Hypofractionated Radiotherapy in Head and Neck Cancer Elderly Patients: A Feasibility and Safety Systematic Review for the Clinician

Abstract

ObjectiveRadiotherapy (RT) in the head and neck (H&N) site are undoubtedly the most challenging treatments for patients. Older and frail patients are not always able to tolerate it, and there are still no clear guidelines on the type of treatments to be preferred for them. The recommendations for Risk-Adapted H&N Cancer Radiation Therapy during the coronavirus disease 2019 (COVID-19) pandemic provided by the ASTRO-ESTRO consensus statement achieved a strong agreement about hypofractionated RT (HFRT). A systematic literature review was conducted in order to evaluate the feasibility and safety of HFRT for older patients affected by H&N malignancies.Materials and MethodsA systematic database search was performed on PubMed and Embase according to Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) guidelines. Original studies, case series, and case reports describing the use of HFRT (with at least 2.2 Gy fractions) in patients with mean age ≥65 years were included. The analysis was based on the type of study, number of patients, mean age, tumor site, histology, performance status (PS), RT details, concomitant chemotherapy (CT), and described clinical outcomes. All the reported doses have been calculated in equivalent dose in 2 Gy fractions (EQD2) and biologically effective dose (BED) using α/β = 10 Gy or α/β = 12 Gy.ResultsWe selected 17 papers that met the inclusion criteria and divided them in 4 categories: 6 articles analyze HFRT performed twice daily in repeated cycles, 3 once a day in repeated cycles, 4 in alternative days, and the last 4 in consecutive days.ConclusionHFRT seems to be a good treatment with an acceptable prolonged disease control. In older patients fit for radical treatments, a 55 Gy in 20 fractions regimen can be proposed as a valid alternative to the standard fractionated RT, but there are a multitude of hypofractionated regimens, ranging from single fraction, quad shot, and 1-, 2-, 3-, 4-, and 5-week schedules that all may be appropriate. The correct regimen for a patient depends on many factors, and it represents the result of a more specific and complex decision.

Patterns-of-Care Analysis for Radiotherapy of Elderly Head-and-Neck Cancer Patients: A Trinational Survey in Germany, Austria and Switzerland

“…Laursen et al investigated 56Gy in 14 fractions (EQD2 of 65Gy) in an elderly patient cohort with a median of 74 years with good tumor response and acceptable tolerability contrasting with the 'Quad shot' regimen (one to three cycles of 14Gy in four fractions given twice daily for two consecutive days) offering effective palliation with minimal toxicity (46,47). A recent review summarized common hypofractionation regimens for elderly patients and concluded that the choice of the correct regimen remains a highly individual decision (48).…”

Clinical Validation of a Deep-Learning Segmentation Software in Head and Neck: An Early Analysis in a Developing Radiation Oncology Center

“…Contour delineation is still among the few procedures of the RT workflow with prevalent manual management, which can result in a high risk in inter-observer variability, and above all, it represents one of the phases with the highest time-consuming rate of all the RT workflows [ 9 , 10 , 11 , 12 ].…”

“…This feature is extremely relevant in the treatment of head and neck districts, where the location of the main disease and the proximity to organs at risk (OARs) with the associated risk of toxicity make the radiation treatment of H&N cancer patients most complex and time-consuming for a radiation oncology team. In H&N cancers, OAR delineation follows strict guidelines, as various studies have demonstrated that OAR and target volume contouring may be affected by significant inter-observer variability [ 9 , 10 , 11 , 12 ].…”

Immunotherapy and Modern Radiotherapy Technique for Older Patients with Locally Advanced Head and Neck Cancer: A Proposed Paradigm by the International Geriatric Radiotherapy Group

“…A review of the literature has reported that hypofractionated radiotherapy is safe and effective for older head and neck cancer patients, either with a palliative or curative intent [ 91 ]. Preliminary data of concurrent chemotherapy and hypofractionated IMRT for locally advanced head and neck cancer have shown excellent local control with an acceptable level of toxicity [ 92 , 93 ].…”