Geriatric Radiation Oncology: What We Know and What Can We Do Better?

Abstract

Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.

Keywords:

• radiation therapy
• elderly
• geriatric assessment

Abbreviations

RT, Radiation therapy; OS, overall survival; Qol, quality of life; RPA, recursive partitioning analysis; MGMT, O-6-methylguanine-DNA methyltransferase; CCNU, lomustine; Gy, Gray; EORTC, European Organisation for Research and Treatment of Cancer; BSC, best supportive care; HNSCC, head and neck squamous cell cancer; SEER, surveillance, epidemiology, and end results; 5-FU, 5-fluorouracil; RTOG, Radiation Therapy Oncology Group; CRP, C-reactive protein; SCLC, small cell lung cancer; NSCLC, non-small cell lung cancer; SABR, stereotactic ablative radiation therapy; ECOG, Eastern Cooperative Group performance score; BC, breast cancer; BCS, breast conserving surgery; ER, estrogen receptor; PR, progesterone receptor; Her2, human epidermal growth factor receptor 2; CALGB, Cancer and leukemia group B; NCCN, National Comprehensive Cancer network; N+, node-positive; EC, esophageal cancer; R+, margin-positive resection US, United States; yrs, years; CCI, Charlson comorbidity score; cCR, clinical complete remission PFS, progression-free survival; DFS, disease-free survival; LARC, locally advanced rectal cancer TNT, total neoadjuvant therapy pCR, pathologic complete remission NOM, non-operative management; COPD, chronic obstructive pulmonal disease; LE, local excision; EBRT, external beam radiation therapy; MTD, maximum tolerated dose; IMRT, intensity-modulated radiation therapy; 2D, two-dimensional; 3D, three-dimensional; LC, local control; MFS, metastases-free survival; MMC, Mitomycin C; LDR, low dose rate; HDR, high dose rate; CSS, cancer-specific survival; PSA, prostate-specific antigen; EAU, European Association of Urology; CGA, comprehensive geriatric assessment; ADT, androgen deprivation therapy; CT, computed tomography.

Disclosure

Falk Roeder received travel grants and lecture honoraria from Intraop Medical and PharmaMar. All other authors reported no competing interests.