Squamous cell carcinoma of the uterine cervix: radiation therapy for patients aged 70 years and older

Impact of CT-based brachytherapy in elderly patients with cervical cancer

PURPOSE

Three-dimensional image-guided brachytherapy (3D-IGBT) has become the standard therapy for patients with cervical cancer. However, in this population, the impact of 3D-IGBT in elderly individuals remains unknown. This study assessed the efficacy of 3D-IGBT for elderly patients with cervical cancer.

METHODS AND MATERIALS

We performed a retrospective chart review of 105 consecutive patients with cervical squamous cell carcinoma aged ≥70 years who received radiotherapy alone between January 2001 and September 2014. All patients were treated with external beam radiotherapy and high-dose-rate intracavitary brachytherapy. We assessed the treatment outcomes in all patients. We then compared outcomes between two groups: patients treated by changing the Point A dose at brachytherapy (Group A, n = 71) and those treated with 3D-IGBT at least twice (Group B, n = 34).

RESULTS

The median followup period was 59 (range, 6-203) months; the median age was 77 years. The 5-year local control and cause-specific survival rates were 89% and 78%, respectively. The 5-year cumulative rates of late toxicities of the rectum and bladder of Grade ≥3 were 2.0% and 4.2%, respectively. No statistically significant differences were observed in the local control and cause-specific survival rates, or in the incidence of rectal toxicities between groups. The 3-year cumulative rates of urinary toxicity of Grade ≥1 were 20.4% and 6.9% in Group A and Group B, respectively (p = 0.035).

CONCLUSION

In elderly patients with cervical cancer, 3D-IGBT could be performed safely and effectively and contributed to decreasing urinary toxicity incidence rates.

Evaluating the Incidence Rate of an Accelerated Short Course High Dose Rate Intravaginal Brachytherapy Complications in Patients with Endometrial Cancer

Background:

Brachytherapy in treatment of endometrial cancer patients is growing and therefore, evaluation of more feasible schedule has become of great importance. The purpose of current study was to evaluate the complications of accelerated short course high dose rate intravaginal brachytherapy (HDR IVB), a new brachytherapy approach which is a more feasible treatment option in developing countries.

Method:

From 2017 to 2018, 54 patients diagnosed with endometrial cancer and FIGO stages IA to IIB who underwent total abdominal hysterectomy with a bilateral salpingo-oophorectomy were enrolled in present study. They were treated with a total dose of 25 Gy in 5 fractions which was prescribed daily. A dose of 5 Gy was prescribed at a depth of 0.5 cm in the upper third and middle third of vagina. Adverse effects related to organs at risk consist of bladder, vagina and rectum were documented based on the Common Terminology Criteria for Adverse Events v3.0 (CTCAE v3.0).

Results:

The accelerated short course HDR IVB was well tolerated and no grade 3 or higher toxicities was reported for patients during the follow up period. There were no chronic rectal toxicities and only one patient showed chronic urinary toxicities. However, the incidence rate of vaginal toxicities at the end of 4-month and 8-month follow up periods was higher than acute toxicities and significantly lower in elderly group compared to younger group.

Conclusion:

Overall, the accelerated HDR IVB was safe and was well tolerated in endometrial cancer patients and the incidence rate of undue complications were equal, if not less, in elderly patients compared to the younger ones.

Radiation therapy for elderly patients with uterine cervical cancer: feasibility of curative treatment

As the average lifespan lengthens worldwide, and the older adult population increases, the number of elderly patients with uterine cervical cancer is increasing. Because intensive and invasive treatments, including surgery, are frequently unacceptable in elderly patients, cancer treatments for these patients must be carefully considered. Elderly patients have undergone radiation therapy as less-invasive curative treatment, and it has been shown to be safe and effective for local control of cervical cancer in this population, even among patients aged ≥80 years treated with curative radiation doses. Although concurrent chemoradiotherapy is the standard treatment for locally advanced cervical cancer, it is unclear whether the addition of chemotherapy to radiation therapy prolongs survival in elderly patients. Elderly patients treated with curative radiation therapy for cervical cancer might develop more therapy-related gastrointestinal and hematological toxicities and insufficiency fractures compared with younger patients. However, advanced techniques of radiation therapy (eg, intensity-modulated radiation therapy and volumetric modulated arc therapy with photons, charged-particle radiation therapy with protons and carbon ions in external-beam radiation therapy, and image-guided adaptive brachytherapy) can minimize radiation-induced toxicities and thus make curative treatment safer and more effective for elderly patients with uterine cervical cancer.

Concurrent Chemoradiotherapy or Radiotherapy Alone for Locally Advanced Cervical Cancer in Elderly Women

Aims and background

To evaluate the efficacy and toxicity of concurrent chemoradiotherapy or radiotherapy alone in elderly patients with locally advanced cervical carcinoma (stage IB2-IVA).

Methods and study design

We retrospectively reviewed the medical records of 105 women aged ≥65 years who received radiotherapy (group I, n = 61) or concurrent chemoradiotherapy (group II, n = 44). Patients received a median dose of 76.4 Gy to point A, including 30-35 Gy of high-dose intracavity brachytherapy. The concurrent chemoradiotherapy group received platinum-based chemotherapy.

Results

The median follow-up was 65 months for surviving patients. There was no significant difference in compliance to radiotherapy between the two groups. Most acute toxicities were hematologic; acute hematologic and gastrointestinal toxicity were significantly more common in group II. Five-year overall survival and cancer-specific survival rates were, respectively, 53.5% and 66.6% in group I and 61.8% and 68.8% in group II. Performance status, comorbidity index, tumor size, and stage were independent prognostic factors for overall survival, whereas stage was the only prognostic factor for cancer-specific survival.

Conclusions

The analysis showed no benefit of concurrent chemoradiotherapy with respect to overall survival and cancer-specific survival in elderly women. A prospective study is needed to determine the role of concurrent chemoradiotherapy in this population. Free full text available at www.tumorionline.it

Radiotherapy for Japanese elderly patients with cervical cancer: preliminary survival outcomes and evaluation of treatment-related toxicity

Purpose

To examine the preliminary survival outcomes and treatment-related toxicity for elderly patients with cervical cancer treated with radiotherapy (RT).

Methods

Forty patients ≥75 years old with cervical cancer who were treated with RT were evaluated. Of these 40 patients, 25 were classified as FIGO stage I or II and 15 as stage III or IVA. Thirty-five patients were treated with radical RT (RRT), and five were treated with surgery plus adjuvant RT (S + ART). External beam radiotherapy combined with high-dose-rate intracavitary brachytherapy was performed on 31 patients who were treated with RRT and on 2 patients who were treated with S + ART because of positive vaginal surgical margins. The patients’ median age was 78 years (range 75–89 years). Concurrent chemotherapy (CCT) was performed on five patients (RRT: 3, S + ART: 2).

Results

The median follow-up period was 20 months (range 1–85 months). Only one patient could not complete RT. The 3-year overall and disease-specific survival (OS and DSS) rates for all patients were 58 and 80%, respectively. Five patients experienced Grade 3 acute toxicity; two were treated with RRT (2/35), and three were treated with S + ART (3/5, 2 of them with CCT). Two patients experienced Grade 3 late toxicity; one was treated with RRT (1/35, with CCT) and the other was treated with S + ART (1/5). No Grade 4 or higher toxicity was experienced.

Conclusions

RRT for elderly patients with cervical cancer is generally effective and safe, but severe toxicity may occur with more aggressive treatment modalities.

Chemoradiation for invasive cervical cancer in elderly patients: outcomes and morbidity

Age may impact survival and treatment in cervical cancer patients. We sought to determine if treatment and survival were different in elderly patients and whether chemoradiation increased morbidity. We performed a retrospective chart review to identify patients treated with definitive radiation therapy at the University of Iowa Hospitals and Clinics between 1997 and 2001. Three hundred sixty-four patients had a new diagnosis of invasive cervical cancer, of which 150 patients were treated with radiation. We excluded patients treated postoperatively or with palliative intent, leaving 96 patients treated with definitive radiation therapy. Patients were divided into two age categories: elderly (>/=65) and nonelderly (<65). We compared these groups with respect to treatment received, morbidity, and survival. Sixty-nine (72%) women were less than 65 years old, and 27 (28%) women were greater than or equal to 65 years old. Chemoradiation was associated with decreased mortality (P < 0.01). The decrease in mortality did not differ between the two age cohorts (all causes: P = 0.66; cancer specific: P = 0.65), nor was there a difference in the complication rate due to chemoradiation (P = 0.70). Although elderly patients were more likely to be diagnosed with nonsquamous histologies (P < 0.01), their odds of receiving chemoradiation were 0.35 (95% CI: 0.13-0.90) times the odds for nonelderly. Elderly cervical cancer patients more often have nonsquamous histology and are likely to receive only radiation therapy compared to younger patients. Treatment with chemoradiation was associated with similar survival increases in both age cohorts. Complication rates between the two were similar. Chemoradiation should be considered in elderly patients with invasive cervical cancer.

FDG-PET in the detection of recurrence of uterine cervical carcinoma following radiation therapy—tumor volume and FDG uptake value

PURPOSE

We evaluated the use of positron emission tomography (PET) with fluorine-18-labeled fluoro-2-deoxy-d-glucose (FDG) in follow-up study after radiation therapy in patients with uterine cervical carcinoma.

MATERIALS AND METHODS

Thirty-two studies in 25 patients were reviewed. Twenty patients were treated with external beam irradiation and intracavitary brachytherapy, and five with irradiation following initial surgery. Time from initial treatment to FDG-PET was 23.3 (5.2-88.0) months. Rationale for FDG-PET was the presence of symptoms in 6 patients, abnormal serum tumor marker values in 13, abnormal lesions on other diagnostic imaging modalities in 19, and patient request in 2. On visualization of a lesion, the maximum standardized uptake value (maxSUV) of the lesion was calculated, and values over 2.0 were classified as FDG-positive. Maximum tumor diameter and tumor volume in the corresponding disease were estimated by computed tomography (CT) or magnetic resonance imaging (MRI).

RESULTS

Sensitivity and specificity of FDG-PET in the detection of recurrent disease were 91.5% (43/47) and 57.1% (4/7), respectively. Four false-negative findings were seen for small lung metastases having a volume less than 1 cm3. Three false-positive cases were a localized pneumonitis, a benign pubic bone fracture, and a fibrosis after interstitial brachytherapy. Sensitivity for extrapelvic lymph node metastases was extremely high (100%); in contrast, sensitivity and specificity for lung and bone lesions were 75.0% (12/16) and 33.3% (1/3), respectively. Regarding tumor volume measurement, good correlation between maxSUV on FDG-PET and tumor volume was obtained (lung metastases, P = 0.03; extrapelvic nodes, P < 0.0001). Within this study, all corresponding lesions over 1 cm3 showed a maxSUV value greater than 2.0.

CONCLUSION

FDG-PET is a useful tool for the detection of extrapelvic lesions during the follow-up period after radiation therapy for cervical cancer. This study suggests that FDG uptake is associated with tumor volume, and FDG-PET has limitations in the detection of lesions less than 1 cm3 or microscopic disease. Careful diagnostic agreement between PET and CT/MRI for positive but benign lesions, such as inflammation and bone fracture, remains important.

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.

Expression of hypoxic-inducible factor 1α predicts metastasis-free survival after radiation therapy alone in stage IIIB cervical squamous cell carcinoma

PURPOSE

Hypoxia-inducible factor-1alpha (HIF-1alpha) is an intrinsic marker of tumor hypoxia. It has been considered that the hypoxic status reduces radiosensitivity, but the role of HIF-1alpha in advanced cervical carcinoma is still unclear. The objective of this study was to clarify the impact of HIF-1alpha, human papillomavirus (HPV), and other molecular factors, such as p53, bax, bcl-2, and their correlations on the outcome of patients with Stage IIIB cervical carcinoma in radiation therapy.

METHODS AND MATERIALS

We analyzed 38 patients with FIGO Stage IIIB squamous cell carcinoma of the cervix treated with radiation therapy alone. All patients received the combination therapy of external beam irradiation and low-dose-rate intracavity brachytherapy. The tumor expressions of HIF-1alpha, p53, bax, and bcl-2 were examined by immunohistochemical staining of the pretreatment paraffin embedded specimens. HPV infection was also detected by polymerase chain reaction. The effects of these parameters on clinical outcomes were analyzed by univariate analysis.

RESULTS

Of 38 patients, high expression of HIF-1alpha, p53, bax, and bcl-2 were seen in 17 (45%), 22 (58%), 15 (39%), and 15 (39%) patients, respectively, and 28 patients (74%) showed positive infection with HPV. There was a significant positive correlation between high HIF-1alpha expression and disease recurrence (p < 0.05). Furthermore, HIF-1alpha had a significant correlation with the recurrence-free survival rate (p = 0.04). No statistical correlation was noted between high HIF-1alpha expression and the local control rate (p = 0.17), whereas the HIF-1alpha status predicted distant metastasis with strong significance (p = 0.03). Conversely, other factors demonstrated no impact on the clinical outcome.

CONCLUSIONS

The present results suggest that HIF-1alpha is an important prognostic factor, especially for predicting future metastasis after radiation therapy for patients with Stage IIIB squamous cell carcinoma of the cervix.

Cervical carcinoma in the elderly

BACKGROUND

Advanced age often is considered a poor prognostic factor for cervical carcinoma. The authors investigated the patterns of care and treatment outcomes of elderly women with cervical carcinoma.

METHODS

A hospital-based tumor registry was used to identify patients with invasive cervical carcinoma who were treated between 1986 and 2003. Patients were divided into 2 cohorts: women age < 70 years and women age > or = 70 years. Survival was examined using the Kaplan-Meier method. Single and multivariate Cox proportional hazards modeling was used to estimate hazard ratios with 95% confidence intervals (95% CI).

RESULTS

In total, 1582 patients were identified, including 1385 patients age < 70 years and 197 patients age > or = 70 years. The elderly patients presented with more advanced stage tumors at diagnosis (P <0.0001) and were more likely to have nonsquamous neoplasms (P=0.002). A marked difference in treatment was noted for the elderly cohort, even after stratifying by disease stage. Only 16% of the older patients underwent surgical treatment compared with 54% of the younger patients (P <0.0001). Elderly women were 9 times more likely to receive no treatment (P <0.0001). In a multivariate model of known prognostic factors, the hazard ratio for death from any cause in women age > 70 years was 2.1 (95% CI, 1.5-3.0). The hazard ratio for death from cervical carcinoma in the elderly women was 1.6 (95% CI, 1.1-2.5).

CONCLUSIONS

Age is an important factor in the allocation of treatment and survival for patients with cervical carcinoma. Elderly women with cervical carcinoma are more likely to receive primary radiotherapy, to forego treatment, and to die from their disease.

Survival and prognosis of women with invasive cervical cancer according to age

OBJECTIVES

We assessed survival and compared clinical and pathological prognostic factors of women with invasive cervical cancer according to the age in order to define a cutoff point where screening should become useless.

METHODS

The survival of 308 women with invasive cervical cancer treated at Bordeaux University Hospital between 1976 and 1996 was evaluated on December 31, 2000. Kaplan-Meier survival curves calculated with regard to age were compared by the log-rank test. Prognostic factors were assessed according to age (cutoff 65 years) and included in a Cox model. Survival of women in our population within a particular age group was compared to survival of women of the same age range, using indirect standardization.

RESULTS

The 5-year survival rate of women under 65 (n = 221), between 65 and 74 (n = 56), and over 75 (n = 31) was 75%, 69%, 42%, respectively (P < 0.001). Compared to women under 65, women over 65 had a significantly lower Karnofsky performance status and a significantly more advanced clinical stage cancer involving vaginal bleeding. Age, gross cervical appearance, clinical vaginal involvement, histologic grade, and microscopic cervical and parametrial involvements were independent prognostic factors. Compared to women under 65, the risk of mortality was 1.3, 95% CI = 0.8-2.7, P = 0.189, for women aged 65-74, and 2.3, 95% CI = 1.1-3.9, P = 0.022, for women over 75. Mortality of women with invasive cervical cancer was significantly higher than that of women in the general population in the indirect standardization model (SMR = 1.9, 95% CI = 1.5-2.2), except beyond age 75.

CONCLUSIONS

Age was a significant prognostic factor in our study and advanced stages were significantly increased after 65. However, survival after 75 was not different from that of the population. These considerations address the question of the maintenance of screening between 65 and 75.

Analysis of recurrence of squamous cell carcinoma of the uterine cervix after definitive radiation therapy alone: patterns of recurrence, latent periods, and prognosis

PURPOSE

A retrospective analysis was performed with emphasis on the patterns of recurrence, latent period, and prognosis in patients with cervical squamous cell carcinoma of the uterus treated with definitive radiation therapy alone. Late recurrence, which was observed more than 5 years after the initial radiation therapy, was finally focused on and discussed.

MATERIALS AND METHODS

Between 1976 and 1994, 256 patients with squamous cell carcinoma of the uterine cervix without hematogenous metastasis were treated with definitive radiation therapy alone. The patients were staged as follows according to the FIGO classification: 26 in Stage I, 56 in Stage II, 124 in Stage III, 28 in Stage IVa, and 22 in Stage IVb. All the patients were treated with external beam irradiation and low-dose-rate intracavitary brachytherapy.

RESULTS

A total of 74 patients had recurrence. The recurrence appeared in 67 cases (90.5%) within 5 years. Metastasis to para-aortic and/or supraclavicular nodes developed later than other types of recurrence. Among patients with lymphogenous metastasis, there were more 5-year survivors after recurrence than with other types of recurrence. Patients with early recurrence, within 2 years of the initial therapy, had a worse prognosis than those with recurrence more than 2 years after treatment. Seven patients (2.7%) in all developed late recurrence more than 5 years after the treatment. The first site of recurrence was an abdominal para-aortic or supraclavicular node in all patients, excluding one patient who developed intrapelvic lymph node metastasis. Six patients had pelvic node metastasis detected with lymphangiography at the initial treatment. Median survival after late recurrence was 16.0 months. Two of 7 patients survived more than 3 years after secondary radiation therapy, and the remainder died of recurrent disease.

CONCLUSION

Patients with para-aortic and/or supraclavicular node metastasis that developed late after the initial treatment are more likely to survive due to secondary radiation therapy. Careful follow-up is emphasized for long-term survivors.

Brachytherapy in the elderly

A rapidly and constantly increasing aged population in the western countries poses a wide range of specific problems to oncologists. A different way to face medical issues should be sought for older patients with cancer, looking at the characteristics that are peculiar to the elderly from different points of view. Brachytherapy is an effective form of radiotherapy which, for its specific characteristics, may be a valid alternative to more complex modalities of treatment, thus allowing a better sparing of normal tissues and structures yet achieving a similar tumor control rate. This paper reviews the literature on the subject of cancer treatment in the elderly, focusing on radiotherapy and brachytherapy, to evaluate the current attitude toward this problem in the medical community and to see if it is possible to identify a patient population that will benefit from this technique.

The effects of p53 status and human papillomavirus infection on the clinical outcome of patients with stage IIIB cervical carcinoma treated with radiation therapy alone

BACKGROUND

It has been suggested that the p53 tumor suppressor gene regulates the radiosensitivity in human malignancies after irradiation; however, in cervical carcinoma, the role of the p53 gene is still unclear because of inactivation of functional p53 by infection with human papillomavirus (HPV). The objective of this study was to clarify the effects of p53 status and HPV infection on the clinical outcome of patients with cervical carcinoma after undergoing radiation therapy.

METHODS

Fifty-two patients with International Federation of Gynecology and Obstetrics Stage IIIB squamous cell carcinoma of the cervix who received radiation therapy alone were reviewed. The combination of external beam irradiation therapy and three sessions of intracavity brachytherapy irradiation was performed for all patients. Genomic DNA extracted from paraffin embedded tissues was examined for HPV types 16, 18 and 33 by the polymerase chain reaction (PCR) method and for p53 status by PCR-single-strand conformation polymorphism (PCR-SSCP) technique. The effects of HPV infection, p53 status, and other parameters on clinical outcome were investigated by univariate analysis.

RESULTS

HPV-DNA was detected in 40 patients (76.9%), and 14 patients (26.9%) had mutations of the p53 gene in the study. There was a significant correlation between the existence of HPV and p53 status (P < 0.001). Mutations of the p53 gene were detected in 6 of 12 patients (50%) who had local recurrent tumors, whereas p53 were wild type in 32 of 40 patients (80%) who achieved local control. The p53 mutation had a significant correlations with local tumor recurrence. Furthermore, p53 status caused statistical significant differences in the curves of the recurrence free survival rate and local control rate as determined by the log rank test (P = 0.02 and P = 0.03, respectively). Conversely, no obvious correlation with any clinical outcome for patients with cervical carcinoma was found concerning HPV infection.

CONCLUSIONS

It is possible that the p53 gene may be used as a predictive factor in radiation therapy for patients with Stage IIIB squamous cell carcinoma of the cervix.

Radiotherapy in the management of cervical cancer in elderly patients

PURPOSE

To report treatment results and complications experienced by elderly patients treated with curatively intended radiotherapy for cancer of the uterine cervix.

PATIENTS AND METHODS

One hundred and fourteen elderly patients (median 75.5 years, range 70.0-85.9) consecutively referred for curative radiotherapy in the period 1987-1996 were prospectively followed with regard to tumour control and complications. The importance of age, stage (FIGO), tumour size, histology, tumour fixation, haemoglobin, concurrent disease, performance status (WHO) and type of radiotherapy were assessed using univariate and multivariate analyses.

RESULTS

Treatment was completed as planned in 68%, delayed in 29% and stopped prematurely in 3%. The frequency of grade 3 late complications was 11% and the actuarial probability at 5 years was 20%. Overall 5-year survival according to FIGO was 61% (I), 34% (II) and 25% (III). Cox multivariate analysis identified tumour size as independent prognostic factor for tumour control, disease-free survival and overall survival. FIGO stage was predictive for late grade 2 complications. We were unable to identify significant factors with respect to grade 3 complications. Age was not a significant parameter for any of the investigated endpoints.

CONCLUSION

Elderly patients in good performance status with advanced cancer of the uterine may tolerate radical radiotherapy with acceptable morbidity and reasonable survival. Radiotherapy may also be a good alternative in early stage disease for surgically unfit elderly patients.

Radiation therapy for elderly patient with squamous cell carcinoma of the uterine cervix

OBJECTIVE

The purpose of this study was to profile cervical squamous cell carcinoma in elderly patients undergoing radiation therapy and to study the treatment outcome and side effects of therapy.

MATERIALS AND METHODS

A retrospective analysis was carried out from the records of 380 patients with squamous cell carcinoma of the uterine cervix who had been given radiation therapy between 1970 and 1994. The patients were divided into three age groups: under 70 years (youngest group; n = 215), 70 to 79 years (intermediate group; n = 124), and 80 years or older (oldest group; n = 41). Radiation therapy was performed by a combination of external beam therapy and three brachytherapy fractions using low-dose-rate sources.

RESULTS

The 5-year overall survival rates in the youngest, intermediate, and oldest groups were 58, 50, and 33%, respectively, while cause-specific survival rates were 68, 70, and 65%, respectively. For the patients with stage III, the 5-year overall survival rates in the youngest, intermediate, and oldest groups were 59, 48, and 36%, respectively, while cause-specific survival rates were 72, 70, and 70%, respectively. There was no statistical significance in the 5-year intrapelvic recurrence rates among the three groups. Grade 3 or 4 complications occurred in 6.5% of the youngest, 11.3% of the intermediate, and 7.3% of the oldest groups.

CONCLUSION

Radiation therapy with external beam combined with three fractions of low-dose-rate brachytherapy proved both highly effective and safe for senior patients with cervical squamous cell carcinoma.

Cancer in patients aged 90 years or older: radiation therapy

PURPOSE

To investigate the clinical efficacy of radiation therapy for cancer in patients aged 90 years or older.

MATERIALS AND METHODS

Cancer cases in 32 patients (11 men, 21 women) aged 90 years or older who underwent radiation therapy in 1970-1997 were retrospectively analyzed. The mean patient age was 92.2 years, with a range of 90-98 years. Head and neck cancer (n = 14 [44%]) and skin cancer (n = 6 [19%]) were the most common.

RESULTS

Eleven (79%) of the 14 patients with head and neck cancer were treated with curative intent. Radiation response without any severe complication was observed in nine (90%) of the 10 patients with head and neck cancer treated with curative intent who finished treatment. The median survival time was 8 months (range, 3-55 months) in the 10 patients with head and neck cancer who completed treatment with curative intent. Complete response was achieved in all of the patients with skin cancer without any major sequelae. Complete response was also observed in all three of the patients with non-Hodgkin lymphoma, but two patients treated with adjuvant chemotherapy died of drug-induced pneumonitis. Palliation was achieved in all nine of the patients treated with palliative intent.

CONCLUSION

Age of 90 years or older is not a limiting factor for radiation therapy.

[Radiotherapy of the elderly patient. Radiotherapy tolerance and results in older patients]

BACKGROUND

Despite a growing number of elderly patients receiving radiation therapy little is known about side effects and outcome of irradiation in this section of the population.

METHODS

In a review article epidemiologic data, aspects of radiation-biology as well as side effects and outcome of radiation therapy of elderly patients are discussed.

RESULTS

Cancer incidence rises with age (Figure 1) and is exceeding 3.5% for males older than 85 years. With a life expectancy of more than 4 years, curative therapy is indicated even at this age. Furthermore several retrospective studies indicate that local control and disease-Specific survival after radiation therapy of elderly patients is comparable with that of younger persons (Tables 3 and 4). The exception contains elderly patients with Grade-III to IV gliomas or with rectal carcinoma who show a reduced survival which is perhaps caused by less aggressive combined treatment (tumor resection). Although some biological and molecular data indicate a rise in radiation sensitivity with growing age like the reduction of the capacity of some DNA-repair enzymes, there is no convincing evidence in animal studies or in retrospective clinical studies that radiation therapy is generally less well tolerated by older individuals (Tables 1 and 2). Some age-depending differences in organ toxicities are described in 3 large studies, which evaluate the data of patients who were enrolled in different EORTC-trials: Older patients suffer more of functional mucositis in case of radiation therapy to the head and neck, they have an increased weight loss and a higher frequency of late esophageal damage when irradiated in the thorax, and they show a higher prevalence of sexual dysfunction when treated with radiation therapy to the pelvis. On the other hand younger patients suffer more from acute toxicity like skin damage, nausea, and deterioration of the performance status during pelvic radiotherapy. When discussing the dose intensity of radiation therapy concomitant disease which leads to extensive atherosclerotic vessel damage should be kept in mind. Old patients should be monitored closely during therapy, since the loss of electrolytes or fluid is often not very well tolerated.

CONCLUSION

The indication to radiation therapy of elderly cancer patients should take into account their performance status as well as the extent and the severity of comorbidity. Age per se is seldom a contraindication for radiation therapy. Regarding the available data in literature there is no indication for a dose reduction in radiation therapy only because of age, especially in the curative setting.

Treatment of anal carcinoma in the elderly: feasibility and outcome of radical radiotherapy with or without concomitant chemotherapy

BACKGROUND

For most cancers, information on treatment tolerance and results for elderly patients is quite limited. This study was conducted to investigate the feasibility and results of curative nonsurgical treatment of patients age 75 years or older with anal carcinoma.

METHODS

From January 1976 through June 1996, invasive anal squamous cell carcinoma was diagnosed in 58 patients age > or = 75 years. Curative treatment was administered to 47 patients (81%), of whom 42 received radiotherapy (RT), either used alone (21) or associated with concomitant chemotherapy (CT). RT was administered in two sequences, the first in which a median dose of 39.6 gray (Gy) was delivered with megavoltage photon beams, followed (after a median interval of 43 days) by a boost with either brachytherapy or external beam (median dose, 20 Gy). CT started on Day 1 and generally consisted of 1 cycle of mitomycin C (MMC; median dose, 9.5 mg/m2) and a 96-hour infusion of 5-fluorouracil (5-FU; median dose, 600 mg/m2/day). The median follow-up for all patients was 48 months (range, 5-163 months).

RESULTS

Of 40 patients (95%) who completed curative treatment, acute toxicity resulted in shortening of the planned first irradiation sequence in 2 patients (1 in each group) and an unplanned treatment break in 11 patients (4 in the RT group and 7 in the RT-CT group). Grade 2 and 3 acute reactions (RTOG) were observed in 43% and 54% of patients, respectively. Among all Grade 3 reactions, 32% occurred in the RT group and 68% in the RT-CT group. In patients receiving RT-CT, Grade 2-3 leukopenia was observed in 25% of patients, Grade 2-3 fatigue was observed in 58% of patients, and Grade 2 cardiac toxicity related to 5-FU occurred in 1 patient. At 5 years, the overall survival was 54% (49% and 59% for the RT and RT-CT groups, respectively, P = 0.28), and the actuarial local control rate was 78.5% (73% and 83% for the RT and RT-CT groups, respectively, P=0.36). Five patients presented with Grade 3-4 late complications, all of them in the RT-CT group.

CONCLUSIONS

The current series confirms the feasibility of sphincter-conserving treatment for elderly patients who present with anal carcinoma. Rates of acute or late complications appeared similar to those observed in younger patients, and the oncologic results were at least as favorable as those commonly reported.

Cervical cancer in the elderly treated with radiation therapy

OBJECTIVES

The aim of this study was to evaluate the tolerance and outcome of elderly cervical carcinoma patients treated with radiation therapy (RT).

METHODS

Three hundred ninety-eight patients with stage I-III cervical carcinoma treated with definitive RT were analyzed. Patients were divided into nonelderly (ages 35-69) (n = 338) and elderly (ages >/= 70) (n = 60) groups. A comparison of patient, tumor and treatment factors, morbidity, and outcome was performed. Median follow-up was 81 months.

RESULTS

Elderly patients had a higher rate of comorbid conditions including diabetes (P = 0. 02), coronary artery disease (P = 0.003), and hypertension (P = 0. 001) than younger patients. Comorbid conditions in the elderly resulted in more frequent treatment breaks and less ability to undergo definitive treatment with intracavitary RT (ICRT). While the 5-year actuarial disease-free (DFS) and cause-specific (CSS) survival rates were comparable between the two groups, disease recurrence and death from cervical cancer were more common beyond 5 years in the elderly group. When patients not undergoing ICRT and those with treatment protraction were excluded, differences in the DFS and CSS curves were no longer evident. The frequency and severity of acute and chronic sequelae were similar.

CONCLUSIONS

Elderly cervical carcinoma patients have an equivalent overall outcome following radiation therapy to younger patients when comparable treatment is delivered. Age per se is not associated with a higher rate of acute or chronic sequelae. Comorbid conditions adversely impacted on the quality and delivery of RT in the elderly group and help explain observed differences in outcome based on age.

Transrectal ultrasonography in evaluation of chronic rectal complications after radiation therapy for carcinoma of the uterine cervix

RATIONALE AND OBJECTIVES

The authors studied the ability of transrectal ultrasonography (TRUS) to assess chronic rectal complications after radiation therapy for carcinoma of the uterine cervix.

METHODS

One hundred twenty-five TRUSs were performed for 67 consecutive patients with carcinoma of the uterine cervix. Transrectal ultrasonography images of the rectal anterior wall and perirectal connective tissue adjacent to the uterine cervix were recorded with real-time scanner with 7.5 MHz transducer. The severity of TRUS abnormalities was graded on a scale developed by the authors. The relationships of the TRUS grade with the clinical grade of chronic rectal complications and with rectal radiation doses were analyzed retrospectively.

RESULTS

Thickening of the perirectal connective tissue associated with obscuration of the submucosal echogenic layer in rectal anterior wall was observed between 6 months to 2 years after radiation therapy in all 19 patients who developed chronic rectal complications. The TRUS grade correlated with the clinical grade of chronic rectal complications, but did not correlate with rectal radiation doses.

CONCLUSIONS

Transrectal ultrasonography can monitor the chronic rectal complications after radiation therapy for the patients with carcinoma of the uterine cervix.

Patterns of care for invasive cervical cancer. Results of a national survey of 1984 and 1990

BACKGROUND

The American College of Surgeons conducted a national patient care and evaluation study of invasive cervical cancer to measure any changes in patterns of care for the years 1984 and 1990.

METHODS

Hospitals with cancer programs were invited to submit data on up to 25 consecutive patients with newly diagnosed invasive cervical cancer for each of the two study years. Data were obtained from 684 hospitals on 5904 patients diagnosed in 1984 and from 700 hospitals on 5817 patients diagnosed in 1990. A long term study of patients diagnosed in 1984 was compared with a short term study of patients diagnosed in 1990. Survival data were described only for patients diagnosed in 1984.

RESULTS

Of a total of 11,721 patients, 59.4% were diagnosed and treated at the reporting institution in 1984 and 54.8% in 1990. The remaining patients were referred for treatment after diagnosis elsewhere. The diagnosis was established by cervical biopsy for 69.8% of patients, by conization alone for 9.3%, and by both procedures for 11.8%. The histopathologic diagnoses were squamous cell carcinoma (79.8%), adenocarcinoma (15.8%), and other (4.4%). The stage distributions were as follows: IA, 15.9%; IB, 36.8%; IIA, 8.2%; IIB, 15.5%; IIIA, 2.5%; IIIB, 13.3%; IVA, 2.6%; and IVB, 5.2%. The stage was listed as unknown for 20.3% of patients. Patients were treated with surgery alone (29.2%), radiation alone (40.7%), chemotherapy alone (0.7%), or combination therapy (21.5%), and 7.9% received no treatment at the reporting institution. The overall survival for patients diagnosed in 1984 was 68.3%. Survival by stage in this group was as follows: IA, 93.7%; IB, 80.0%; IIA, 67.2%; IIB, 64.7%; III, 37.9%; and IV, 11.3%.

CONCLUSIONS

These data indicate that invasive cervical cancer is highly curable when diagnosed early. During the 5-year period, stage distributions were similar, the use of extended hysterectomy increased, and gynecologic oncologists were more often the primary surgeons. The use of radiation alone decreased.