Biological Basis of Geriatric Oncology: 124 (Cancer Treatment and Research)

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One study found that a Vulnerable Elders Survey VES score above 7 was associated with around 3 times greater probability for not completing a radiation treatment [ ]. Patients determined to be high-risk by the prognostic index had a significantly higher risk for fracture rate Radiation treatments can negatively impact the quality of life for older adults in ways other than acute and long-term toxicities. As described above, older patients can be encumbered by geriatric syndromes that can reduce the effectiveness of anticancer treatments. Protocols and fractionation schedules that do not acknowledge the severity of these syndromes can subject older patients to treatment noncompliance and further deterioration in health.

The efficacy of radiation treatment lies in its successful delivery. To this end, patient cooperation throughout radiation treatment procedures is necessary. Presence of certain geriatric syndromes might affect a patient's ability to complete parts of the radiation treatment process [ 6 ].

For instance, patients with hearing impairments, highly prevalent among older adults, may not be able to promptly listen to directions during dynamic e. Similarly, patients with dementia may not be able to verbalize sensations of discomfort or pain during radiation or remember instructions. Furthermore, patients with movement disorders like Parkinsonian tremors, or severe arthritis, may have difficulty with immobilization or positioning. Those with frailty or severe physical impairment may have difficulty accomplishing stressful maneuvers such as breath-holding or abdominal compression [ ].

A focused evaluation of these potential issues upfront may allow workaround solutions to be developed that could make treatments less taxing and more manageable. Special accommodations may be made by treatment facilities or hospitals to make these techniques possible for patients with certain disabilities.

For instance, respiratory motion management techniques can have visual or auditory guides e. Over the past decade, newer approaches have been developed that can potentially address some of these technical challenges. Respiratory motion tracking allows for radiation to be delivered without the need for a breath hold [ ]. However, these techniques tend to lengthen the treatment session time, which can increase patient discomfort common in older patients, as previously mentioned.

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Four-dimensional computed tomography 4D-CT and image guidance 4D-IG tracks organ movement over time through frequent image capture during the radiation course [ , ]. Adaptive radiation therapy ART individualizes radiation treatment by replanning and redosing radiation daily, allowing for complicated patients who require varying treatment set-ups [ , ]. Another important consideration must be made for the socioeconomic factors that often play a role in radiotherapy effectiveness in older adults.

Extended fractionation schedules may require frequent travel between the radiotherapy facility and the patient's residence. Since older adults are vulnerable to treatment-related fatigue and deficits in physical activity, constant travel may severely impact their quality of life or may simply not be feasible [ — ]. In consideration of the socioeconomic factors and toxicities, older patients may fare better with shorter fractionation schedules without compromising tumor control.

Hypofractionation has been studied to be an effective alternative to conservative fractionation in different cancers [ — ]. In breast cancer, older patients treated with hypofractionated RT Hypofractionated courses can also be useful in the palliative setting. For instance, in palliation of bone metastases, a lower incidence of acute toxicities e.

However, hypofractionated courses may present with an additional inconvenience for older patients. Although the physical dose is lower, the dose per session is higher, which may lead to a higher likelihood of acute toxicities in normal tissues if the same tolerances used in normofractionated schedules are applied. It is important to emphasize the necessity of adjusting the dose constraints in hypofractionated schedules.

A reasonable alternative to delivering radiotherapy is omitting it in favor of more supportive measures. Supportive care alone may benefit some selected cancer patients [ ]. However, caution must be made before making the decision to omit radiotherapy, as withholding adjuvant radiotherapy can risk tumor recurrence and worsening of tumor progression [ , ]. It has been shown that combined chemoradiation can improve survival in certain cancers, like that of head and neck, brain, endometrium, and lung [ — ].

However, chemotherapy adds toxicities that can compound those of radiation therapy, such as mucositis, cytopenia, and cardiotoxicity [ , ]. In addition, because of their age-related reductions in kidney and liver function, older adults are prone to increased chemotherapy potency [ 6 ]. Evidence has shown that older individuals receiving combined chemoradiation treatments can experience amplified toxicities leading to more frequent hospitalizations and worse survival [ ]. On the other hand, some trials have revealed that older patients may be able to tolerate chemoradiation for particular cancers similar to younger counterparts [ , ].

However, most of these trials only included older individuals who were medically fit and with few or no comorbidities [ ]. Thus, results may not be routinely generalizable to patients with an increased number of comorbidities or functional impairments. Toxicities may be better controlled by employing the use of more precise radiation technologies during chemoradiation.

Chemoradiotherapy using IMRT for treatment of cervical cancer has been shown to limit spread of radiation to the bone marrow and reduce incidence of hematologic toxicity [ ]. Use of tomotherapy-based IGRT in chemoradiation for small cell lung cancer was associated with no grades 3 to 4 pneumonitis, although other toxicities like esophagitis and pulmonary embolism was still observed in some patients [ ].

Combining chemotherapy with hypofractionated radiation may be feasible without increasing overall toxicity. A retrospective analysis examining the concurrent use of temozolomide TMZ and radiotherapy in glioblastoma found that older patients receiving hypofractionation and TMZ generally tolerated the combined regimen well [ ]. Older adults with poorer functional status may better tolerate sequential, rather than concurrent, chemoradiation [ ].

One study found that patients with nasopharyngeal carcinoma receiving sequential chemoradiation had overall less severe acute toxicities leukopenia, anemia, mucositis, and weight loss than those who underwent concurrent chemoradiotherapy; however, there was no significant difference in survival between the two modalities [ ]. The use of more precise radiation technologies, hypofractionation, and sequential chemoradiation may benefit older individuals with poor functional status. A central question is how to best utilize the skillset of specialty-level geriatrics to optimize cancer treatment for older patients.

A conceptual model utilizing four domains tumor behavior, noncancer related competing risks, functional reserve, and palliative needs described by G. Smith can be considered a foundation for making tailored radiation treatment plans [ ].

Managing an Older Adult with Cancer: Considerations for Radiation Oncologists

A comprehensive geriatric assessment and other abbreviated, easy-to-use geriatric assessment screening tools augment this model by facilitating ascertainment of objective data about competing health risks and functional reserve [ 8 , 54 ]. Routine use of these assessment tools in practice may help risk-stratify geriatric patients and guide treatment decision-making. An objective and complete assessment of an older patient may uncover potentially modifiable geriatric impairments.

These in turn might affect the choice of radiation treatment modality, set-up, technique, dose, and fractionation that would be most appropriate based upon an individual's unique set of clinical characteristics and circumstances [ 50 , 51 , 53 , 67 ].

At the same time, a full geriatric assessment may be time-consuming and resource intensive [ 41 ]. Not every cancer clinician may be trained to perform one, and not every older individual may require one. Additional studies are needed to find reliable, routine, and easy-to-use screening tools for radiation oncologists' use that can expedite assessment [ 41 , ]. Quality of life and functional independence may be highly valued among older adults with cancer.

At the same time, undergoing radiotherapy, like any other anticancer treatments, can be an arduous endeavor and may be associated with temporary or permanent detriments in quality of life and function that persist and even worsen at times after treatment is over. An upfront discussion of the potential risks, benefits, and acceptable trade-offs of treatment can be more thoroughly and clearly conducted by recognizing the multidimensional factors in caring for the older adult and screening for geriatric impairments that might directly impact a patient's treatment outcome.

It may be reasonable in many instances to involve extra supportive services earlier in a treatment course for older adults at higher risk e. These might include supportive oncology specialists whose role is to add a layer of support for both patients and caregivers.

This type of care may be delivered by palliative care clinicians whose role is to care for any type of cancer patient regardless of cancer type, stage, intent of treatment, or age. Incorporating supportive oncology specialists earlier in the management of cancer patients is associated with better patient-reported quality of life in multiple domains [ ]. It is important for radiation oncologists to recognize the limitations that their older patients may have in terms of completing radiation treatment courses.

Many patients may experience treatment interruptions for a variety of reasons toxicity-related, patient-related, caregiver-related, treatment machine-related, etc. The efficacy of the treatment, however, depends upon it being completed with minimal interruptions [ 76 , 77 ]. The data gathered from a geriatric assessment allows radiation oncologists to deepen their understanding of potential treatment implications for older patients in a way that can facilitate better informed shared decision-making.

A multidisciplinary supportive care approach involving geriatric expertise, social work services, visiting nurse assistance, nutritional support, physical therapy, and others can be employed in a timely manner, possibly preventing a consequence of treatment such as that described in the introductory vignette. Supportive services may also include individuals specializing in psychosocial oncology [ ]. Attention to psychosocial health is a critical aspect of comprehensive supportive care for cancer patients of all ages.

The overall approach to delivering any cancer treatment for the geriatric patient, whether it consists of surgery, chemotherapy, radiotherapy, or the combination of these, requires a global understanding of physical, functional, and social well-being. Assessment tools are available for more optimal evaluation of older individuals with cancer. Integrating abbreviated versions of these tools is feasible to do within the routine flow of a radiation oncology clinic. The decision to pursue specific treatments requires patient-centered communication of preferences, concerns, risks, and benefits among patients, caregivers, and clinicians.

This work is supported by a grant from the Claude D. National Center for Biotechnology Information , U. Journal List Biomed Res Int v. Published online Dec Sanders Chang , 1 Nathan E. Goldstein , 1 , 2 and Kavita V. Dharmarajan 1 , 2 , 3. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract Older adults with cancer present a unique set of management complexities for oncologists and radiation oncologists. Phenotype of the Older Adult Aging is a coordinated process associated with many physiological and biologic changes in the human body. Morbidity in the Older Adult With a growing population of older adults, morbidity is becoming an increasing concern in the geriatric population. Principles of the Geriatric Assessment An older person's ability to perform activities of daily living may impact the tolerability of cancer treatments.

Table 1 Examples of available screening tools currently used to conduct a geriatric assessment CGA , adapted from [ 8 , 9 ]. Open in a separate window. Table 2 Selected screening tools currently available to perform an abbreviated geriatric assessment, adapted from [ 41 ]. Screening tools Purpose Method of assessment References G8 screening questionnaire Identify geriatric impairments in elderly patients across all CGA domains 8-item clinical assessment conducted by health care provider: Frailty As patients age, changes in physical health and functional abilities become increasingly complex and thereby cannot be easily attributed to a single underlying clinical condition such as cancer.

Table 3 Phenotypic criteria for the Fried Frailty Index, adapted from [ 18 ]. Characteristics of frailty Criteria used to define frailty from Fried et al. Special Radiation Treatment Considerations Radiotherapy is an important anticancer modality and sometimes the treatment of choice for patients regardless of age or comorbid condition for example, prostate cancer.

Biological Basis of Geriatric Oncology - Google Livres

Issues regarding the Biology of the Older Human Body Older adults are susceptible to the same toxicities of radiation that affect their younger counterparts [ 78 ]. Increased Treatment Precision Can Reduce Toxicities Over the years, advances in technology have led to radiation techniques that efficiently deliver adequate amount of radiation to an area with potential for reduced toxicity. Issues regarding Treatment-Related Burdens Radiation treatments can negatively impact the quality of life for older adults in ways other than acute and long-term toxicities.

Issues regarding Concurrent Chemoradiation Treatments It has been shown that combined chemoradiation can improve survival in certain cancers, like that of head and neck, brain, endometrium, and lung [ — ]. A Framework for Making Management Decisions A central question is how to best utilize the skillset of specialty-level geriatrics to optimize cancer treatment for older patients. Conclusion The overall approach to delivering any cancer treatment for the geriatric patient, whether it consists of surgery, chemotherapy, radiotherapy, or the combination of these, requires a global understanding of physical, functional, and social well-being.

Acknowledgments This work is supported by a grant from the Claude D. Conflicts of Interest The authors declare that they have no conflicts of interest. Hyperfractionated or accelerated radiotherapy in head and neck cancer: Key indicators of well-being. Future of cancer incidence in the United States: Journal of Clinical Oncology.

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Biological Basis of Cancer in the Older Person

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