Radiotherapy in the Aged

3D conformal radiation therapy for prostate cancer in elderly patients

BACKGROUND AND PURPOSE

The aim of this study was to evaluate if conformal radiation therapy for localized prostate cancer with doses of 70 Gy is well tolerated in patients aged 75 years or older, and if the side effects and the biochemical recurrence free (bNED) survival are comparable to younger patients.

PATIENTS AND METHODS

Eighty patients>or=75 years received definitive conformal radiotherapy for prostate cancer. Acute and late side effects as well as bNED survival (ASTRO criteria) were compared to 221 patients younger than 75 years who were treated during the same period of time.

RESULTS

Median dose to the prostate was 70 Gy in both groups. There were no significant differences in acute or late side effects between age groups. The frequency of grade III late symptoms was low and ranged between 0 and 4% for the evaluated symptoms irrespective of age group. Older patients had a better bNED survival than younger patients (bNED survival at 4 years: 76 vs. 61%, P=0.042).

CONCLUSIONS

High-dose conformal radiation therapy for prostate cancer is well tolerated in patients aged 75 years or older. In terms of bNED survival radiation treatment is at least as effective as it is for younger patients.

Utilizing geriatric skills in radiation oncology

After heart disease, cancer is the second leading cause of death in the United States and is expected to become the leading cause of death in the next decade. Approximately 60% of all cancer patients will receive radiation therapy at some point in their oncology continuum. It becomes important for nurses to be familiar with the physiological changes in older adults and be able to recognize the changes that could occur from an oncology treatment such as radiation therapy. Radiation therapy is one modality that the elderly can tolerate if they have adequate functional status. Astute physical assessment skills are needed to distinguish between normal aging and the acute and long-term effects of radiation therapy.

Cancer and age in the USA

Cancer in the older person has become an increasingly common problem with the aging of the population. The goal of this paper is to review the influence of age on cancer biology and cancer management. Specific interactions of cancer and aging include: Increased incidence of cancer with the age: This association may be reported to three factors: duration of carcinogenesis; increased susceptibility of older tissues to late stage carcinogens, and systemic effects of aging, including immune-senescence and enhanced cytokine production. Biological behavior of cancer: With aging, the prognosis of certain neoplasms, including acute myelogenous leukemia and large-cell non-Hodgkin's lymphoma worsens, whereas the behavior of other tumors becomes more indolent. In these biologic variations one may recognize both a 'seed" effect (different tumor cells) and a "soil" effect (different ways in which the older tumor host handles tumor growth. Goals of prevention and treatment: Given the limited life-expectancy of older individuals and reduced tolerance of clinical intervention, the main goal is compression of morbidity, rather than prolongation of survival. Cancer prevention in the older person: In virtue of increased susceptibility to environmental carcinogens, the older person appears an ideal candidate for primary prevention of cancer, including chemoprevention; though randomized controlled studies have not been performed, the older person may benefit from secondary prevention (screening), when the average life-expectancy is 3 years or longer. Cancer treatment: The risk of surgical complications increases only slightly with age for elective surgery, but increases dramatically for emergency surgery. Radiation therapy appears a valuable method of cancer treatment in patients of all ages. Chemotherapy can be made safer by the following provisions: use of hemopoietic growth factors for patients aged 70 and older receiving moderately toxic chemotherapy (CHOP and CHOP-like); maintenance of hemoglobin levels at 12 g/dl with erythropoietin; adjustment of the dose of renally excreted agents to the glomerular filtration rate; selection of the best candidates for chemotherapy based on comprehensive geriatric assessment.

Radiation therapy in cancer patients 80 years of age and older

There is a paucity of clinical data regarding radiation therapy in elderly patients. This is a retrospective study of all patients aged 80 years and older who underwent treatment with external beam irradiation at a single site. There were a total of 183 patients treated with 226 courses of therapy. The mean age was 84 years (range: 80-98 years). Fifty-eight percent of the patients were male. The treatment was deemed palliative in 51% and curative in 49%. The primary cancer diagnoses were: prostate 36, lung 28, breast 25, head and neck 23, gastrointestinal 21, hematologic 12, gynecologic 11, skin 11, genitourinary 9, unknown primary 6, central nervous system 1. The patients were able to complete the prescribed therapy in 173 of 226 courses (77%). Treatment breaks during the radiation courses were required in 81 (36%) of the courses. Radiation therapy can be safely administered to an elderly population with both curative and palliative intent with the expectation of completion in more than 80% of patients. The reasons for inability to complete therapy as prescribed are multifactorial, but careful patient selection and attention to comorbidity may optimize outcome. Further research is needed to better define these parameters.

Geriatric oncology: challenges for the new century

The management of cancer in the older aged person represents one of the major immediate challenges of medicine. The response to this challenge involves answers to the following questions: I. Who is old? Currently. 70 years of age may he considered the lower limit of senescence because the majority of age-related changes occur after this age. Individual estimates of life expectancy and functional reserve may be obtained by a comprehensive and time-consuming multidimensional geriatric assessment. The current instrument may be fine-tuned and new instruments, including laboratory tests of ageing. may be developed. 2. Why do older persons develop more cancer? It is clear that ageing tissues are more susceptible to late-stage carcinogen. Older persons may represent a natural monitor system for new environmental carcinogens, and may also represent a fruitful ground to study the late stages of carcinogenesis. 3. Is cancer different in younger and older persons? Clearly. the behaviour of some tumors. including acute myeloid leukaemia, non-Hodgkin's lymphoma and breast cancer change with the age of the patient. The mechanisms of these changes that may involve both the tumour cell and the tumour host are poorly understood. 4. Can cancer he prevented in older individuals? Chemoprevention offers a new horizon of possibilities for cancer prevention: older persons may benefit most from chemoprevention due to increased susceptibility to environmental carcinogens. Screening tests may become more accurate in older individuals due to increased prevalence of cancer. hut may he less beneficial due to more limited patient life expectancy. 5. Do older persons benefit from cytotoxic treatment? The answer to this question partly stands on proper patient selection. partly on the development of safer forms of cancer treatment and prudent use of antidotes to chemotherapy toxicity. 6. What is the cost of treating older cancer patients? The treatment of older patients is generally more costly. This cost should be assessed against the cost of not treating cancer and promoting functional dependence. which by itself is extremely costly. 7. What are the endpoints of clinical trials in older cancer patients? With more limited life expectancy. the effect of treatment on quality of life is paramount. Reliable assessment of quality of life is essential for interpreting clinical trials in older individuals. 2000 Elsevier Science Ltd. All rights reserved.

Radiotherapy for non-small cell lung cancer in patients aged 75 and over: safety, effectiveness and possible impact on survival

For patients with advanced, inoperable non-small cell lung cancer (NSCLC), increasing age seems to be the primary reason of receiving no treatment. The elderly aged 75 years and over are more likely to be given only supportive care (irrespective of symptoms) or no therapy at all. We evaluated the outcome of 48 patients, aged 75 years and over, treated with radiation therapy for advanced (stage IIIA-B), inoperable, symptomatic NSCLC. A median dose of 50 Gy was delivered to the primary site and mediastinum with standard fractionation. Based on WHO criteria, of 47 assessable patients, 21 had partial remission, 17 stable disease, and nine had progressive disease. Most symptoms were successfully palliated. Toxicity was negligible and mainly consisted of WHO grade I-II esophagitis. Despite the overall median survival being short (5 months), dose-related survival was much better in patients given at least 50 Gy than in those treated with lower doses: 52% versus 35% at 6 months, and 28% versus 4% at 13 months. These results confirm that radiation therapy may be safely delivered to very aged patients with advanced NSCLC at not merely palliative doses, both to achieve better local control and to give likely survival benefits. Adequate pretreatment evaluation should be always performed to exclude any comorbidity unfit to chest radiation and to individualize treatment to the single patient requirements. Because a large amount of literature data now concurs with the feasibility and safety of high-dose radiotherapy in the elderly, specifically designed, age-oriented trials are needed to settle definitively the issue of survival advantage from curative radiotherapy in these patients.