Muscle-Invasive Bladder Cancer in Elderly-Unfit Patients with Concomitant Illness: Can a Curative Radiation Therapy be Delivered?

Non-stereotactic radiotherapy in older cancer patients

Old or very old oncological patients represent a heterogeneous and frail population due to concomitant comorbidities. Whether radiotherapy alone or in combination with novel cancer drugs may provide a clear benefit in this setting of patients is still a matter of debate.

The aim of our review is to analyze the evaluation process and the different therapeutic possibilities in older cancer patients, focusing on the different and most disparate applications of radiotherapy. We reviewed the most recent literature on radiotherapy in older patients providing clinical evidence of treatment related toxicity, tolerance and outcomes using standard fractionated and/or hypofractionated irradiation alone or in combination with chemotherapy, targeted and immunotherapy.

In older cancer patients unfit for systemic therapy or surgery, radiotherapy represents a valid therapeutic approach, both with curative and palliative intents, ensuring excellent patient compliance in terms of local toxicity and adherence to therapy.

Hypofractionated radiation therapy for treatment of bladder carcinoma in patients aged 90 years and more: A new paradigm to be explored?

INTRODUCTION

There are only scarce data on the optimal management of patients who present with a bladder carcinoma and who are aged 90 years and older.

PATIENTS AND METHODS

We retrospectively reviewed records from radiotherapy departments from two university hospitals, two private centers and one public center to identify patients who underwent radiotherapy for bladder cancer over the past decade and who were aged 90 years or older. From 2003 to 2013, 14 patients aged 90 years or older receiving RT for bladder malignant tumors were identified.

RESULTS

Mean age was 92.7 years. Ten patients (71 %) had a general health status altered (PS 2-3) at the beginning of RT. A total of 14 RT courses were delivered, including six treatments (43 %) with curative intent and eight treatments (57 %) with palliative intent. Palliative intent mainly encompassed hemostatic RT (36 %). At last follow-up, two patients (14 %) experienced complete response, one patient (7 %) experienced partial response, three patients (21 %) had their disease stable, and three patients (21 %) experienced tumor progression, of whom two patients with the progression of symptoms. There was no reported high-grade acute local toxicity in 14 patients (100 %). One patient experienced delayed grade 2 toxicity with pain and lower urinary tract symptoms. At last follow-up, seven patients (50 %) were deceased. Cancer was the cause of death for five patients.

CONCLUSION

Hypofractionated radiotherapy remains feasible for nonagenarians with bladder cancer. Further investigations including analysis of geriatric comorbidities and impact of treatments on quality of life should be conducted.

Very elderly (>80 years), frail patients with muscle-invasive bladder cancer and comorbidities: is curative irradiation feasible?

PURPOSE

To evaluate clinical results in elderly and frail patients with bladder cancer treated with curative conformal irradiation alone.

METHODS

The records of ambulatory frail elderly patients, age >80 years, Charlson Comorbidity Index (CCI) >5, with invasive bladder cancer, were retrospectively analyzed. The patients were irradiated with curative intent. Acute and late toxicities were evaluated.

RESULTS

A total of 27 ambulatory patients were treated. Median age was 84.5 years and a median CCI of 6.5 was recorded. Median delivered radiation dose was 64 Gy. All patients completed the planned treatment. Grade 1-2 gastrointestinal (GI) and genitourinary (GU) toxicities were observed in 55.5% of patients (15/27). At the last follow-up, no late G3+ toxicities have been observed, with G1-2 toxicities reported in 11.1% of patients (3/27). Higher values of CCI were associated with higher acute GU/GI toxicities; there was a correlation between CCI and acute GU toxicity (r = 0.43, p = 0.027). The mean survival time was 23.5 months (95% confidence interval 20.9-26.1) and no median was reached. Locoregional disease-free events and metastasis-free survival showed a 2-year actuarial rate of 90% and 87%, respectively, with an actuarial 2-year overall survival of 84.5%.

CONCLUSIONS

Our results demonstrate safety and feasibility of curative radiation therapy in very elderly and frail patients with bladder cancer using 3D conformal radiation therapy.

Intensity modulated radiotherapy for elderly bladder cancer patients

BACKGROUND

To review our experience and evaluate treatment planning using intensity-modulated radiotherapy (IMRT) and helical tomotherapy (HT) for the treatment of elderly patients with bladder cancer.

METHODS

From November 2006 through November 2009, we enrolled 19 elderly patients with histologically confirmed bladder cancer, 9 in the IMRT and 10 in the HT group. The patients received 64.8 Gy to the bladder with or without concurrent chemotherapy. Conventional 4-field "box" pelvic radiation therapy (2DRT) plans were generated for comparison.

RESULTS

The median patient age was 80 years old (range, 65-90 years old). The median survival was 21 months (5 to 26 months). The actuarial 2-year overall survival (OS) for the IMRT vs. the HT group was 26.3% vs .37.5%, respectively; the corresponding values for disease-free survival were 58.3% vs. 83.3%, respectively; for locoregional progression-free survival (LRPFS), the values were 87.5% vs. 83.3%, respectively; and for metastases-free survival, the values were 66.7% vs. 60.0%, respectively. The 2-year OS rates for T1, 2 vs. T3, 4 were 66.7% vs. 35.4%, respectively (p = 0.046). The 2-year OS rate was poor for those whose RT completion time greater than 8 weeks when compared with the RT completed within 8 wks (37.9% vs. 0%, p = 0.004).

CONCLUSION

IMRT and HT provide good LRPFS with tolerable toxicity for elderly patients with invasive bladder cancer. IMRT and HT dosimetry and organ sparing capability were superior to that of 2DRT, and HT provides better sparing ability than IMRT. The T category and the RT completion time influence OS rate.

Radical Radiotherapy For Bladder Cancer: Retrospective Analysis of a Series of 459 Patients Treated in an Italian Institution

AIMS

To contribute to the available evidence about the efficacy of exclusive radiotherapy for bladder cancer through a retrospective analysis of a large series of patients consecutively treated in a single institution.

MATERIALS AND METHODS

A total of 459 patients with UICC categories T1-T4, N0-Nx and M0 bladder cancer consecutively treated with radiotherapy alone with radical intent formed the clinical basis for this study. Many of them (and particularly the T1 cases) had poor medical conditions or were unfit for surgery. About half of the cases (54%) had a T2 tumour, and about 18% had T3-T4 disease. Eighty per cent of the cases received minimal doses in the target volume in the range 60-70 Gy; pelvic lymph nodes were treated in 34%. Simple radiotherapy techniques were used in most cases. Average follow-up for living patients was 4.4 years. Results were analysed according to number and type of relapses: overall survival, disease-specific survival, failure-free survival probability, acute and late toxicity (RTOG scale).

RESULTS

Actuarial 5-year overall survival, disease-specific survival and failure-free survival rates at 5 years for the entire series were 36%, 56%, 33%, respectively. Age, T category (for all the end points) and tumour dose (only for failure-free survival) were significantly related to prognosis at multivariate survival analysis. Late enteric toxicity (6.1% of the cases) was significantly linked with the treated volumes (univariate analysis). Urinary late toxicity (23% of cases) was linked with age and T category (multivariate analysis). In both cases, toxicity was mostly Grade 1 or 2.

CONCLUSIONS

The results of radiotherapy in this negatively selected series, accrued over a long period of time in patients treated with unsophisticated techniques, are reasonably good; they add to the evidence available to support the use of modern bladder-sparing programmes, including the association of chemo- and radiotherapy.