Cancer in patients aged 90 years or older: radiation therapy

Outcome of radiotherapy for the treatment of laryngeal squamous cell carcinoma in the very elderly population

BACKGROUND

Treatment selection for squamous cell carcinoma patients aged over 84 years is controversial. This retrospective chart review examined and compared characteristics of laryngeal squamous cell carcinoma in very elderly (over 84 years) and younger patients (approximately 65 years). The secondary objective was to further evaluate the outcome of radiotherapy as a treatment modality in this patient population.

METHODS

Of all 23 very elderly patients with laryngeal squamous cell carcinoma treated with radiotherapy, with or without surgery, in the Davidoff Cancer Center, from 1992 to 2012, 19 had sufficient data for analysis, and comprised the study group.

RESULTS

Median age at diagnosis was 86 years. Disease stage at diagnosis was I, II, III and IVA in 53 per cent, 21 per cent, 21 per cent and 5 per cent, respectively. Median radiotherapy dose was 60 Gy given in 25 fractions. Three patients had recurrence. No patient discontinued treatment because of toxicity. Median overall survival was 3.6 years (range, 0-10 years).

CONCLUSION

Very elderly laryngeal squamous cell carcinoma patients may derive a similar survival advantage as younger counterparts. Modern radiotherapy is effective and safe for treating laryngeal squamous cell carcinoma in this study population. Further, large-scale studies are needed.

Radiotherapy for nonagenarians: the value of biological versus chronological age

Background

The number of nonagenarian cancer patients (≥ 90 years) is continuously increasing, and radiotherapy is performed in a relevant proportion of patients, as surgery and chemotherapy are often not feasible for these patients. However, the evidence regarding the feasibility and treatment outcomes after radiotherapy for this patient group is very limited.

Methods

All nonagenarian patients receiving (chemo) radiotherapy between 2009 and 2019 at the University of Freiburg - Medical Center were analyzed for patterns of care, overall survival (OS) and therapy-associated toxicities according to the Common Terminology Criteria for Adverse Events. Uni- and multivariate Cox regression analyses were conducted to assess the influence of patient- and treatment-related factors on patient outcomes.

Results

One hundred nineteen patients with a total of 137 irradiated lesions were included in this analysis. After a median follow-up of 27 months, median OS was 10 months with a 3-year OS amounting to 11.1%. Univariate analyses demonstrated that a reduced performance status (HR = 1.56, 95% CI 1.00–2.45, p < 0.05), a higher burden of comorbidities (HR = 2.00, 95% CI 1.00–4.10, p < 0.05) and higher UICC tumor stages (HR = 2.21, 95% CI 1.14–4.26, p < 0.05) were associated with impaired survival rates. Split-course treatments (HR = 2.05, 95% CI 1.07–3.94, p < 0.05), non-completion of radiotherapy (HR = 7.17, 95% CI 3.88–13.26, p < 0.001) and palliative treatments (HR = 2.84, 95% CI 1.68–4.81, p < 0.05) were found to result in significantly reduced OS. In the multivariate analysis, split-course concepts (HR = 2.21, 95% CI 1.10–4.37, p < 0.05) and palliative treatments (HR = 3.19, 95% CI 1.77–5.75, p < 0.001) significantly deteriorated outcomes, while impaired ECOG status (HR = 1.49, 95% CI 0.91–2.43, p = 0.11) did not. The vast majority of patients reported either no (n = 40; 33.6%) or grade 1–2 acute toxicities (n = 66; 55.5%), and only very few higher-grade toxicities were observed in our study.

Conclusion

Radiotherapy for nonagenarian patients is generally feasible and associated with a low toxicity profile. Given the relatively poor OS rates and the importance of the quality of life for this patient group, individualized treatment regimens including hypofractionation concepts should be considered.

Free Flaps for Advanced Oral Cancer in the "Older Old" and "Oldest Old": A Retrospective Multi-Institutional Study

Introduction: Surgery followed by adjuvant therapy represents the most adequate treatment for advanced oral squamous cell carcinoma (OSCC). Free flaps are considered the best reconstructive option after major oral surgery. In the last decades, OSCC has increased in the elderly due to an augmented life span. The aim of this work is to evaluate the feasibility of microvascular surgery in patients older than 75 years, focusing on clinical and surgical prognosticators.

Methods: “Older old” (aged ≥ 75) and “oldest old” (>85) patients who underwent microvascular reconstruction for OSCC from 2002 to 2018 were retrospectively evaluated in three referral Head and Neck Departments. Demographic, clinical, and surgical data were collected and analyzed. Pre-operative assessment was performed by ASA and ACE-27 scores. Complications were grouped as medical or surgical, and major or minor according to the Clavien-Dindo scale.

Results: Eighty-four patients (72 “older old” and 12 “oldest old”) were treated with a free flap success rate of 94.1%. Thirty-seven (44.7%) and nine (10.7%) patients had minor and major medical complications, respectively; 18 (21.4%) and 17 (20.2%) had minor and major surgical complications, respectively. Twenty-one (25%) patients had both medical and surgical complications (with a statistically significant association, p = 0.018). Overall, 52 (61.9%) patients had at least one complication: ASA score, diabetes mellitus, and duration of general anesthesia (DGA) significantly impacted the complication rate at multivariate analysis.

Conclusion: Our data confirm the feasibility of free flaps for OSCC reconstruction in appropriately selected elderly patients. Pre-operative assessment and aggressive management of glycemia in patients with diabetes is mandatory. DGA should be reduced as much as possible to prevent post-surgical complications. Comprehensive geriatric assessment is of paramount importance in this subset of patients.

Palliative beam radiotherapy offered real-world survival benefit to metastatic rectal cancer: A large US population-based and propensity score-matched study

Purpose: Radiotherapy (RT) has been reported to effectively palliate many symptoms of patients with metastatic rectal cancer (mRC). The objective of this study was to evaluate the survival benefit of RT in mRC. Methods: A retrospective population-based cohort study was performed using the Surveillance, Epidemiology, and End Results Program (SEER) database. Patient baseline demographic characteristics between the RT and no-RT groups were compared using Pearson chi-square tests. The outcome of interest was cause-specific survival (CSS). Propensity score (PS) matching and Cox proportional hazards regression analyses were performed to evaluate the prognostic power of variables on CSS. Results: A total of 8851 patients with mRC were identified in the SEER database. Multivariable Cox regression analysis showed that RT was a protective factor in mRC (hazard ratio [HR]= 0.702, 95% confidence interval [CI]=0.665-0.741, p<0.001). In subgroup analysis, multivariate Cox analysis demonstrated that patients of both surgery and no-surgery subgroups treated with RT had better CSS than those not treated with RT (HR=0.654, 95%CI=0.607-0.704, p<0.001 for the surgery group; HR=0.779, 95%CI=0.717-0.847, p<0.001 for the no-surgery group), PS matching resulted in 4170 mRC patients and RT group presented significantly improved survival benefit than no-RT group (22.0 vs. 13.5%, P <0.001). In surgery subgroup after PS matching, in especial, RT group showed more evidently improved survival benefit than no-RT group (30.3 vs. 18.0%, p <0.001). Conclusion: Using the SEER database, we definitely demonstrated that RT was associated with a significant survival advantage beyond the relief of a variety of pelvic symptoms in the setting of mRC. This study strongly supports the use of RT in selected patients with mRC, especially in patients who have undergone surgery. More studies need to be conducted to accurately define the role of RT in mRC.

Radical radiotherapy for carcinoma of the larynx in the elderly: Functional and oncological outcomes from a tertiary cancer care center in India

INTRODUCTION

It is estimated that around 10% of all head and neck cancer patients in India are aged over 70 years. Elderly patients are often subjected to palliative or inadequate treatment for head and neck cancers in spite of being candidates for curative intent therapy. In this study we evaluated our use of radical radiotherapy in carcinoma larynx for patients over seventy years of age to determine morbidity, likelihood of completing therapy, functional and oncological outcomes.

MATERIALS AND METHODS

132 patients of squamous cell carcinoma of the larynx treated between 2005-2015 at Amrita Institute of Medical Sciences, Kochi who were seventy years of age or older were included. The endpoint for analysis was overall survival. Survival curves were generated using Kaplan Meier method and univariable analysis was performed using log rank test.

RESULTS

The median age of patients was 77 years (range 70-102). All patients (100%) completed radiotherapy with 6 (5%) requiring treatment breaks. All patients had at least minor (grade I/II) toxicities. Grade III toxicities were seen in 10 (8%) of patients. No grade IV reactions or treatment related deaths occurred. When a univariate analysis was performed for determinants of major toxicities with age range, performance status, smoking, number of co-morbidities or TNM stage, no determinants were statistically significant. 2-year disease free survival for stage I, II, III and IV was 100%, 98%, 80% and 64% respectively, and the 2-year overall survival for all four stages was 100%.

CONCLUSION

Patients over seventy years tolerate radical radiotherapy for treatment of laryngeal cancer. In spite of minor toxicities, all patients completed treatment and had good oncological outcomes. Patients with stage III/IV unfit for concomitant chemotherapy administration treated with radiotherapy alone had a good disease free survival. Curative intent therapy should not be withheld from elderly patients on the basis of age.

Head and Neck Cancer and the Elderly Patient

Management of head and neck cancer in the elderly patient is particularly challenging given the high morbidity associated with treatment. Surgery, radiotherapy, and chemotherapy have all been demonstrated as effective in older patients; however, older patients are more susceptible to treatment-induced toxicity, which can limit the survival benefits of certain interventions. This susceptibility is better associated with the presence of multiple comorbidities and decreasing functional status than with age alone. Screening tools allow for risk stratification, treatment deintensification, and even treatment avoidance in patients who are deemed at high-risk of being harmed by standard therapy.

IMRT/VMAT for malignancies in the head-and-neck region : Outcome in patients aged 80

Objective

Elderly patients with malignant head-and-neck tumors (HNT) often pose a therapeutic challenge. They frequently have significant comorbidities which may influence their ability to tolerate tumor-specific therapies. Our aim was to investigate the outcome of patients aged 80+ years undergoing curative intent intensity- or volume-modulated radiation therapy (IMRT/VMAT).

Methods

We retrospectively reviewed our HNT patients aged 80+ treated with curative IMRT/VMAT from December 2003 to November 2015. Overall survival (OS), disease-free survival (DFS), local control (LC), and treatment tolerance were assessed. Outcome results were compared with that of a younger HNT patient cohort from our hospital.

Results

A total of 140 consecutive patients were included (65 postoperative, 75 definitive). Mean/median age at treatment start was 84.8/84.1 years (range 80–96 years). Mean/median follow-up time was 25/16 months (range 2–92 months). Of the 140 patients, 80 were alive with no evidence of disease when last seen, 28 had died due to the cancer, 12 remained alive with disease, the remaining 20 died intercurrently. Systemic concomitant therapy was administered in 7 %. Late grade 3–4 toxicity was observed in 2 %. All patients completed treatment. Hospitalization and feeding tube rates were 26 % and 11 %, respectively. The 2‑/3-year LC, DFS, and OS rates for the entire cohort were 81/80 %, 69/63 %, and 68/66 %, respectively. Squamous cell carcinoma (SCC) patients showed an inferior 3-year OS rate as compared to non-SCC patients (62 % vs 77 %, p = 0.0002), while LC and DFS did not differ. Patients undergoing postoperative radiation attained a higher OS compared to the definitively irradiated subgroup with 74 vs. 60 % at 3 years (p = 0.01); however, DFS rates were similar for both groups (68 vs. 61 %, p = 0.15). Corresponding rates for >1400 HNT patients <80 years treated during the same time interval were 81/80 %, 69/67 %, and 77/72 %, respectively.

Conclusions

Treatment tolerance in our patients aged 80+ was high. These results suggest that elderly HNT patients should not be denied potentially curative treatment strategies.

[Survey on the Choice of the Treatment in Elderly Patients with Head and Neck Cancer]

The elderly population has been increasing, in Japan. With this increase, the incidence of elderly patients with head and neck cancer is likely to increase concomitantly. Therefore, a strategy for addressing this problem must be defined. In this study, a questionnaire for head and neck cancer specialists, certified by the Japanese Society of Head and Neck Surgery, is analyzed. The survey was conducted in 225 head and neck cancer specialists, and 122 answers were complete and bare analyzed in this study. Comorbidity was found to be the most important factor in decision making for head and neck cancer, even though it is subclinical. Especially important was the cognitive state, the dysfunction of which might decrease the feeling of struggle against the disease. These results indicate that we must choose the appropriate treatment based on the evaluation of the physical and emotional condition of the patients and their families, not only on their age. However, this suggestion includes some problems, such as the fact that the criteria are not definite and the choice of the treatment might be at risk of being judged by only one doctor.

Optimal management of the elderly patient with head and neck cancer: Issues regarding surgery, irradiation and chemotherapy

Head and neck cancer (HNC) represents the sixth most common malignancy and accounts for approximately 6% of new cancer cases annually worldwide. As life expectancy constantly increases, the onset of HNC in patients older than 65 years of age at diagnosis is not rare and up to one fourth of cases occurs in patients older that 70 years at age. Because elderly cancer patients are severely under-represented in clinical trials, there is a clear need to address the particular aspects of this specific patient group, especially in the context of novel multidisciplinary therapeutic approaches. The frailty of elderly patients with HNC is attributed to the high incidence of smoking and alcohol abuse in this malignancy and the presence of substantial cardiovascular, respiratory or metabolic comorbidities. In the current work, I provide an overview of current and emerging treatment approaches, in elderly patients with HNC. In particular, I discuss modern surgical approaches that improve radical excision rates while preserving functionality, the incorporation of modern radiotherapeutic techniques and the introduction of novel chemotherapeutic combinations and molecular targeted agents in an effort to reduce toxicity without compromising efficacy. Finally, there is an urgent need to increase accrual and active participation of elderly patients with HNC in clinical trials, including biomarker evaluation in biopsy specimens towards an individualized therapeutic approach.

Treatment of older patients with head and neck cancer: a review

The incidence of head and neck cancer (HNC) in the elderly is increasing. The treatment of HNC often includes multimodality therapy that can be quite morbid. Older patients (herein, defined as ≥65 years) with HNC often have significant comorbidity and impaired functional status that may hinder their ability to receive and tolerate combined modality therapy. They have often been excluded from clinical trials that have defined standards of care. Therefore, tailoring cancer therapy for older patients with HNC can be quite challenging. In this paper, we performed a comprehensive literature review to better understand and discuss issues related to therapeutic recommendations that are particular to patients 65 years and older. Evidence suggests that older patients have similar survival outcomes compared with their younger peers; however, they may experience worse toxicity, especially with treatment intensification. Similarly, older patients may require more supportive care throughout the treatment process. Future studies incorporating geriatric tools for predictive and interventional purposes will potentially allow for improved patient selection and tolerance to intensive treatment.

The added challenges of bone metastases treatment in elderly patients

Most cancers occur in those older than the age of 65 years. As the population of the world ages and life expectancies continue to increase, it is important to address treatment challenges for elderly patients. This narrative review details the challenges of palliative radiotherapy treatment for elderly patients with bone metastases. We begin with the definition of elderly and its appropriateness, outlining recent demographic data of patients with cancer. The current status of elderly participation in clinical trials is discussed by reviewing the recent literature and clinical trial data. Factors affecting enrolment of the elderly are assessed, with a focus on palliative radiotherapy trials, and what we can do to improve accrual in this data-driven setting. At present, there is a lack of level 1 evidence that evaluates the optimal treatment for elderly patients with bone metastases. Therefore, a review of safety and efficacy is given based on previously published reports. Palliative radiotherapy for elderly patients is a worthwhile treatment and should be recommended regardless of age, as supported by available evidence. Patient, family and physician concerns about physical burden may be reduced as single treatments (that often can be done in a single visit) are as beneficial as multiple treatments for painful bone metastases. In elderly patients, radiotherapy may even be the best treatment for these cases as opioid-related adverse events are amplified in this group and often dosages are more difficult to titrate. Clinicians should continue to encourage the enrolment of elderly patients on to clinical trials as these data form the basis of optimal treatment guidelines. Radiation oncologists are encouraged to reduce the physical burden for elderly patients by offering single treatments where appropriate and completing consultation, treatment simulation and treatment in a single clinical visit.

Squamous cell carcinoma of the head and neck in the elderly

The incidence of head and neck squamous cell carcinoma (HNSCC) peaks between the fifth and seventh decades of life. With prolongation of life expectancy, however, the proportion of elderly HNSCC patients is also increasing, which makes HNSCC in this life period an important issue for healthcare providers. With features characteristic to the older patient groups coupled with the inherent complexity of the disease, HNSCC in the elderly represents a considerable challenge to clinicians. Indeed, to expedite the progress and improve the healthcare system to meet the needs of this unique population of patients, several essential issues related to the clinical profile, diagnostics, optimal treatment and support are of concern and should be addressed in properly conducted clinical trials. In the present review, we analyzed a literature series comparing different age groups with regard to their clinical characteristics, therapy, outcome and quality of life in an attempt to determine their implications on treatment-decision-making for elderly patients with HNSCC.

Aging, cancer, and cancer vaccines

World population has experienced continuous growth since 1400 A.D. Current projections show a continued increase - but a steady decline in the population growth rate - with the number expected to reach between 8 and 10.5 billion people within 40 years. The elderly population is rapidly rising: in 1950 there were 205 million people aged 60 or older, while in 2000 there were 606 million. By 2050, the global population aged 60 or over is projected to expand by more than three times, reaching nearly 2 billion people [1]. Most cancers are age-related diseases: in the US, 50% of all malignancies occur in people aged 65-95. 60% of all cancers are expected to be diagnosed in elderly patients by 2020 [2]. Further, cancer-related mortality increases with age: 70% of all malignancy-related deaths are registered in people aged 65 years or older [3]. Here we introduce the microscopic aspects of aging, the pro-inflammatory phenotype of the elderly, and the changes related to immunosenescence. Then we deal with cancer disease and its development, the difficulty of treatment administration in the geriatric population, and the importance of a comprehensive geriatric assessment. Finally, we aim to analyze the complex interactions of aging with cancer and cancer vaccinology, and the importance of this last approach as a complementary therapy to different levels of prevention and treatment. Cancer vaccines, in fact, should at present be recommended in association to a stronger cancer prevention and conventional therapies (surgery, chemotherapy, radiation therapy), both for curative and palliative intent, in order to reduce morbidity and mortality associated to cancer progression.

Is advanced age a barrier to effective cancer treatment? The experience of nonagenarians receiving radiation therapy

AIM

Decision-making about elderly patients is difficult due to the absence of clinical experience or evidence-based results to develop optimal treatment plans. This study aims to determine the tolerability and impact of radiation therapy (RT) when delivered to patients aged >89 years.

METHODS

A retrospective review was conducted on all nonagenarian patients (defined as aged 90 years or over) managed with RT between 2005 and 2007. Patients' records were reviewed in regard to their characteristics, the presence of significant medical comorbidities, performance status, management intent, cancer diagnosis and RT modality. Outcome end-points were overall survival and the tolerability of RT (presence of grade 3 or 4 morbidity, hospital admission or treatment interruption).

RESULTS

Between 2005 and 2007, 2762 new courses of RT were delivered to patients at the Northern Sydney Cancer Centre, of whom 55, or 2%, were nonagenarians. Median age at treatment was 92 years, with range 90-104 years. A total of 56% were managed with radical intent, 31% had significant comorbidities, 55% had non-skin primary tumors and 78% received linac-based treatment. The mean follow up for survivors was 19.8 months (10.2-41.8 months). RT was well tolerated, with 89% completing planned RT and only 18% requiring interruption. One patient was hospitalized due to RT toxicity. Median survival post-RT was 13.0 months, with 56% of patients alive at 12 months. Survival duration was associated with radical management intent (P= 0.001), cutaneous primary site (P= 0.001) and female gender (P= 0.043).

CONCLUSION

Nonagenarian patients receiving treatment had satisfactory tolerability and achieved expected survival rates post-RT.

The use of radiation therapy in the geriatric population

The foregoing, it is hoped, has provided at least a taste of the past, present, and future in the use of RT for the elderly population. Based on many ongoing studies, it becomes clear that the radiation oncology world has come to recognize the geriatric population’s ability to tolerate, and perhaps even thrive from, a course of RT, when it is offered appropriately. In the final analysis, it has become clear that no simple age cutoff can substitute for clinical acumen and a thorough assessment of patients’ general health before the best treatment regimen can be chosen. One need only follow the trend both in American and in European trials (the RTOG and the EORTC) to appreciate the acceptance that has taken hold that there need not be an age cutoff so much as a set of clinical criteria, including performance status and other assessments of function and comorbidity, prior to patient enrollment in anational trial. With such an outlook, we eagerly anticipate the results from these trials and look forward to implementing them in our treatment of young and old patients alike.

Principles of surgical oncology in the elderly

Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.

Elderly patients with painful bone metastases should be offered palliative radiotherapy

PURPOSE

To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients.

METHODS AND MATERIALS

The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed.

RESULTS

No significant difference was found in the response rate in patients aged >or=65, >or=70, and >or=75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status.

CONCLUSION

Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.

A population-based study of the fractionation of palliative radiotherapy for bone metastasis in Ontario

PURPOSE

To describe the use of palliative radiotherapy (PRT) for bone metastases in Ontario between 1984 and 2001 and identify factors associated with the choice of fractionation.

METHODS AND MATERIALS

Electronic RT records from the nine provincial RT centers in Ontario were linked to the Ontario Cancer Registry to identify all courses of PRT for bone metastases.

RESULTS

Between 1984 and 2001, 44,884 patients received 74,432 courses of PRT for bone metastases in Ontario. The mean number of courses per patient was 1.7, and 65% of patients received only a single course of PRT for bone metastasis. The mean number of fractions per course was 3.9. The proportion of patients treated with a single fraction increased from 27.2% in 1984-1986 to 40.3% in 1987-1992 and decreased thereafter. Single fractions were used more frequently in patients with a shorter life expectancy, in older patients, and in patients who lived further from an RT center. Single fractions were used more frequently when the prevailing waiting time for RT was longer. There were wide variations in the use of single fractions among the different RT centers (intercenter range, 11.8-62.3%). Intercenter variations persisted throughout the study period and were not explained by differences in case mix.

CONCLUSIONS

Despite increasing evidence of the effectiveness of single-fraction PRT for bone metastases, most patients continued to receive fractionated PRT throughout the two decades of this study. Single fractions were used more frequently when waiting times were longer. There was persistent, unexplained variation in the fractionation of PRT among different centers.

Use of palliative radiotherapy among patients with metastatic non-small-cell lung cancer

PURPOSE

Radiotherapy (RT) is known to effectively palliate many symptoms of patients with metastatic non-small-cell lung cancer (NSCLC). Anecdotally, RT is believed to be commonly used in this setting, but limited population-based data are available. The objective of this study was to examine the utilization patterns of palliative RT among elderly patients with Stage IV NSCLC and, in particular, to identify factors associated with its use.

METHODS AND MATERIALS

A retrospective population-based cohort study was performed using linked Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify 11,084 Medicare beneficiaries aged > or =65 years who presented with Stage IV NSCLC in the 11 SEER regions between 1991 and 1996. The primary outcome was receipt of RT. Logistic regression analysis was used to identify factors associated with receipt of RT.

RESULTS

A total of 58% of these patients received RT, with its use decreasing over time (p = 0.01). Increasing age was negatively associated with receipt of treatment (p <0.001), as was increasing comorbidities (p <0.001). Factors positively associated with the receipt of RT included income (p = 0.001), hospitalization (p <0.001), and treatment with chemotherapy (p <0.001). Although the use varied across the SEER regions (p = 0.001), gender, race/ethnicity, and distance to the nearest RT facility were not associated with treatment.

CONCLUSIONS

Elderly patients with metastatic NSCLC frequently receive palliative RT, but its use varies, especially with age and receipt of chemotherapy. Additional research is needed to determine whether this variability reflects good quality care.

Radiation therapy in the elderly

The purpose of this review is to highlight aspects of radiation oncology specifically related to aging and caring for the older patient with cancer. Particular emphasis is placed on the preclinical and clinical studies focusing on the efficacy and toxicity of RT in this population. Special techniques are also reviewed that have particular relevance to the treatment of the elderly.

Treatment of head and neck cancer in elderly patients: state of the art and guidelines

Although the majority of head and neck cancers occur between the fifth and sixth decade, their onset in patients older than 60 years is not a rare event. A peculiar characteristic of almost all case series is the lower prevalence of radical treatments among elderly as compared to younger patients, in particular surgery and combined treatment of surgery plus radiation therapy or chemotherapy and radiation therapy. Radiotherapy is a feasible treatment in elderly patients, also in very advanced age groups and, in the era of organ preservation, chemotherapy combined with RT has a paramount importance. Therapeutical planning must be based not only on tumor characteristics, but also on the physiological, rather than the chronological age the patient. The main clinical problem is, therefore, the selection of patients to be administered anticancer treatment. In patients aged 70 or older, complete geriatric assessment and a multidisciplinary approach are the crucial points.

A 104-year-old woman with advanced cervical carcinoma of the uterus

BACKGROUND

Treatment of elderly patient with advanced cancer includes considerable problems because of their limited life expectancy.

CASE

A 104-year-old woman with FIGO stage IIIB uterine cervical carcinoma treated with external beam radiotherapy and high dose-rate brachytherapy. After the treatment, the serum squamous cell carcinoma (SCC) antigen had fallen to normal level. She is now living 66 months after the treatment without recurrent symptoms.

CONCLUSION

In this specific case, the significance of this treatment is that the patient is surviving at the age of 109.

Radiotherapy for head and neck cancer in elderly patients

BACKGROUND AND PURPOSE

Elderly patients with head and neck cancer may not be treated aggressively with radiotherapy, due to concerns regarding tolerance of treatment and toxicity. A retrospective study was undertaken of patients aged 80 years and over, treated by definitive radiotherapy for head and neck cancer.

MATERIAL AND METHODS

98 patients aged 80-92 received radiotherapy for carcinoma of the head and neck between 1991 and 1995. All patients received beam directed radiotherapy with radical intent using an immobilisation shell.

RESULTS

Cancer specific survival was 59% and overall local control was 70% at 5 years. Both were significantly affected by T stage and site of disease. Cancer specific survival was comparable to that of patients aged below 80 years. Seven patients died within 6 months of the treatment. Three patients developed severe late toxicity. Metastatic disease occurred in eight patients.

CONCLUSIONS

Radiotherapy is a beneficial and well tolerated treatment in elderly patients with carcinoma of the head and neck.

Radiotherapy of skin tumors

The incidence of cancers of the skin is increasing, as is life expectancy among most of the population. Besides surgery, all skin cancers can be treated with radiotherapy, with excellent results. Unfortunately, both less training and less equipment are available than earlier, which means that dermatologists also have less experience in this field. We would like to propose radiotherapy for medium-sized or larger lesions, especially on the face in elderly people. Good indications are keratoacanthomas, extensive actinic keratoses, Bowen's disease including erythroplasia of Queyrat, basal cell and squamous cell carcinomas, but also lentigo maligna and lentigo maligna melanomas. These tumors can be treated in a curative way. Excellent results of palliative X-ray therapy are achieved in Kaposi's sarcoma and in lymphomas, and also in Merkel cell tumors. After 100 years of treatment of skin cancers by radiotherapy, dermatologists should not forget that if appropriate principles are followed and precautions are taken, X-ray treatment is still a safe and effective method.

Factors affecting the use of palliative radiotherapy in Ontario

PURPOSE

To describe the use of palliative radiotherapy (PRT) and to identify factors associated with the use of PRT.

MATERIALS AND METHODS

The Ontario Cancer Registry was used to identify 193,253 adult patients who died of cancer between 1986 and 1995. Radiotherapy records from all Ontario cancer centers and the data on socioeconomic status (SES) from the Canadian Census were linked to the Ontario Cancer Registry data. The proportion of cases who received at least one course of PRT at any time within 2 years of death (PRT(2Y)) was used as a primary measure of the use rate of PRT.

RESULTS

Overall, 26.4% of cases underwent at least one course of PRT. PRT(2Y) remained relatively constant over the study period. PRT(2Y) was disease-specific and ranged from 4% for pancreatic cancer to 41% for prostate cancer. Age was negatively associated with PRT(2Y) (adjusted odds ratio [OR], 4.5 for the youngest group), and SES was positively associated with PRT(2Y) (adjusted OR, 1.2 for patients from wealthy communities). Patients who were initially diagnosed in a hospital affiliated with a cancer center (adjusted OR, 1.4) or who lived in a county in which a cancer center is located (adjusted OR, 1.2), or who resided in certain regions (adjusted OR, 1.20 for Hamilton and 1.17 for Kingston), were more likely to be treated with PRT.

CONCLUSION

The use of PRT varied across the dispersed population in Ontario and was influenced by factors unrelated to the patient's needs. An effort should be made to reduce barriers to access for disadvantaged groups.