Strahlenther Onkol. 2016 Aug;192(8):526-36.
IMRT/VMAT for malignancies in the head-and-neck region : Outcome in patients aged 80.
Authors: Michelle L Brown 1, Christoph Glanzmann 1,5, Gerhard Huber 2, Marius Bredell 3, Tamara Rordorf 4, Gabriela Studer 1,5
1 Department of Radiation Oncology, Head Neck Cancer Center, University Hospital Zurich (USZ), Switzerland
2 Department of Otorhinolaryngology, Head Neck Cancer Center, Head and Neck Surgery, University Hospital Zurich (USZ), Switzerland
3 Department of Craniomaxillofacial and Oral Surgery, Head Neck Cancer Center, University Hospital Zurich (USZ), Switzerland
4 Department of Medical Oncology, Head Neck Cancer Center, University Hospital Zurich (USZ), Switzerland
5 Institute of Radiation Oncology, Cantonal Hospital Lucerne (LUKS), 6000 Lucerne 16, Switzerland
Address for correspondence:
Institute for Radiation Oncology, Cantonal Hospital Lucerne (LUKS), Spitalstrasse, 6000 Lucerne 16, CH – Switzerland
Fax: +41 41 205 58 04
phone: +41 41 205 58 00
Supplement title: Outcome in patients aged 80+ following curative IMRT for head neck tumors
Elderly patients with malignant tumors in the head and neck region (HNT) often pose a therapeutic challenge. They frequently have significant co-morbidities which may influence their ability to tolerate tumor-specific therapies. HNT is typically a cancer of the elderly population and U.S. data demonstrates that 47% of mucosal HNT patients diagnosed between 1973 and 2008 were aged greater than 65 years . In Switzerland, the life expectancy for women and men in 2009 was 84.4 years and 79.8 years, respectively, one of the highest in the developed world. The percentage aged greater than 65 years was 17% in 2009 and is projected to reach 28% by 2050 . This projected increase in the number of elderly patients will result in an increased number of cancer diagnoses, as age is a known risk factor for cancer development. Defining ‘elderly’ remains problematic and is often based on chronological age alone. The National Institute on Aging and National Institutes of Health have defined 3 categories: young old (65-74 years), older old (75-85 years) and oldest old (>85 years) . Although such definitions are helpful to subdivide chronological age, the impact of co-morbidities, quality of life and functional status is not captured in such definitions. It is prudent to consider and improve upon methods by which elderly patients will be assessed for curative therapies , and to determine the outcomes for treatment in order to provide adequate and accurate information to patients.
The optimal radio-therapeutic management of elderly HNT patients cannot be easily defined at present, due to the paucity of randomized data, particularly of very elderly patients. There is under-representation of the elderly in HNT clinical trials, where the age limit is often restricted to 70-75 years . Extrapolation of outcome from pre-existing data from the 3D-dimensional (3D) treatment planning era should be undertaken with caution, as contemporary management utilizes intensity- modulated radiotherapy (IMRT) or volume-modulated arc therapy (VMAT) which may confer a more advantageous toxicity profile as demonstrated in clinical trials . The role of chemotherapy in elderly patients remains controversial as the Meta-Analysis of Chemotherapy in Head and Neck Cancer (MACH-NC) demonstrated a diminishing effect on survival with increasing age .
Our aim was to investigate the outcome of patients aged 80+ years undergoing curative intent IMRT/VMAT . This is, to our knowledge, the largest published group of ‘older and oldest old’ HNT patients treated with modern radiation techniques (Table 1).
We retrospectively reviewed our HNT patients aged 80+ treated with curative IMRT/VMAT from 12/2003 to 11/2015. Overall survival (OS), disease-free survival (DFS), local control (LC) and treatment tolerance were assessed. Outcome results were compared with that of our younger HNT patient cohort. In order to compare own outcome data, results from other centers for elderly HNC patients treated with radiation alone (Table 1) as well as from cohorts treated with radiation-chemotherapy (Table 2) were compared.
Methodical limitations: Treatment decisions made at our weekly interdisciplinary head and neck cancer centre tumour board represent a selection process in favour of fitter patients, as patients considered too ill or non-compliant to undergo treatment with potentially substantial side effects were not selected for curative radiation (few of the board-presented cases). In addition, having a diagnosis of cancer at an advanced age and being an older individual who is well enough to attend for a specialist consultation, may already represent a substantial positive pre-selection for curative treatment. The follow up (FU) of our cohort is relatively short (Figure 1), mainly due to age-related logistic difficulties to organize repetitive consultations at the centre, patients’ preference to rather see their GP, or additional mobility limiting comorbidity or death.
140 consecutive 80+ patients were included (65 postoperative, 75 definitive irradiation). Mean/median age at treatment start was 84.8/84.1 years (80-96). Mean/median follow up time was 25/16 months (2-92). 80/140 patients were alive with no evidence of disease when last seen, 28 died of disease, 12 remained alive with disease, the remaining 20 died inter-currently. 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, Table 3. 2-/3-year LC, DFS and OS rates for the entire 80+ cohort were 81/80%, 69/63% and 68/66%, respectively (Figure 1). The corresponding survival rates for >1400 HNT IMRT patients aged <80 years (mean/median 60.9/ 62.7 years, range 16-79.8) treated in the same time interval (with additional simultaneous systemic therapy in 71%) at our center were 81/80% (NS), 69/67% (NS) and 77/72% (p<0.001), respectively. DFS (Figure 2) and LC rates (data not shown) of the 80+ cohort were comparable to our younger IMRT HNT patients; OS was inferior in the 80+ cohort (Figure 3). Ambulatory elderly patients showed higher 3-year OS than inpatients (~70% vs ~50%, p=0.006). In addition, 80+ patients with pre-IMRT WHO performance status (PS) 0-1 demonstrated higher 3-year OS than patients with PS 2-3 (~70% vs ~40%, p=0.01). Gender did not impact on OS (p=0.7) or DFS (p=0.5). Additionally, the need for a feeding tube did not result in any significant difference in OS (p=0.8); however, the sample size of patients was unbalanced (n=15 vs. 135 with and without a feeding tube, respectively). Patients undergoing postoperative radiation attained a higher OS compared to the definitively irradiated subgroup (fit enough for surgery and/or smaller tumors),with 74% vs. 60% at 3 years (p=0.01); however, DFS rates were similar for both groups (68% vs. 61%, p=0.15). SCC patients (66%) showed an inferior 3y OS rate as compared to non-SCC patients (62% vs. 77%, p=0.0002), whilst LC and DFS did not differ (NS).
Treatment tolerance in our patient cohort aged 80+ was high. Local and disease free survival rates were similar to that of younger HNT patients treated at our centre. These results suggest that very elderly patients should be considered for potentially curative treatment strategies.
Figure 1 Disease control
Figure 2 Disease-free survival related to age intervals
Figure 3 Overall survival rates related to age intervals
Table 1 Radiotherapy alone studies in elderly HNT patients
Abbreviations: NA not available, LC local control, OS overall survival, CR complete response, RR response rate, CSS cause specific survival, PS performance status, G Grade, RTOG Radiation Therapy Oncology Group, EORTC European Organisation for the Research and Treatment of Cancer
Table 2 Radio-chemotherapy studies in elderly patients with HNT
Legend: NA – not available; f- fractions; re-RT – re-irradiation; RT – radiotherapy; IC – induction chemotherapy; G1-4 – grade 1-4; OS – overall survival; DSS – disease specific survival; LC – local control; LRC – loco-regional control
Table 3 Treatment related parameters
CONFLICT OF INTEREST:
On behalf of all authors, the corresponding author states that there is no conflict of interest.
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