Irrespective of age, the acute and late toxicity profile after high-dose radiotherapy is related to the extent of the radiation field. Only in the most recent studies on combined modality treatment has conformal radiotherapy been introduced. Most studies used two-dimensional large radiation fields that included elective nodal areas. Systematic integration of three-dimensional conformal radiotherapy and target delineation based on functional imaging will undoubtedly influence the oesophageal and pulmonary toxicity after chemoradiation.
Our group has engaged in a Phase I/II radiation dose escalation trial using helical tomotherapy with a fixed dose of weekly low-dose chemotherapy consisting of cisplatin and docetaxel at a dose of 20 mg/m2 each. The toxicity profile of this approach was published earlier.24
geriatric assessment (CGA) is a multidisciplinary evaluation, by oncologists and geriatricians, in which the multiple problems of older patients are uncovered, described and explained. It typically consists of evaluation of an older individual’s functional status, co-morbid conditions, cognition, psychological state, social support and nutritional status and a review of the patient’s medications.26
We thereafter compared treatment-related toxicity, impact of treatment on quality of life and differences in outcome between younger (<70 years, n=42) and older (≥70 years, n=17) patients. Besides an increased rate of neutropenia, elderly patients did not experience increased toxicity or decreased quality of life after concurrent chemoradiation. A comparable survival was achieved with median survival time of 18.5 months in younger versus 17.9 months in the older patient group (p=0.6105).
Comprehensive Geriatric Assessment-based Approach
The current standard of functional status assessment using Eastern Cooperative Oncology Group (ECOG) or Karnofsky scales poorly predicts functional impairment in the elderly.25
1. Gridelli C, Perrone F, Monfardini S, Lung cancer in the elderly, Eur J Cancer, 1997;33:2313–4.
2. Balducci L, Geriatric oncology: challenges for the new century, Eur J Cancer, 2000;36:1741–5.
3. Extermann M, Aapro M, Bernabei R, et al., Use of comprehensive geriatric assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG), Crit Rev Oncol Hematol, 2005;55:241–52.
4. Pallis AG, Gridelli C, Van Meerbeeck JP, et al., EORTC Elderly task Force and Lung Group and International Society of Geriatric Oncology (SIOG) experts’ opinion for the treatment of non-small-cell lung cancer in an elderly population, Ann Oncol, 2010;21:692–706.
5. De Ruysscher D, Botterweck A, Dirix M, et al., Eligibility for concurrent chemotherapy and radiotherapy of locally advanced lung cancer patients: a prospective, population- based study, Ann Oncol, 2009;20:98–102.
6. De Ruysscher D, Kirsch CM, PET scans in radiotherapy planning of lung cancer, Radiother Oncol, 2010;96:335–8.
7. Liao ZX, Komaki R, Thames D, et al., Influence of technologic advances on outcomes in patients with unresectable, locally advanced non-small cell lung cancer receiving concomitant chemoradiotherapy, Int J Radiat Oncol Biol Phys, 2010;76:775–81.
8. Pignon T, Gregor A, Schaake-Koning C, et al., Age has no impact on acute and late toxicity after curative thoracic radiotherapy, Radiother Oncol, 1998;46:239–48.
9. Lonardi F, Coeli M, Pavanato G, et al., Radiotherapy for non- small cell lung cancer in patients aged 75 and over: safety, effectiveness and possible impact on survival, Lung Cancer, 2000;28:43–50.
10. Schaake-Koning C, Van den Bogaert W, Dalesio W, et al., Effects of concomitant cisplatin and radiotherapy on inoperable non-small cell lung cancer, N Engl J Med, 1992;326:524–30.
strong evidence that a CGA detects problems that may have been missed by a regular clinical evaluation. Accumulating data show the benefit of incorporating a CGA in the initial evaluation of older patients with cancer because it uncovers problems relevant to cancer care that would otherwise go unrecognised and a CGA can predict morbidity and mortality in older patients with cancer. Pre-treatment values of instrumental activities of daily living (IADL) correlate with survival.3
Therefore, the integration of geriatric
assessment into studies with a high proportion of older patients needs to be encouraged.
Concurrent chemoradiation should be offered to elderly patients suffering from LA-NSCLC since a survival benefit can be achieved. Even in the absence of prospective elderly-specific data, authors encourage treatment of older patients with CCRT since elderly patients treated with CCRT outside the clinical trial setting experience the same survival benefit albeit with a shorter survival duration. Elderly-specific CCRT trials incorporating modern radiation techniques and geriatric assessment should be encouraged to truly establish the place of CCRT in the older patient with LA-NSCLC. n
11. Pijls-Johannesma M, Houben R, Boersma L, et al., High dose radiotherapy or concurrent chemo-radiation in lung cancer patients only induces a temporary, reversible decline in QoL, Radiother Oncol, 2009;91:443–8.
12. Aupérin A, Le Péchoux C, Rolland E, et al., Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced non-small cell lung canecr, J Clin Oncol, 2010:28:2181–90.
13. American Society of Clinical Oncology: Clinical practice guidelines for the treatment of unresectable non-small cell lung cancer, J Clin Oncol, 1997;15:2996–3018.
14. Rocha Lima CM, Herndon JE II, Kosty M, et al., Therapy choices among older patients with lung carcinoma: An evaluation of two trials of the Cancer and Leukemia Group B, Cancer, 2002;94:181–7.
15. Atagi S, Kawahara M, Tamura T, et al., Standard thoracic radiotherapy with or without concurrent daily low-dose carboplatin in elderly patients with locally advanced non- small cell lung cancer: a phase III trial of the Japan Clinical Oncology Group (JCOG9812), Jpn J Clin Oncol, 2005;35:195–201.
16. Werner-Wasik M, Scott C, Cox JD, et al., Recursive partitioning analysis of 1999 Radiation Therapy Oncology Group (RTOG) patients with locally advanced non-small cell lung cancer (LA-NSCLC): Identification of five groups with different survival, Int J Radiat Oncol Biol Phys, 2000:48:1475–82.
17. Movsas B, Scott C, Sause W, et al., The benefit of treatment intensification is age and histology-dependent in patients with locally advanced non-small cell lung cancer (NSCLC): a quality-adjusted survival analysis of Radiation Therapy Oncology Group (RTOG) chemoradiation studies, Int J Radiat Oncol Biol Phys, 1999;45:1143–9.
18. Langer CJ, Hsu C, Curran WJ, et al., Elderly patients with locally advanced non-small cell lung cancer benefit from combined modality therapy. Secondary analysis of Radiation Therapy Oncology Group (RTOG) 94-10, Proc Am Soc Clin Oncol,
2002;21:299a (abstr. 1193).
19. Schild SE, Stella PJ, Geyer SM, et al., The outcome of combined-modality therapy for stage III non-small cell lung cancer in the elderly, J Clin Oncol, 2003;21:3201–6.
20. Langer C, Scott C, Byhardt R, et al., Effect of advanced age on outcome in Radiation Therapy Oncology Group studies of locally advanced NSCLC, Lung Cancer, 2000:29:119 (Suppl. 1).
21. Non-Small Cell Lung Cancer Collaborative Group, Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials, BMJ, 1995;311:899–90.
22. Davidoff A, Gardner J, Seal B, et al., Population-based estimates of survival benefit associated with combined modality therapy in elderly patients with locally advanced non-small cell lung cancer, J Thorac Oncol, 2011;6:934–41.
23. Semrau S, Bier A, Thierbach U, et al., 6-Year experience of concurrent radiochemotherapy with vinorelbine plus a platinum compound in multimorbid or aged patients with inoperable non-small cell lung cancer, Strahlenther Onkol, 2007;192:30–5.
24. Bral S, Duchateau M, Versmessen H, et al., Toxicity report of a phase 1/2 dose-escalation study in patients with inoperable, loaclly advanced nonsmall cell lung cancer with helical tomotherapy and concurrent chemotherapy, Cancer, 2010;116:241–50.
25. Repetto L, Fratino L, Audisio RA, et al., Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: An Italian Group for Geriatric Oncology Study, J Clin Oncol, 2003;20:494–502.
26. Extermann M, Hurria A. Comprehensive geriatric assessment of older patients with cancer, J Clin Oncol, 2007;25:1824–9.
27. Gridelli C, Langer C, Maione P, et al., Lung cancer in the elderly, J Clin Oncol, 2007;25:1898–907.
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