Management of The Elderly Cancer Patients Complexity: The Radiation Oncology Potential

Prevalence and types of cancer in older Indians: A multicentric observational study across 17 institutions in India

The global demographic and epidemiological transition have led to a rapidly increasing burden of cancer, particularly among older adults. There are scant data on the prevalence and demographic pattern of cancer in older Indian persons. This was a multicentric observational study conducted between January 2019 and December 2020. Data were retrieved from existing electronic databases to gather information on two key variables: the total number of patients registered with oncologists and the number of patients aged 60 years and above. The primary objective was to determine the percentage of older adults among patients with cancer served by these hospitals. Secondary objectives included understanding the prevalence of different types of cancer in the older population, and the sex- and geographic distribution of cancer in older Indian patients. We included 272,488 patients with cancer from 17 institutes across India. Among them, 97,962 individuals (36 %) were aged 60 years and above. The proportion of older adults varied between 20.6 % and 53.6 % across the participating institutes. The median age of the older patients with cancer was 67 (interquartile range, 63-72) years. Of the 54,281 patients for whom the details regarding sex were available, 32,243 (59.4 %) were male. Of the 56,903 older patients, head and neck malignancies were the most prevalent, accounting for 11,158 cases (19.6 %), followed by breast cancer (6260 cases, 11 %), genitourinary cancers (6242 cases, 10.9 %), lung cancers (6082 cases, 10.7 %), hepatopancreaticobiliary (6074, 10.7 %), and hematological malignancies (5226 cases, 9.2 %). Over one-third of Indian patients with cancer are aged 60 years and above, with a male predominance. Head and neck, breast, and genitourinary cancers are the most prevalent in this age group. Characterizing the burden of cancer in older adults is crucial to enable tailored interventions and additional research to improve the care and support for this vulnerable population.

The impact of the senescent microenvironment on tumorigenesis: Insights for cancer therapy

The growing global burden of cancer, especially among people aged 60 years and over, has become a key public health issue. This trend suggests the need for a deeper understanding of the various cancer types in order to develop universally effective treatments. A prospective area of research involves elucidating the interplay between the senescent microenvironment and tumor genesis. Currently, most oncology research focuses on adulthood and tends to ignore the potential role of senescent individuals on tumor progression. Senescent cells produce a senescence-associated secretory phenotype (SASP) that has a dual role in the tumor microenvironment (TME). While SASP components can remodel the TME and thus hinder tumor cell proliferation, they can also promote tumorigenesis and progression via pro-inflammatory and pro-proliferative mechanisms. To address this gap, our review seeks to investigate the influence of senescent microenvironment changes on tumor development and their potential implications for cancer therapies.

Symptom networks in older adults with cancer: A network analysis

INTRODUCTION

Due to aging, older adults with cancer (OAC) may be confronted with a complex interplay of multiple age-related issues; coupled with receiving cancer treatment, OAC may experience multiple concurrent symptoms that require the identification of the core symptom for effective management. Constructing symptom networks will help in the identification of core symptoms and help achieve personalized and precise interventions. Currently, few studies have used symptom networks to identify core symptoms in OAC. Our objectives were to construct symptom networks of OAC, explore the core symptoms, and compare the differences in symptom networks among various subgroups.

MATERIALS AND METHODS

Secondary analysis was performed using data from 485 OAC collected in 2021 from a cross-sectional survey named the Shanghai CANcer Survivor (SCANS) Report. The MD Anderson Symptom Inventory (MDASI) was used to assess the incidence and severity of cancer-related symptoms. We used the R package to construct symptom networks and identify the centrality indices. The network comparison test was used to compare network differences among the subgroups.

RESULTS

The most common and severe symptoms reported were fatigue, disturbed sleep, and difficulty remembering. The network density was 0.718. Vomiting (rs = 1.81, rb = 2.13), fatigue (rs = 1.54, rb = 1.93), and sadness (rs = 0.81, rb = 0.69) showed the highest strength values, which suggested that these symptoms were more likely to co-occur with other symptoms. The network comparison tests showed significant differences in symptom network density between the subgroups categorized as survival "< 5 years" and survival "≥ 5 years" (p = 0.002), as well as between the those with comorbidities and those without comorbidities (p = 0.037).

DISCUSSION

Our study identified symptom networks in 485 OAC. Vomiting, fatigue, and sadness were important symptoms in the symptom networks of OAC. The symptom networks differed among populations with different survival durations and comorbidities. Our network analysis provides a reference for future targeted symptom management and interventions in OAC. In the future, conducting dynamic research on symptom networks will be crucial to explore interaction mechanisms and change trends between symptoms.

Efficacy and Safety of External-beam Radiation Therapy for Unresectable Primary or Local Recurrent Cholangiocarcinoma

BACKGROUND/AIM

Treatment options for unresectable cholangiocarcinoma are limited. The aim of the study was to evaluate the clinical outcomes of definitive external-beam radiation therapy (EBRT) for patients with unresectable cholangiocarcinoma.

PATIENTS AND METHODS

Patients with unresectable primary cholangiocarcinoma, or local recurrent cholangiocarcinoma after primary surgery, without distant metastasis who received definitive EBRT (≥45 Gy) between January 2006 and December 2020 at our Institution were analyzed retrospectively. EBRT was basically performed using conventional fractionation (1.8-2 Gy per fraction). Prophylactic nodal irradiation was not performed.

RESULTS

A total of 21 consecutive patients were analyzed: 7 primary and 14 recurrent cases. The median age was 70 (range=38-85) years at initiation of EBRT. A median dose of 54 (range=45-60) Gy comprising 1.8 (range=1.8-3) Gy per fraction was administered to the primary/recurrent local tumor site. The median follow-up period was 21.6 months. The 2-year overall survival, cause-specific survival, progression-free survival, and local recurrence-free rates were 35.7, 35.7, 16.1, and 32.7%, respectively. Long-term local control (>2 years after EBRT) was achieved in 19.0%. Grade 3 toxicities related to EBRT were observed in 4.8% (duodenum hemorrhage). No grade 4 or higher toxicities were observed.

CONCLUSION

Definitive EBRT for unresectable cholangiocarcinoma was feasible and achieved long-term local control in a subset of patients. As the avoidance of local recurrence may lead to the benefits of prolonging biliary patency and subsequently alleviating the need for an invasive procedure for biliary drainage, EBRT could be one sustainable therapeutic option for patients with unresectable cholangiocarcinoma.

Immunotherapy and radiotherapy in melanoma: a multidisciplinary comprehensive review

Melanoma is an extremely aggressive tumor and is considered to be an extremely immunogenic tumor because compared to other cancers it usually presents a well-expressed lymphoid infiltration. The aim of this paper is to perform a multidisciplinary comprehensive review of the evidence available about the combination of radiotherapy and immunotherapy for melanoma. Radiation, in fact, can increase tumor antigens visibility and promote priming of T cells but can also exert immunosuppressive action on tumor microenvironment. Combining radiotherapy with immunotherapy provides an opportunity to increase immunostimulatory potential of radiation. We therefore provide the latest clinical evidence about radiobiological rationale, radiotherapy techniques, timing, and role both in advanced and systemic disease (with a special focus on ocular melanoma and brain, liver, and bone metastases) with a particular attention also in geriatric patients. The combination of immunotherapy and radiotherapy seems to be a safe therapeutic option, supported by a clear biological rationale, even though the available data confirm that radiotherapy is employed more for metastatic than for non-metastatic disease. Such a combination shows promising results in terms of survival outcomes; however, further studies, hopefully prospective, are needed to confirm such evidence.

Contact skin radiotherapy (brachytherapy) for the treatment of non-melanoma skin cancers during COVID-19 pandemic

In the context of the SARS-CoV-2 pandemic, it is important to ensure the quality of cancer treatment as well as patients and health professionals' safety. Individual-based treatment options should be considered in patients with advanced epithelial skin cancer, who are typically elderly and frail. Aim of this study was to assess feasibility and safety of Contact Skin Radiation Therapy (CSRT) to treat basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) during SARS-CoV-2 pandemic. Patients with advanced and difficult-to-treat BCC or SCC were discussed at skin multidisciplinary tumor board (S-MDTB) from February the 21st to May the 4th (phase 1 Italian Pandemic) and retrospectively analyzed. Patient's triage following internal recommendations was daily performed. CSRT was delivered in 8 fractions of 5 Gy each, twice a day. Beyond the clinical outcomes, treatment success indicators, such as the completion of CSRT without SARS-CoV-2 occurrence, were identified to evaluate the feasibility of CSRT during pandemic. A post-treatment psychological assessment regarding patient's safety perception was performed. Six male patients (median age 80 years; range 62-92) with histologically confirmed BCC or SCC were treated with CSRT. Complete clinical remission was achieved in 5/6 patients (83.4%). No high-grade acute toxicities occurred during treatment. No patients or healthcare personnel developed SARS-CoV-2 infection. All the treatment success indicators were achieved. CSRT represents a safe, and feasible treatment option even during the pandemic emergency period. Hypofractionation could be an option to reduce total number of fractions and, consequently, infective risk exposition.

Older cancer patients receiving radiotherapy: a systematic review for the role of sarcopenia in treatment outcomes

BACKGROUND

Previous studies have evaluated the prognostic effects of sarcopenia in cancer patients receiving various treatments, including chemotherapy and surgery, but few studies have focused on radiotherapy (RT).

AIMS

We aimed to investigate the prevalence of sarcopenia and the relationship between sarcopenia and outcomes in older cancer patients who underwent RT without chemotherapy.

METHODS

A systematic review of the literature was conducted in Pubmed/Medline and Cochrane databases in September 2021. We used the search terms and medical subject heading terms "sarcopenia," "low muscle mass (LMM)," "low muscle strength," "LMM and low muscle strength," "LMM and low muscle strength and low physical performance," and "RT." Outcomes were overall survival (OS), progression-free survival, non-cancer death, cancer death, disease-specific survival, local failure-free survival, distant failure-free survival, and RT-related toxicities.

RESULTS

Among 460 studies, 8 studies were eligible for inclusion. The prevalence of sarcopenia was between 42.8% and 72%. Sarcopenia was not associated with OS or OS at 3 years in seven studies in which it was defined as the presence of LMM, while it was related in one study, in which it was defined as the concomitant presence of LMM and muscle strength/function.

DISCUSSION

There was heterogeneity between the studies because there was diversity in their inclusion criteria, definition and assessment methods used for detection of sarcopenia, considered cutoffs for low muscle mass and strength, cross-sectional locations on imaging to assess muscle mass and included covariates. The discrepancy in the results of the studies may also result from the variations in diagnoses, sample sizes, and treatment modalities. The low number of included studies and a small number of patients in each study limited generalizability.

CONCLUSIONS

Sarcopenia may be a prognostic factor, especially in OS when low muscle strength/function is integrated into its definition. We suggest that clinicians focus on muscle strength/function while considering sarcopenia and its association with cancer and RT-related outcomes.

Perspectives and limits of cancer treatment in an oldest old population

BACKGROUND

Population of oldest old will grow dramatically in the next future and cancer, physiologically related to aging, will be very prevalent among them. Lack of evidence is a huge problem to manage cancer in oldest old and will be more and more in the next years.

AIMS

Our purpose was to investigate the characteristics of a population of oldest old patients with cancer treated in the Radiation Oncology Unit of Fondazione Policlinico A. Gemelli IRCCS.

METHODS

We conducted a retrospective study. The primary outcome was to evaluate which characteristics of the population could influence the choice of oncological treatment (with radical or non-radical intent).

RESULTS

We identified a total of 348 patients: 140 were on follow-up; 177 were under treatment; 31 were considered not eligible for treatments. Patients under treatment had a high comorbidity index (mean Charlson Comorbidity Index 5.4), and a high prevalence of polypharmacy (mean number of drugs 5.6). More than half (53.1%) was treated with radical intent. Patients treated with radical intent were 1 year younger (87.1 years old vs 88.1 years old), more performant (ECOG 0.7 vs 1.3), and had less prevalence of metastatic neoplasia (6.4% vs 34.9%); comorbidities and drugs did not show differences in the two groups.

CONCLUSION

Oldest old, usually not considered in international guidelines, are treated for oncological disease, often with radical intent. The treatment seems not to be tailored considering comorbidities but on performance status.

Is a tailored strategy using proton beam radiotherapy for reirradiation advantageous for elderly women? A case report

BACKGROUND

The management of primary or recurrent vaginal tumours in an aging population is challenging for gynecologic and radiation oncologists. In patients unsuited for surgery and already irradiated on the pelvis, proton beam radiotherapy may be worthwhile due to its ballistic advantages.

CASE REPORT

We report the case of an 80-year-old woman with a squamous cell carcinoma of the vagina after a history of pelvic radiation and vaginal brachytherapy delivered for a previous endometrial adenocarcinoma. She received proton beam radiotherapy with a complete response after 12 months and mild toxicity.

CONCLUSIONS

The complexity of reirradiation management in the frail and elderly population requires attention. Efforts should be focused on maintaining autonomy and quality of life in order to improve adherence and clinical compliance to the treatment. In the era of the tailored approach, hadrontherapy can play an important role to minimize toxicity, obtain good local control, and reduce the overall treatment time.

Different Impact of Definitions of Sarcopenia in Defining Frailty Status in a Population of Older Women with Early Breast Cancer

Sarcopenia is a geriatric syndrome characterized by losses of quantity and quality of skeletal muscle, which is associated with negative outcomes in older adults and in cancer patients. Different definitions of sarcopenia have been used, with quantitative data more frequently used in oncology, while functional measures have been advocated in the geriatric literature. Little is known about the correlation between frailty status as assessed by comprehensive geriatric assessment (CGA) and sarcopenia in cancer patients. We retrospectively analyzed data from 96 older women with early breast cancer who underwent CGAs and Dual X-ray Absorptiometry (DXA) scans for muscle mass assessment before cancer treatment at a single cancer center from 2016 to 2019 to explore the correlation between frailty status as assessed by CGA and sarcopenia using different definitions. Based on the results of the CGA, 35 patients (36.5%) were defined as frail. Using DXA Appendicular Skeletal Mass (ASM) or the Skeletal Muscle Index (SMI=ASM/height^2), 41 patients were found to be sarcopenic (42.7%), with no significant difference in prevalence between frail and nonfrail subjects. Using the European Working Group on Sarcopenia in Older People (EWGSOP2) definition of sarcopenia (where both muscle function and mass are required), 58 patients were classified as "probably" sarcopenic; among these, 25 were sarcopenic and 17 "severely" sarcopenic. Only 13 patients satisfied both the requirements for being defined as sarcopenic and frail. Grade 3-4 treatment-related toxicities (according to Common Terminology Criteria for Adverse Events) were more common in sarcopenic and frail sarcopenic patients. Our data support the use of a definition of sarcopenia that includes both quantitative and functional data in order to identify frail patients who need tailored treatment.

Biological and Functional Biomarkers of Aging: Definition, Characteristics, and How They Can Impact Everyday Cancer Treatment

Purpose of Review

Recognize which are the elements that predict why a person is aging faster or slower and which intervention we can arrange to slow down the process, which permits to prevent or delay the progression of multimorbidity and disability.

Recent Findings

Aging is a complex process that leads to changes in all the systems of the body and all the functions of the person; however, aging develops at different rates in different people, and chronological age is not always consistent with biological age.

Summary

Gerontologists are focused not only on finding the best theory able to explain aging but also on identifying one or more markers, which are able to describe aging processes. These biomarkers are necessary to better define the aging-related pathologies, manage multimorbidity, and improve the quality of life. The aim of this paper is to review the most recent evidence on aging biomarkers and the clusters related to them for personalization of treatments.

Palliative Radiation Therapy in Older Adults With Cancer: Age-Related Considerations

There are many additional considerations when treating older adults with cancer, especially in the context of palliative care. Currently, radiation therapy is underutilised in some countries and disease sites, but there is also evidence of unnecessary treatment in other contexts. Making rational treatment decisions for older adults necessitates an underlying appraisal of the person's physiological reserve capacity. This is termed 'frailty', and there is considerable heterogeneity in its clinical presentation, from patients who are relatively robust and suitable for standard treatment, to those who are frail and perhaps require a different approach. Frailty assessment also presents an important opportunity for intervention, when followed by Comprehensive Geriatric Assessment (CGA) in those who require it. Generally, a two-step approach, with a short initial screening, followed by CGA, is advocated in geriatric oncology guidelines. This has the potential to optimise care of the older person, and may also reverse or slow the development of frailty. It therefore has an important impact on the patient's quality of life, which is especially valued in the context of palliative care. Frailty assessment also allows a more informed discussion of treatment outcomes and a shared decision-making approach. With regards to the radiotherapy regimen itself, there are many adaptations that can better facilitate the older person, from positioning and immobilisation, to treatment prescriptions. Treatment courses should be as short as possible and take into account the older person's unique circumstances. The additional burden of travel to treatment for the patient, caregiver or family/support network should also be considered. Reducing treatments to single fractions may be appropriate, or alternatively, hypofractionated regimens. In order to enhance care and meet the demands of a rapidly ageing population, future radiation oncology professionals require education on the basic principles of geriatric medicine, as many aspects remain poorly understood.