Radiation Treatment in Older Patients: A Framework for Clinical Decision Making

Abstract

In older patients, radiation treatment plays a vital role in curative and palliative cancer therapy. Radiation treatment recommendations should be informed by a comprehensive, personalized risk-benefit assessment that evaluates treatment efficacy and toxicity. We review several clinical factors that distinctly affect efficacy and toxicity of radiation treatment in older patients. First, locoregional tumor behavior may be more indolent in older patients for some disease sites but more aggressive for other sites. Assessment of expected locoregional relapse risk informs the magnitude and timeframe of expected radiation treatment benefits. Second, assessment of the competing cancer versus noncancer mortality and morbidity risks contextualizes cancer treatment priorities holistically within patients' entire spectrum and time course of health needs. Third, assessment of functional reserve helps predict patients' acute treatment tolerance, differentiating those patients who are unlikely to benefit from treatment or who are at high risk for treatment complications. Potential radiation treatment options include immediate curative treatment, delayed curative treatment, and no treatment, with additional consideration given to altered radiation target, dose, or sequencing with chemotherapy and/or surgery. Finally, when cure is not feasible, palliative radiation therapy remains valuable for managing symptoms and achieving meaningful quality-of-life improvements. Our proposed decision-making framework integrates these factors to help radiation oncologists formulate strategic treatment recommendations within a multidisciplinary context. Future research is still needed to identify how advanced technologies can be judiciously applied in curative and palliative settings to enhance risk-benefit profiles of radiation treatment in older patients and more accurately quantify treatment efficacy in this group.

Trends in tumors in the central nervous system in elderly in Denmark, 2008–2012

“…It may be speculated if co-morbidity may influence the less survival benefit experienced by the elderly patients and that these patients should be offered an alternative treatment regimen. As described recently by Smith et al [21] there is no consensus regarding the ''right'' treatment of elderly patients. In order to help solve this challenge the EORTC 26062 is currently investigating the use of TMZ and shortcourse radiation versus short-course radiation alone in the treatment of newly diagnosed GBM in elderly patients (aged 65 years and older).…”

Influence of Age on Guideline-Concordant Cancer Care for Elderly Patients in the United States

“…Finally, decision-making in elderly patients are driven by additional considerations such as life expectancy, comorbidities (45,46), functional status, biologic aggressiveness of disease (47–48), benefits of palliation, availability of alternatives, and access to treatments are all important considerations in treatment choice (12,49,50), as well as patient preference, including decisions favoring less than curative treatment.…”

Pan-Cancer Analysis of Genomic Sequencing Among the Elderly

“…Elderly cancer patients have numerous nonradical treatment options available to them, including chemotherapy, radiation therapy, immunotherapy, and targeted systemic agents. The toxicity profile of each of these therapies can be elevated in elderly populations, which often clouds treatment decisions owing to uncertain risk/benefit ratios (14)(15)(16)(17). Identifying the molecular characteristics that define elderly subpopulations most likely to benefit from a given therapy could help optimize treatment for these atrisk patients, even in the face of potentially increased toxicity.…”