel Targets to Enhance Radiosensitivity-From Bench to Clinic

DNA replication is a process fundamental in all living organisms in which deregulation, known as replication stress, often leads to genomic instability, a hallmark of cancer. Most malignant tumors sustain persistent proliferation and tolerate replication stress via increasing reliance to the replication stress response. So whilst replication stress induces genomic instability and tumorigenesis, the replication stress response exhibits a unique cancer-specific vulnerability that can be targeted to induce catastrophic cell proliferation. Radiation therapy, most used in cancer treatment, induces a plethora of DNA lesions that affect DNA integrity and, in-turn, DNA replication. Owing to radiation dose limitations for specific organs and tumor tissue resistance, the therapeutic window is narrow. Thus, a means to eliminate or reduce tumor radioresistance is urgently needed. Current research trends have highlighted the potential of combining replication stress regulators with radiation therapy to capitalize on the high replication stress of tumors. Here, we review the current body of evidence regarding the role of replication stress in tumor progression and discuss potential means of enhancing tumor radiosensitivity by targeting the replication stress response. We offer new insights into the possibility of combining radiation therapy with replication stress drugs for clinical use.

Geriatric impairments are prevalent and predictive of survival in older patients with cancer receiving radiotherapy: a prospective observational study

BACKGROUND

A systematic assessment of problems that are frequent in older age (geriatric assessment [GA]) provides prognostic information for patients undergoing cancer surgery and systemic cancer treatment. We aimed to investigate the prevalence of geriatric impairments and their impact on survival in older patients with cancer receiving radiotherapy (RT).

MATERIAL AND METHODS

A single-centre prospective observational study was conducted including patients ≥65 years referred for curative or palliative RT. Prior to RT, we performed a modified GA (mGA) assessing comorbidities, medications, nutritional status basic- and instrumental activities of daily living (IADL) mobility, falls, cognition and depressive symptoms. Impairments in each mGA domain were defined. Overall survival (OS) was presented by Kaplan Meier plots for groups defined according to the number of impairments, and compared by log-rank test. The association between mGA domains and OS was assessed by Cox proportional hazard regression analysis.

RESULTS

Between February 2017 and July 2018, 301 patients were included, 142 (47.2%) were women. Mean age was 73.6 (SD 6.3) years, 162 (53.8%) received curative RT. During the median observation time of 24.2 months (min 0.3, max 25.9), 123 (40.9%) patients died. In the overall cohort, 49 (16.3%) patients had no geriatric impairment, 81 (26.9%) had four or more. OS significantly decreased with an increasing number of impairments (p < .01). Nutritional status (HR 0.90, 95% CI [0.81; 0.99], p = .038) and IADL function (HR 0.98, 95% CI [0.95; 1.00], p = .027) were independent predictors of OS.

CONCLUSION

Geriatric impairments were frequent among older patients with cancer receiving RT and nutritional status and IADL function predicted OS. Targeted interventions to remediate modifiable impairments may have the potential to improve OS.

TRIAL REGISTRATION

Cinicaltrials.gov ID:NCT03071640.

The Impact of Frailty Screening on Radiation Treatment Modification

BACKGROUND

Care overburden makes it difficult to perform comprehensive geriatric assessments (CGAs) in oncology settings. We analyzed if screening tools modified radiotherapy in oncogeriatric patients.

METHODS

Patients ≥ 65 years, irradiated between December 2020 and March 2021 at the Hospital Provincial de Castellón, completed the frailty G8 and estimated survival Charlson questionnaires. The cohort was stratified between G8 score ≤ 14 (fragile) or >14 (robust); the cutoff point for the Charlson index was established at five.

RESULTS

Of 161 patients; 69.4% were male, the median age was 75 years (range 65-91), and the prevailing performance status (PS) was 0-1 (83.1%). Overall, 28.7% of the cohort were frail based on G8 scores, while the estimated survival at 10 years was 2.25% based on the Charlson test. The treatment administered changed up to 21% after frailty analysis. The therapies prescribed were 5.8 times more likely to be modified in frail patients based on the G8 test. In addition, patients ≥ 85 years (p = 0.01), a PS ≥ 2 (p = 0.008), and limited mobility (p = 0.024) were also associated with a potential change.

CONCLUSIONS

CGAs remain the optimal assessment tool in oncogeriatry. However, we found that the G8 fragility screening test, which is easier to integrate into patient consultations, is a reliable and efficient aid to rapid decision making.

International efforts in geriatric radiation oncology

INTRODUCTION

Geriatric assessment (GA) has been recommended to form part of treatment decision making for older adults with cancer. However despite consensus guidelines from various organizations, GA does not appear to be a part of routine practice in radiation oncology. The aim of the current study was to explore the implementation of GA in radiation oncology.

MATERIALS AND METHODS

This anonymous international survey investigated current use of GA in patients presenting for radiation therapy aged 65 years and over, in accordance with Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines. The survey was designed, using Qualitrics™, an online survey tool. It was distributed via SIOG, social media and radiation oncology professional organizations. Survey responses were analyzed using simple descriptive statistics. An additional analysis by creating a dichotomous variable based on awareness of major clinical practice guidelines and current use of GA.

RESULTS

Among 158 respondents, there was relatively low awareness of GA guidelines and low uptake of validated tools and processes. A minority of participants, only 16%, stated that they had a specialized geriatric oncology program in their institution. Approximately a third (34%) of respondents were unaware of any GA clinical practice guidelines. With regard to what way participants assess older patients differently to younger patients, 16% reported formally using specific validated tools, whereas 73% reported an informal assessment based on their own judgment, with 5% reporting no difference between younger and older patients. Regarding the use of validated screening tools for geriatric impairments, over half reported using none (57%). Regarding GA implementation, the main barriers highlighted included a lack of clinical/support staff, a lack of training, knowledge, understanding or experience about GA and a lack of time.

DISCUSSION

Relatively low awareness of guidelines and low uptake of formal GA tools and processes were found. The integration of GA principles into radiation oncology appears to be ad hoc and very much in its infancy. There is a clear need for increased interdisciplinary education and collaboration between the disciplines of radiation oncology and geriatric medicine.

Geriatric assessment with management for older patients with cancer receiving radiotherapy. Protocol of a Norwegian cluster-randomised controlled pilot study

About 50% of patients with cancer are expected to need radiotherapy (RT), and the majority of these are older. To improve outcomes for older patients with cancer, geriatric assessment (GA) with management (GAM) is highly recommended. Evidence for its benefits is still scarce, in particular for patients receiving RT. We report the protocol of a cluster-randomised pilot study designed to test the effect, feasibility and health economic impact of a GAM intervention for patients ≥65 years, referred for palliative or curative RT. The randomising units are municipalities and city districts. The intervention is municipality-based and carried out in collaboration between hospital and municipal health services from the start of RT to eight weeks after the end of RT. Its main constituents are an initial GA followed by measures adapted to individual patients' impairments and needs, systematic symptom assessments and regular follow-up by municipal cancer nurses, appointed to coordinate the patient's care. Follow-up includes at least one weekly phone call, and a house call four weeks after the end of RT. All patients receive an individually adapted physical exercise program and nutritional counselling. Detailed guidelines for management of patients' impairments are provided. Patients allocated to the intervention group will be compared to controls receiving standard care. The primary outcome is physical function assessed by the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire C-30. Secondary outcomes are global quality of life, objectively tested physical performance and use of health care services. Economic evaluation will be based on a comparison of costs and effects (measured by the main outcome measures). Feasibility will be assessed with mixed methodology, based on log notes and questionnaires filled in by the municipal nurses and interviews with patients and nurses. The study is carried out at two Norwegian RT centres. It was opened in May 2019. Follow-up will proceed until June 2022. Statistical analyses will start by the end of 2021. We expect the trial to provide important new knowledge about the effect, feasibility and costs of a GAM intervention for older patients receiving RT. Trial registration: ClinTrials.gov, ID NCT03881137, initial release 13th of March 2019.

Protective Effects of Biscoclaurine Alkaloids on Leukopenia Induced by 60Co-γ Radiation

Objective

Leukopenia, a common complication of tumor chemoradiotherapy, contributes serious damage to the hematopoietic, gastrointestinal, and immune systems of the body and can cause delay, discontinuation, or even failure to tumor treatment, thereby greatly threatening human health. The present study aims to investigate the protective effects of biscoclaurine alkaloids (BA) on leukopenia.

Methods

This study was conducted on 60 Kunming mice, which were randomly divided into six groups containing 10 animals each. A hematology analyzer was used to count white blood cells (WBC) in the peripheral blood cell. Mice serum was collected, and the granulocyte-macrophage colony-stimulating factor, vascular cell adhesion molecule 1 (VCAM-1), and interferon-γ (IFN-γ) were detected by enzyme-linked immunosorbent assays. Pathological changes were detected through hematoxylin and eosin staining in the liver and spleen of mice. The spleen and liver ultrastructures were observed via electron microscopy.

Results

Results showed that BA ameliorated WBC, PLT reduction in the peripheral blood and significantly increased the levels of IFN-γ and VCAM-1 in mice serum. BA reduced ionizing radiation-induced injuries to spleen, mitigated the reduction of superoxide dismutase (SOD), and significantly decreased the malonaldehyde (MDA) and xanthine oxidase (XOD) levels in the liver.

Conclusion

BA enhanced the immune and hematopoietic functions and ameliorated the oxidative stress induced by ⁶⁰Co-γ radiation, revealing its therapeutic potential both as a radioprotector and as a radiation mitigator for leukopenia induced by ⁶⁰Co-γ radiation.

Trametes robiniophila Murr in the treatment of breast cancer

Breast cancer is the leading cause of cancer death among women across the world. Trametes robiniophila Murr (Huaier), a traditional herbal medicine, has been used in China to protect human health for about 1600 years. Recent years, Huaier had been proven to be effective for multiple types of malignancies. This systematic review focused on breast cancer treatment, summarizing the curative function of Huaier aqueous extract and polysaccharides in preclinical researches. Huaier could markedly inhibit breast cancer progression with low toxicity, enhance immune response and increase the sensitivity to radiation and chemotherapy. The therapeutic effect of Huaier granule in clinical studies was also included. This review amalgamated the current studies and highlighted the promising role of Huaier and its polysaccharides as complementary alternative medicine in breast cancer treatment.

Feasibility and safety of 1.5 T MR-guided and daily adapted abdominal-pelvic SBRT for elderly cancer patients: geriatric assessment tools and preliminary patient-reported outcomes

BACKGROUND

We present preliminary data of the first older cancer patients treated with Hybrid Linac for stereotactic body radiotherapy (SBRT) consisting of 1.5 T MRI-guided and daily-adapted treatment. The aim was to assess feasibility, safety and the role of G8 and Charlson Comorbidity Index (CCI) questionnaires in predicting patients' QoL, evaluated by patient-reported outcome measures (PROMs).

METHODS

Two groups of patients with localized prostate cancer or abdominal-pelvic oligometastases were analyzed. SBRT schedule consisted of 35 Gy delivered in 5 fractions. The primary endpoint was to measure the impact of G8 and CCI on PROMs. Both G8 and the CCI were performed at baseline, while the EORTC Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) for PROMs assessment was prospectively performed at baseline and after SBRT.

RESULTS

Forty older patients were analyzed. The median age was 73 years (range 65-85). For the entire population, the median G8 score was 15 (10-17) and the median CCI score was 6 (4-11). Concerning the PROMS, the EORTC-QLQ C30 questionnaire reported no difference between the pre- and post-SBRT evaluation in all patients, except for the fatigue item that declined after SBRT, especially in the group of patients with a G8 score < 15 and with age < 75 years (p = 0.049). No grade 3 or higher acute toxicity occurred.

CONCLUSION

This is the first report documenting for older cancer patients that 1.5 T MRI-guided daily-adapted SBRT is feasible, safe and does not impact on the QoL at the end of treatment. Longer follow-up is advocated to report long-term outcomes.

TRIAL REGISTRATION

Date of approval April 2019 and numbered MRI/LINAC no. 23748.

Moderate hypofractionated helical tomotherapy for prostate cancer in a cohort of older patients: a mono-institutional report of toxicity and clinical outcomes

PURPOSE OR OBJECTIVE

To evaluate toxicity and outcomes of moderately hypofractionated helical tomotherapy for the curative treatment of a cohort of patients aged ≥ 75 years with localized prostate cancer (PC).

MATERIALS AND METHODS

From January 2013 to February 2017, 95 patients with median age 77 years (range 75-88) were treated for PC. 39% were low risk, 33% intermediate risk (IR), 28% high risk (HR). Median iPSA was 9.42 ng/ml (1.6-107). Androgen deprivation was prescribed according to NCCN recommendations. All patients received 70 Gy in 28 fractions to the prostate; 61.6 Gy were delivered to the seminal vesicles for IR; whole pelvis irradiation with a total dose of 50.4 Gy was added in the HR group. Toxicity evaluation was based on CTCAE V4.0 criteria, biochemical failure was defined following Phoenix criteria. Quality of Life was assessed with the EPIC-26 index. Overall survival and biochemical failure-free survival were analysed with Kaplan-Meier method.

RESULTS

With a median follow-up of 36 months (range 24-73), acute and late toxicity were acceptable. No correlation between toxicity patterns and clinical or dosimetric parameter was registered. EPIC-26 showed a negligible difference in urinary and bowel function post-treatment that did not reach statistical significance. The 2- and 3-years OS were 93% and 87% with cancer specific survival of 97.9% and 96.2%.

CONCLUSION

Moderate hypofractionated RT reported excellent outcomes in our cohort of older patients. Shorter schedules may be proposed regardless of chronological age facilitating the treatment compliance in the older population.

Rectification of radiotherapy-induced cognitive impairments in aged mice by reconstituted Sca-1+ stem cells from young donors

Background

Radiotherapy is widely used and effective for treating brain tumours, but inevitably impairs cognition as it arrests cellular processes important for learning and memory. This is particularly evident in the aged brain with limited regenerative capacity, where radiation produces irreparable neuronal damage and activation of neighbouring microglia. The latter is responsible for increased neuronal death and contributes to cognitive decline after treatment. To date, there are few effective means to prevent cognitive deficits after radiotherapy.

Methods

Here we implanted hematopoietic stem cells (HSCs) from young or old (2- or 18-month-old, respectively) donor mice expressing green fluorescent protein (GFP) into old recipients and assessed cognitive abilities 3 months post-reconstitution.

Results

Regardless of donor age, GFP⁺ cells homed to the brain of old recipients and expressed the macrophage/microglial marker, Iba1. However, only young cells attenuated deficits in novel object recognition and spatial memory and learning in old mice post-irradiation. Mechanistically, old recipients that received young HSCs, but not old, displayed significantly greater dendritic spine density and long-term potentiation (LTP) in CA1 neurons of the hippocampus. Lastly, we found that GFP⁺/Iba1⁺ cells from young and old donors were differentially polarized to an anti- and pro-inflammatory phenotype and produced neuroprotective factors and reactive nitrogen species in vivo, respectively.

Conclusion

Our results suggest aged peripherally derived microglia-like cells may exacerbate cognitive impairments after radiotherapy, whereas young microglia-like cells are polarized to a reparative phenotype in the irradiated brain, particularly in neural circuits associated with rewards, learning, and memory. These findings present a proof-of-principle for effectively reinstating central cognitive function of irradiated brains with peripheral stem cells from young donor bone marrow.

Electronic supplementary material

The online version of this article (10.1186/s12974-019-1681-3) contains supplementary material, which is available to authorized users.

Addressing frailty in patients with breast cancer: A review of the literature

Various studies have documented variation in the management of older patients with breast cancer, and some of this variation stems from different approaches to balancing the expected benefit of different treatments, with the ability of patients to tolerate them. Frailty is an emerging concept that can help to make clinical decisions for older patients more consistent, not least by providing a measure of 'biological' ageing. This would reduce reliance on 'chronological' age, which is not a reliable guide for decisions on the appropriate breast cancer care for older patients. This article examines the potential of frailty assessment to inform on breast cancer treatments. Overall, the current evidence highlights various benefits from implementing comprehensive geriatric assessment and screening for frailty in breast cancer patients. This includes a role in supporting the selection of appropriate therapies and improving physical fitness prior to treatment. However, there are challenges in implementing routine frailty assessments in a breast cancer service. Studies have used a diverse array of frailty assessment instruments, which hampers the generalisability of research findings. Consequently, a number of issues need to be addressed to clearly establish the optimal timing of frailty assessment and the role of geriatric medicine specialists in the breast cancer care pathway.

New horizons in radiotherapy for older people

Radiotherapy is an effective, albeit underutilised, treatment for cancer in older adults, especially for those who are surgically inoperable or for whom chemotherapy poses too great a risk. It is estimated that approximately half of patients with cancer could benefit from radiotherapeutic management. This article synthesises the basics of how radiotherapy works, recent developments in the field and considers how this treatment modality may be adapted in an older patient population or may evolve in the future. Technological advances of relevance include Intensity Modulated Radiotherapy (IMRT), Volumetric Modulated Arc therapy (VMAT), Stereotactic Ablative Body Radiotherapy (SABR), proton therapy, MR guided radiotherapy, as well as better image guidance during irradiation in order to improve precision and accuracy. New approaches for better integration of geriatric medicine principles into the oncologic assessment and workup will also be considered, in order to provide more age attuned care. For more informed decision making, a baseline assessment of older radiotherapy patients should encompass some form of Comprehensive Geriatric Assessment. This can facilitate the optimal radiotherapy regime to be selected, to avoid overly toxic regimes in patients with frailty. The review discusses how these new initiatives and technologies have potential for effective oncologic management and can help to reduce the toxicity of treatment for older adults. It concludes by highlighting the need for more evidence in this patient population including better patient selection and support for treatment to enhance person-centred care.

The protective effects of 1,2-propanediol against radiation-induced hematopoietic injury in mice

Agents that provide protection against irradiation-induced hematopoietic injury are urgently needed for radiotherapy. We examined the effects of the small molecule, 1,2-propanediol (PPD), on total body irradiation (TBI)-induced hematopoietic injury in C57BL/6 mice. PPD administration 1 h before TBI significantly increased hematopoietic parameters such as white blood cell, platelet, red blood cell, and lymphocyte counts in vivo and enhanced the survival of mice exposed to TBI (7.0 and 7.5 Gy). PPD administration 1 h before TBI improved bone marrow (BM) and spleen recovery after TBI, with increases in both BM cellularity and spleen index. The number of colony-forming-units in bone marrow mononuclear cells (BMNCs) in vitro also increased significantly. PPD pretreatment increased the numbers of hematopoietic stem cells and hematopoietic progenitor cells in BM. Importantly, PPD also maintained endogenous antioxidant status by decreasing levels of malondialdehyde and increasing the expression of reduced glutathione, superoxide dismutase and catalase in the serum of irradiated mice. PPD alleviated the levels of apoptosis in HSCs induced by TBI, thus increasing the proportion of dividing BMNCs. These results suggest that PPD protects against TBI-induced hematopoietic injury through the increased activities of antioxidant enzymes and the inhibition of apoptosis in HSCs. PPD increased the serum levels of granulocyte-colony stimulating factor and interleukin-6 irrespective of TBI. In conclusion, these data suggest that PPD acts as a radioprotector against radiation-induced hematopoietic injury.

Preventing Treatment-Related Functional Decline: Strategies to Maximize Resilience

The majority of patients with cancer are older adults. A comprehensive geriatric assessment (CGA) will help the clinical team identify underlying medical and functional status issues that can affect cancer treatment delivery, cancer prognosis, and treatment tolerability. The CGA, as well as more abbreviated assessments and geriatric screening tools, can aid in the treatment decision-making process through improved individualized prediction of mortality, toxicity of cancer therapy, and postoperative complications and can also help clinicians develop an integrated care plan for the older adult with cancer. In this article, we will review the latest evidence with regard to the use of CGA in oncology. In addition, we will describe the benefits of conducting a CGA and the types of interventions that can be taken by the interprofessional team to improve the treatment outcomes and well-being of older adults.