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ORIGINAL ARTICLE
Year : 2019  |  Volume : 56  |  Issue : 2  |  Page : 163-166
 

Efficacy and tolerance of thoracic radiotherapy in the oldest old patients: A case series


1 Department of Medical Oncology and Radiotherapy, Institut de Cancérologie Lucien Neuwirth, 42271 Saint Priest en Jarez, France
2 Department of Radiotherapy, Centre Clinique de la Porte de Saint Cloud, Boulogne-Billancourt, France
3 Department of Radiotherapy, Centre Antoine Lacassagne, Nice, France
4 Department of Radiotherapy, Clinique Claude Bernard, Albi, France
5 Department of Radiation Oncology, Gustave Roussy Cancer Center, 94800, Villejuif, France

Date of Web Publication2-May-2019

Correspondence Address:
Nicolas Magn
Department of Medical Oncology and Radiotherapy, Institut de Cancérologie Lucien Neuwirth, 42271 Saint Priest en Jarez
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_346_18

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 » Abstract 


BACKGROUND: There are only scarce data on the management of nonagenarians with lung cancer, and more particularly on the place of radiation therapy. The aim of the present study was to retrospectively evaluate the efficacy and tolerance of radiotherapy (RT) in nonagenarians with thoracic cancer.
PATIENTS AND METHODS: Records from RT departments from four institutions were reviewed to identify patients 90 years old of age and older undergoing RT over the past decade for thoracic cancer and more particularly lung cancer. Tumors' characteristics as well as treatment specificities and its intent were examined.
RESULTS: Thirteen patients receiving RT courses were identified, mean age 91.9 years. Treatment was given with curative and palliative intent in 15.4% and 84.6%, respectively. The median total prescribed dose was 30 Gy (4–70). The median number of fractions was equal to 10 (1-35). The median dose received for each fraction was 3 Gy (1.7–7). RT could not be completed in 2 patients (15.4%). At last follow-up, 11 patients (76.9%) were deceased, cancer being the cause of death for 90% of them. Most toxicities were grade 1 or 2. Two patients (15.4% of cases) have developed grade 2 toxicity during treatment. One patient (7.7% of cases) experienced an acute grade 3 toxicity.
CONCLUSION: The study shows that RT for thoracic cancer is feasible in nonagenarians. Although the definitive benefit of RT could not be addressed here, hypofractionated therapy allowed a certain measure of control with acceptable side effects.


Keywords: Elderly patients, radiotherapy, thoracic cancer


How to cite this article:
Méry B, Rancoule C, Assouline A, Aissou L, Falk AT, Auberdiac P, Vallard A, Chargari C, Magn N. Efficacy and tolerance of thoracic radiotherapy in the oldest old patients: A case series. Indian J Cancer 2019;56:163-6

How to cite this URL:
Méry B, Rancoule C, Assouline A, Aissou L, Falk AT, Auberdiac P, Vallard A, Chargari C, Magn N. Efficacy and tolerance of thoracic radiotherapy in the oldest old patients: A case series. Indian J Cancer [serial online] 2019 [cited 2019 Dec 10];56:163-6. Available from: http://www.indianjcancer.com/text.asp?2019/56/2/163/257553





 » Introduction Top


Lung cancer is the most common cancer in the world and the leading cause of cancer-related deaths in Europe and in other Western countries.[1] Its incidence rises with advancing age; it is highest in the 70- to 80-year-old group and does not start to trail off until age 90 years or older.[2] In the US, nonagenarians are the fastest growing segment of the population. By the year 2050, over 20 million of Americans are expected to be in that age range.[3] The number of lung cancer cases in nonagenarians is expected to increase rapidly in the near future, and physicians will have to deal with these patients.[4] However, the elderly are under-represented in clinical research trials evaluating new treatments in advanced disease.[5] Very little information is available to guide the oncologists in the treatment of the oldest old and especially on the response of nonagenarians to thoracic radiotherapy (RT) given for lung cancer. This seems to result in strikingly low rates of treatment in patients aged 85 years and above.[6] RT plays a prominent therapeutic role in malignant intra-thoracic tumors, and particularly, in non-small cell lung carcinoma (NSCLC), the most common type of lung cancer. Surgical resection is the preferred treatment for localized NSCLC, but more than one-third of patients present with locally advanced, unresectable tumors (stage IIIA or IIIB).[7] The standard treatment for locally advanced inoperable NSCLC is concurrent chemoradiation: it is believed to offer these patients the highest potential for prolonged disease-free and overall survival.[8] Although cisplatin-based therapy has yielded improved survival in patients with advanced NSCLC, the role of combination therapy in the elderly has not been explored systematically.[9],[10],[11] Because of the tolerance to radical treatment is not well-documented in older age groups, there is a tendency to consider the elderly for more conservative management because of their altered physical function and increased incidence of comorbid disease. Such a nihilistic approach to treatment may not be appropriate in all cases. Radical radiation therapy with curative intent may offer a viable alternative to surgery in those patients who are either medically unfit or too old for surgery. Several recent reports have suggested that a substantial number of medically inoperable patients with early stage NSCLC treated by radiation therapy alone can experience good resolution of their disease, and that this translates into cure in a significant proportion of patients.[12],[13],[14],[15] Besides, it should also be noted that the use of newer conformal radiation therapy techniques may lead to higher control rates and a better toxicity profile both for early stage and advanced disease; therefore, it is imperative to explore the issue of RT in the elderly population and particularly among nonagenarians.[16],[17],[18],[19] To provide broader clinical data about effectiveness, delivery modalities, and tolerance to radiation therapy in nonagenarians with thoracic cancer, we decided to review the experience of 13 patients aged 90 years old or older with lung cancers or mesotheliomas, in four different French centers.


 » Patients and Methods Top


Characteristics of patients, tumors, and previous treatments

Over a period extending from 2003 to 2013, four health facilities have contributed for this retrospective study (two university hospitals [or similar] and two private centers). Patients aged 90 years or older with thoracic cancer and who received RT were included. A selection has been made from RT medical records. We have analyzed patient's characteristics (age, gender, performance status, and living place), tumor data (primary site and stage), and treatment anterior to RT (surgery, pleurodesis, chemotherapy, or RT). No patient had undergone geriatric assessment.

RT modalities

All patients treated with RT were divided into two distinct groups: the first group corresponded to nonagenarians treated with curative intent, and the second group was nonagenarians treated with a palliative goal. The purpose of treatment was determined by the initial medical decision. The following parameters were examined: total dose, fractionation, and RT duration.

Data analysis

We have used the National Cancer Institute Common Toxicity Criteria (CTCAE v4.0 criteria) for classifying toxicity data until the last follow-up. Acute toxicity was defined as toxicity, which occurred during RT treatment. Late toxicity was defined as any toxicity occurring more than 6 months after the end of RT. Follow-up was calculated from the day of completion of irradiation. The treatment intent was evaluated at follow-up.


 » Results Top


Patient's data

Thirteen patients aged 90 years or older and who received RT in the setting of thoracic cancer were included in the study. The mean age was 91.9 years (standard deviation 1.4). Ten patients (76.9% of cases) had a performance status (PS) ≥2. The female to male ratio was 0.44. Regarding the place of stay during the course, 8 patients (61.5%) were living at home, and 4 patients (30.8%) were living in an institution. Eleven patients (84.6% of cases) had been treated in private centers, and 2 patients (15.4% of cases) had been treated in public health care centers. Patient's characteristics are detailed in [Table 1].
Table 1: Characteristics of patients, tumors, and previous treatments

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Tumor's characteristics and previous treatments

We have identified 10 non-small cell lung cancers (76.9% of cases), two pleural mesotheliomas (15.4% of cases), and one patient without histology. Almost half of the patients had metastatic disease (6 patients, 46.1% of cases). Two patients had received anterior treatment to RT for thoracic cancer, including previous surgery and pleurodesis [Table 1].

Treatment aim and radiotherapy parameters

Among the 13 patients, 11 patients belonged to the group with palliative intent (84.6% of cases), and 2 patients belonged to the group with curative intent (15.4% of cases). Palliative objectives were essentially pain control (7 patients, 53.8% of cases), hemostatic therapy (1 patient, 7.7% of cases), cleanliness (1 patient, 7.7% of cases), and decompression (1 patient, 7.7% of cases). For one patient, the palliative objective was not reported. The target volume was bone metastasis for 53.8% of cases [Table 2].
Table 2: Radiotherapy parameters

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For all RT treatments, we used high-energy megavoltage linear accelerators and conformal treatment plan. The median total dose was equal to 30 Gy (4 to 70 Gy). The median number of fractions was equal to 10 (1–35 fractions). The median dose received for each fraction was 3 Gy (1.7–7 Gy). There was no concomitant chemotherapy. The median total treatment duration was 15 days [Table 2].

Follow-up data

The median follow-up of patients from the date of completion of RT was 10 weeks (0–168 weeks) [Table 3]. Three patients (23.1% of cases) have been followed up more than 6 months. In contrast, 6 patients (46.1% of cases) were followed up less than a month after the end of RT. At the last follow-up, 3 patients were alive (23.1% of cases) against 11 patients who had died (76.9% of cases). The most common cause of death was cancer progression (90% of cases). One patient committed suicide after treatment. Treatment was stopped prematurely for 2 patients (15.4% of cases) [Table 3]. The 2 patients treated with curative intent had a positive response as regards tumor control. Among the other objectives, the control of pain was achieved for 5 patients (71.4%) as well as the discontinuing of hemoptysis for 1 patient. However, cleanliness and decompression were not achieved for 2 patients.
Table 3: Follow-up

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Toxicity data

Two patients (15.4% of cases) have developed grade 2 toxicity during treatment [Table 4]: The first patient had a grade 2 asthenia associated with grade 2 dyspnea at the end of RT (received dose of 58 Gy) to the lung tumor and the mediastinum. The second patient developed a grade 2 asthenia during irradiation of a femoral bone metastasis of lung cancer (received dose of 30 Gy). One patient (7.7% of cases) showed an acute grade 3 toxicity: Grade 3 asthenia during RT to pelvic bone metastases of the pelvis (received dose of 23 Gy).
Table 4: Toxicity data

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 » Discussion Top


It is clear that a significant proportion of elderly patients are not referred or do not receive treatments comparable to younger patients and may as a consequence obtain inferior survival and palliation.[20] The considerable increase in life expectancy, with its concomitant increase in the risk of cancer, has led to a significant increase in the incidence of lung cancer in older people; it is, therefore, an enormous health burden and will pose a significant challenge to health services worldwide as the age distribution of the population skews toward the nonagenarian.[21] The British Thoracic Society recommends that all patients should have equal access to lung cancer services, regardless of age.[22] A total of 13 nonagenarians with thoracic cancer were studied. Among them, 10 had NSCLC that represents 85% of all lung cancer cases in older people.[23],[24] Brown JS et al. showed that the use of surgery and chemotherapy in patients with NSCLC was 18% and 21%, respectively, of patients aged <65 years, compared with 2.1% and 0% for patients aged >75 years.[21] In the present study, 1 patient had received surgery before RT. Because of its favorable cost-benefit ratio and well-documented palliative benefits, radiotherapy has been a mainstay of multimodal care for decades. Considering more particularly palliative RT, as almost half of our patients had metastatic disease, Erridge SC et al. showed that even patients with modest survival expectation should be considered for consultation with a radiation oncologist.[25] In fact, it has long been recognized that patients with lung cancer experience a considerable symptom burden when their disease becomes refractory to a given line of treatment and in the terminal phase. Although if local treatments are unable to control the progress of spread throughout the body, they are highly efficacious in improving symptoms and quality of life. Common indications for palliative treatment with RT include pain due to bony metastases, respiratory distress secondary to airway compression, hemoptysis, and neurologic symptoms caused by brain metastases or spinal cord compression.[26] Although these symptoms occur frequently, little information is available about how often metastatic lung cancer patients receive RT. Anecdotally, palliative RT is thought to be commonly used, but little population-based data are available regarding the patterns of, and factors associated with, its use.[27–30] On the basis of data from select U.S. radiation oncology facilities, it has been estimated that up to 60% of all U.S. cancer patients undergo RT at some point in the course of their illness, and that approximately, 50% of all courses of RT are administered with palliative intent.[30],[31] Nonetheless, few studies have looked at the oldest old, and particularly at nonagenarians. In our study, approximately 85% of patients did not develop grade 2 toxicity during treatment, and more than 90% of patients did not show grade 3 toxicity. However, the low prevalence of toxicities in palliative RT cannot be used to generalize the integration of radiation to lung cancers with radical intent treatment. Considering these data, palliative RT should be an integral part of multimodal, interdisciplinary management of nonagenarian patients with lung cancer, given its minimal toxicity, whereas radical RT should be selectively offered to physiologically fit patients. Moreover, this present study raises the crucial need to perform oncogeriatric assessments, as 76.9% of patients were deceased at last follow-up. An integrated oncogeriatrics approach should have been done before treatment to accurately select patients suitable for treatment. In fact, the elderly are a complex patient group with increasing co-morbidity and shrinking physiological reserve. Physiological rather than chronological age should determine the management of cancer in each individual.[32] There are ongoing efforts by the International Society of Geriatric Oncology to develop validated scales that can help clinicians identify patients at high-risk of treatment complications to decide the best treatment regimens that are both effective and tolerable.[33] However, if the concept of oncogeriatry is not too recent, its implementation in clinical practice through oncogeriatric programs takes time as demonstrated in our study, in which patients treated did not have access to a global geriatric assessment, as it was not available at that time. Progress has been made since, with notably integrated oncogeriatric approach for the management of elderly patients, and this study was also a practice analysis to improve our way of working. Finally, in the current study, we came to the conclusion that RT is still feasible for nonagenarians in thoracic cancer. However, important questions still require answers. The inclusion of elderly patients in randomized clinical trials will bring about advances and also will provide a sound scientific basis for treatment decisions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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