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The Role of Radiation Therapy in the Older Patient

  • Geriatric Oncology (L Balducci, Section Editor)
  • Published:
Current Oncology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Older patients represent a unique subgroup of the cancer patient population for which the role of radiation therapy (RT) requires special consideration. This review will discuss many of these considerations as well as various radiation treatment techniques in the context of a variety of disease sites.

Recent Findings

Several recent studies give insight into the management of older cancer patients considering their age, performance status, comorbid conditions, quality of life, genetics, cost, and individual goals. RT plays an evolving and pivotal role in providing optimal care for this population. Recent advances in RT technique allow for more precise treatment delivery and reduced toxicity. Studies evaluating the use of radiation therapy in breast, brain, lung, prostate, rectal, pancreatic, esophageal, and oligometastatic cancer are summarized and discussed in the context of treating the older patient population.

Summary

Individual age, performance and functional status, comorbid conditions, and patients’ objectives and goals should all be considered when presenting treatment options for older patients and age alone should not disqualify patients from curative intent treatments. When possible, hypofractionated courses should be utilized as outcomes are often equivalent and toxicities are reduced. In many cases, RT may be preferable to other treatment options due to decreased toxicity profile and acceptable disease control.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Browner I. Applications in geriatric oncology [Internet]. 2017 [cited 2020 May 1]. Available from: https://www.hopkinsmedicine.org/gec/series/cancer_aging.html. Accessed 1 May 2020.

  2. Kochanek KD, Murphy SL, Xu J, Arias E. Deaths: final data for 2017. 2019; Available from: https://stacks.cdc.gov/view/cdc/79486. Accessed 17 Aug 2020.

  3. Lutz ST, Jones J, Chow E. Role of radiation therapy in palliative care of the patient with cancer. J Clin Oncol. 2014;32:2913–9.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Peck A, Boland J. Emotional reactions to radiation treatment. Cancer. 1977;40:180–4.

    Article  CAS  PubMed  Google Scholar 

  5. Alteri R, Bandi P, Brinton L, Casares C, Cokkinides V, Gansler T, et al. Breast cancer facts & figures 2011--2012. Am Cancer Soc. 2011:1–36.

  6. Altekruse SF, Kosary CL, Krapcho M, et al. Surveillance, epidemiology, and end results cancer statistics review, 1975-2007. Bethesda: National Cancer Institute; 2010.

    Google Scholar 

  7. Beadle BM, Woodward WA, Buchholz TA. The impact of age on outcome in early-stage breast cancer. Semin Radiat Oncol. 2011;21:26–34.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sparano JA. TAILORx: trial assigning individualized options for treatment (Rx). Clin Breast Cancer. 2006;7:347–50 This is a discussion of the TAILORx trial and its use in clinical decision-making, specifically the use of molecular diagnostic testing to identify patients who would benefit from chemotherapy.

    Article  PubMed  Google Scholar 

  9. Cardoso F, Van’t Veer L, Rutgers E, Loi S, Mook S, Piccart-Gebhart MJ. Clinical application of the 70-gene profile: the MINDACT trial. J Clin Oncol. 2008;26:729–35.

    Article  PubMed  Google Scholar 

  10. Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans V, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366:2087–106.

    Article  CAS  PubMed  Google Scholar 

  11. Mogal HD, Clark C, Dodson R, Fino NF, Howard-McNatt M. Outcomes after mastectomy and lumpectomy in elderly patients with early-stage breast cancer. Ann Surg Oncol. 2017;24:100–7.

    Article  PubMed  Google Scholar 

  12. NCCN Clinical practice guidelines in oncology [Internet]. [cited 2020 May 20]. Available from: https://www.nccn.org/professionals/physician_gls/default.aspx. Accessed 20 May 2020.

  13. EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C, Correa C, Cutter D, Duane F, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383:2127–35.

    Article  Google Scholar 

  14. Smith BD, Haffty BG, Hurria A, Galusha DH, Gross CP. Postmastectomy radiation and survival in older women with breast cancer. J Clin Oncol. 2006;24:4901–7.

    Article  PubMed  Google Scholar 

  15. Shirvani SM, Pan I-W, Buchholz TA, Shih Y-CT, Hoffman KE, Giordano SH, et al. Impact of evidence-based clinical guidelines on the adoption of postmastectomy radiation in older women. Cancer. 2011;117:4595–605 This paper uses SEER data to show that, in women ≥ 66 years who underwent mastectomy, a large number with high-risk disease did not receive post-mastectomy radiation therapy (PMRT) despite guideline changes to do so. In fact, only 54.8% of high-risk patients evaluated between 1999 and 2005 received PMRT.

  16. Dowsett M, Cuzick J, Ingle J, Coates A, Forbes J, Bliss J, et al. Meta-analysis of breast cancer outcomes in adjuvant trials of aromatase inhibitors versus tamoxifen. J Clin Oncol. 2010;28:509–18.

    Article  CAS  PubMed  Google Scholar 

  17. Wagner LI, Gray RJ, Sparano JA, Whelan TJ, Garcia SF, Yanez B, et al. Patient-reported cognitive impairment among women with early breast cancer randomly assigned to endocrine therapy alone versus chemoendocrine therapy: results from TAILORx. J Clin Oncol. 2020:JCO1901866.

  18. Dispinzieri M, La Rocca E, Meneghini E, Fiorentino A, Lozza L, Di Cosimo S, et al. Discontinuation of hormone therapy for elderly breast cancer patients after hypofractionated whole-breast radiotherapy. Med Oncol. 2018;35:107.

    Article  PubMed  Google Scholar 

  19. Broman K, Sun W, Zhou J-M, Fridley B, Diaz R, Laronga C. Outcomes of selective whole breast irradiation following lumpectomy with intraoperative radiation therapy for hormone receptor positive breast cancer. Am J Surg. 2019;218:749–54.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Hershman DL, Kushi LH, Shao T, Buono D, Kershenbaum A, Tsai W-Y, et al. Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early-stage breast cancer patients. J Clin Oncol. 2010;28:4120–8 This paper reviews adherence to hormone therapy for women with hormone-sensitive breast cancer. Younger or older age, lumpectomy (versus mastectomy), and comorbidities were associated with earlier discontinuation. By 4.5 years, 32% discontinued therapy.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Bhattacharya IS, Haviland JS, Kirby AM, Kirwan CC, Hopwood P, Yarnold JR, et al. Patient-reported outcomes over 5 years after whole- or partial-breast radiotherapy: longitudinal analysis of the IMPORT LOW (CRUK/06/003) phase III randomized controlled trial [Internet]. J Clin Oncol. 2019:305–17. Available from. https://doi.org/10.1200/jco.18.00982.

  22. Brownlee Z, Garg R, Listo M, Zavitsanos P, Wazer DE, Huber KE. Late complications of radiation therapy for breast cancer: evolution in techniques and risk over time. Gland Surg. 2018;7:371–8.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Buszek SM, Lin HY, Bedrosian I, Tamirisa N, Babiera GV, Shen Y, et al. Lumpectomy plus hormone or radiation therapy alone for women aged 70 years or older with hormone receptor–positive early stage breast cancer in the modern era: an analysis of the National Cancer Database [Internet]. Int J Radiat Oncol Biol Phys. 2019:795–802. Available from. https://doi.org/10.1016/j.ijrobp.2019.07.052.

  24. Shah C, Vicini F, Shaitelman SF, Hepel J, Keisch M, Arthur D, et al. The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy. 2018;17:154–70.

    Article  PubMed  Google Scholar 

  25. Kirby AM. Updated ASTRO guidelines on accelerated partial breast irradiation (APBI): to whom can we offer APBI outside a clinical trial? Br J Radiol. 2018;91:20170565.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Sumodhee S, Levy J, Chamorey E, Lam Cham Kee D, Chand M-E, Gautier M, et al. Accelerated partial breast irradiation for elderly women with early breast cancer: a compromise between whole breast irradiation and omission of radiotherapy. Brachytherapy. 2017;16:929–34.

    Article  PubMed  Google Scholar 

  27. Dragun AE. Treatment efficacy with accelerated partial breast irradiation (APBI): final analysis of the American Society of Breast Surgeons MammoSite® Breast Brachytherapy Registry trial [Internet]: Breast Diseases: A Year Book Quarterly; 2014. p. 77–8. Available from:. https://doi.org/10.1016/j.breastdis.2014.01.021. Accessed 14 July 2020.

  28. Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Keshtgar M, et al. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014;383:603–13.

    Article  PubMed  Google Scholar 

  29. Veronesi U, Orecchia R, Maisonneuve P, Viale G, Rotmensz N, Sangalli C, et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol. 2013;14:1269–77.

    Article  PubMed  Google Scholar 

  30. Neumaier C, Elena S, Grit W, Yasser A-M, Uta K-T, Anke K, et al. TARGIT-E(lderly)—Prospective phase II study of intraoperative radiotherapy (IORT) in elderly patients with small breast cancer. BMC Cancer. 2012;12:171.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Holmes CE, Muss HB. Diagnosis and treatment of breast cancer in the elderly. CA Cancer J Clin. 2003;53:227–44.

    Article  PubMed  Google Scholar 

  32. Doyle JJ, Neugut AI, Jacobson JS, Grann VR, Hershman DL. Chemotherapy and cardiotoxicity in older breast cancer patients: a population-based study. J Clin Oncol. 2005;23:8597–605.

    Article  PubMed  Google Scholar 

  33. Daugherty EC, Daugherty MR, Bogart JA, Shapiro A. Adjuvant radiation improves survival in older women following breast-conserving surgery for estrogen receptor–negative breast cancer. Clin Breast Cancer. 2016;16:500–6.e2.

    Article  PubMed  Google Scholar 

  34. Haque W, Kee Yuan DM, Verma V, Butler EB, Teh BS, Wiederhold L, et al. Radiation therapy utilization and outcomes for older women with breast cancer: Impact of molecular subtype and tumor grade. Breast. 2017;35:34–41.

    Article  PubMed  Google Scholar 

  35. Johansson ALV, Trewin CB, Hjerkind KV, Ellingjord-Dale M, Johannesen TB, Ursin G. Breast cancer-specific survival by clinical subtype after 7 years follow-up of young and elderly women in a nationwide cohort. Int J Cancer. 2019;144:1251–61.

    Article  CAS  PubMed  Google Scholar 

  36. de Kruijf EM, Bastiaannet E, Rubertá F, de Craen AJM, Kuppen PJK, Smit VTHBM, et al. Comparison of frequencies and prognostic effect of molecular subtypes between young and elderly breast cancer patients. Mol Oncol. 2014;8:1014–25.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Engels CC, Kiderlen M, Bastiaannet E, Mooyaart AL, van Vlierberghe R, Smit VTHBM, et al. The clinical prognostic value of molecular intrinsic tumor subtypes in older breast cancer patients: a FOCUS study analysis. Mol Oncol. 2016;10:594–600.

    Article  CAS  PubMed  Google Scholar 

  38. Durbecq V, Ameye L, Veys I, Paesmans M, Desmedt C, Sirtaine N, et al. A significant proportion of elderly patients develop hormone-dependant “luminal-B” tumours associated with aggressive characteristics. Crit Rev Oncol Hematol. 2008;67:80–92.

    Article  CAS  PubMed  Google Scholar 

  39. Coles CE. Patient reported outcomes over 5 years following whole or partial breast radiotherapy: longitudinal analysis of the IMPORT LOW phase III randomised controlled trial. Proc Am Soc Clin Oncol. 2019; Available from: https://www.repository.cam.ac.uk/handle/1810/288038. Accessed 14 July 2020.

  40. Badakhshi H, Gruen A, Sehouli J, Budach V, Boehmer D. The impact of patient compliance with adjuvant radiotherapy: a comprehensive cohort study. Cancer Med. 2013;2:712–7.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Saiki H, Petersen IA, Scott CG, Bailey KR, Dunlay SM, Finley RR, et al. Risk of heart failure with preserved ejection fraction in older women after contemporary radiotherapy for breast cancer. Circulation. 2017;135:1388–96.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Marks L, Constine LS, Adams J, Schild SE. Cardiotoxicity of radiation therapy for breast cancer and other malignancies. UpToDate [Internet]. 2017; Available from: https://www.uptodate.com/contents/cardiotoxicity-of-radiation-therapy-for-breast-cancer-and-other-malignancies. Accessed 11 Aug 2020.

  43. Shumway DA, Griffith KA, Sabel MS, Jones RD, Forstner JM, Bott-Kothari TL, et al. Surgeon and radiation oncologist views on omission of adjuvant radiotherapy for older women with early-stage breast cancer. Ann Surg Oncol. 2017;24:3518–26.

    Article  PubMed  Google Scholar 

  44. Hamelinck VC, Stiggelbout AM, van de Velde CJH, Liefers G-J, Bastiaannet E. Treatment recommendations for older women with breast cancer: a survey among surgical, radiation and medical oncologists. Eur J Surg Oncol. 2017;43:1288–96.

    Article  CAS  PubMed  Google Scholar 

  45. Ostrom QT, Cioffi G, Gittleman H, Patil N, Waite K, Kruchko C, et al. CBTRUS statistical report: primary brain and other central nervous system tumors diagnosed in the United States in 2012–2016. Neuro Oncol Oxford Academic. 2019;21:v1–100.

    Article  Google Scholar 

  46. Fokas E, Henzel M, Surber G, Hamm K, Engenhart-Cabillic R. Stereotactic radiotherapy of benign meningioma in the elderly: clinical outcome and toxicity in 121 patients. Radiother Oncol. 2014;111:457–62.

    Article  PubMed  Google Scholar 

  47. Agboola O, Benoit B, Cross P, Da Silva V, Esche B, Lesiuk H, et al. Prognostic factors derived from recursive partition analysis (RPA) of radiation therapy oncology group (RTOG) brain metastases trials applied to surgically resected and irradiated brain metastatic cases [Internet]. Int J Radiat Oncol Biol Phys. 1998:155–9. Available from:. https://doi.org/10.1016/s0360-3016(98)00198-9.

  48. Sperduto PW, Kased N, Roberge D, Xu Z, Shanley R, Luo X, et al. Summary report on the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. J Clin Oncol. 2012;30:419–25.

    Article  PubMed  Google Scholar 

  49. Brown PD, Jaeckle K, Ballman KV, Farace E, Cerhan JH, Anderson SK, et al. Effect of radiosurgery alone vs radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases: a randomized clinical trial. JAMA. 2016;316:401–9 This clinical trial evaluated the cognitive function of patients treated with either SRS alone or SRS with WBRT. There were 213 randomized participants. Less cognitive deterioration at 3 months after SRS alone than when combined with WBRT (difference, − 28.2%; 90% CI, − 41.9 to − 14.4%; p< 0.001). No difference was seen in overall survival.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Noel G, Bollet MA, Noel S, Feuvret L, Boisserie G, Tep B, et al. Linac stereotactic radiosurgery: an effective and safe treatment for elderly patients with brain metastases. Int J Radiat Oncol Biol Phys. 2005;63:1555–61.

    Article  PubMed  Google Scholar 

  51. Kim S-H, Weil RJ, Chao ST, Toms SA, Angelov L, Vogelbaum MA, et al. Stereotactic radiosurgical treatment of brain metastases in older patients. Cancer. 2008;113:834–40.

    Article  PubMed  Google Scholar 

  52. Minniti G, Esposito V, Clarke E, Scaringi C, Bozzao A, Lanzetta G, et al. Stereotactic radiosurgery in elderly patients with brain metastases. J Neuro-Oncol. 2013;111:319–25.

    Article  Google Scholar 

  53. Brown PD, Gondi V, Pugh S, Tome WA, Wefel JS, Armstrong TS, et al. Hippocampal avoidance during whole-brain radiotherapy plus memantine for patients with brain metastases: phase III trial NRG Oncology CC001. J Clin Oncol. 2020;38:1019–29.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Aoyama H, Shirato H, Tago M, Nakagawa K, Toyoda T, Hatano K, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 2006;295:2483–91.

    Article  CAS  PubMed  Google Scholar 

  55. DeAngelis LM. Whither whole brain radiotherapy for primary CNS lymphoma? Neuro-Oncology. 2014;16:1032–4.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Omuro AMP, Ben-Porat LS, Panageas KS, Kim AK, Correa DD, Yahalom J, et al. Delayed neurotoxicity in primary central nervous system lymphoma. Arch Neurol. 2005;62:1595–600.

    Article  PubMed  Google Scholar 

  57. Correa DD, Shi W, Abrey LE, Deangelis LM, Omuro AM, Deutsch MB, et al. Cognitive functions in primary CNS lymphoma after single or combined modality regimens. Neuro-Oncology. 2012;14:101–8.

    Article  CAS  PubMed  Google Scholar 

  58. Gavrilovic IT, Hormigo A, Yahalom J, DeAngelis LM, Abrey LE. Long-term follow-up of high-dose methotrexate-based therapy with and without whole brain irradiation for newly diagnosed primary CNS lymphoma. J Clin Oncol. 2006;24:4570–4.

    Article  CAS  PubMed  Google Scholar 

  59. Fliessbach K, Helmstaedter C, Urbach H, Althaus A, Pels H, Linnebank M, et al. Neuropsychological outcome after chemotherapy for primary CNS lymphoma: a prospective study. Neurology. 2005;64:1184–8.

    Article  CAS  PubMed  Google Scholar 

  60. Rubenstein JL, Hsi ED, Johnson JL, Jung S-H, Nakashima MO, Grant B, et al. Intensive chemotherapy and immunotherapy in patients with newly diagnosed primary CNS lymphoma: CALGB 50202 (Alliance 50202). J Clin Oncol. 2013;31:3061–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. Soussain C, Hoang-Xuan K, Taillandier L, Fourme E, Choquet S, Witz F, et al. Intensive chemotherapy followed by hematopoietic stem-cell rescue for refractory and recurrent primary CNS and intraocular lymphoma: Société Française de Greffe de Moëlle Osseuse-Thérapie Cellulaire. J Clin Oncol. 2008;26:2512–8.

    Article  PubMed  Google Scholar 

  62. Correa DD, Rocco-Donovan M, DeAngelis LM, Dolgoff-Kaspar R, Iwamoto F, Yahalom J, et al. Prospective cognitive follow-up in primary CNS lymphoma patients treated with chemotherapy and reduced-dose radiotherapy. J Neuro-Oncol. 2009;91:315–21.

    Article  CAS  Google Scholar 

  63. Morris PG, Correa DD, Yahalom J, Raizer JJ, Schiff D, Grant B, et al. Rituximab, methotrexate, procarbazine, and vincristine followed by consolidation reduced-dose whole-brain radiotherapy and cytarabine in newly diagnosed primary CNS lymphoma: final results and long-term outcome. J Clin Oncol. 2013;31:3971–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Molinaro AM, Hervey-Jumper S, Morshed RA, Young J, Han SJ, Chunduru P, et al. Association of maximal extent of resection of contrast-enhanced and non–contrast-enhanced tumor with survival within molecular subgroups of patients with newly diagnosed glioblastoma [Internet]. JAMA Oncol. 2020:495. Available from:. https://doi.org/10.1001/jamaoncol.2019.6143.

  65. Iwamoto FM, Reiner AS, Panageas KS, Elkin EB, Abrey LE. Patterns of care in elderly glioblastoma patients. Ann Neurol. 2008;64:628–34.

    Article  PubMed  Google Scholar 

  66. Hoffermann M, Bruckmann L, Kariem Mahdy A, Asslaber M, Payer F, von Campe G. Treatment results and outcome in elderly patients with glioblastoma multiforme--a retrospective single institution analysis. Clin Neurol Neurosurg. 2015;128:60–9.

    Article  PubMed  Google Scholar 

  67. Brandes AA, Tosoni A, Franceschi E, Blatt V, Santoro A, Faedi M, et al. Fotemustine as second-line treatment for recurrent or progressive glioblastoma after concomitant and/or adjuvant temozolomide: a phase II trial of Gruppo Italiano Cooperativo di Neuro-Oncologia (GICNO). Cancer Chemother Pharmacol Springer. 2009;64:769.

    Article  CAS  Google Scholar 

  68. Roa W, Brasher PMA, Bauman G, Anthes M, Bruera E, Chan A, et al. Abbreviated course of radiation therapy in older patients with glioblastoma multiforme: a prospective randomized clinical trial. J Clin Oncol. 2004;22:1583–8.

    Article  CAS  PubMed  Google Scholar 

  69. Cao JQ, Fisher BJ, Bauman GS, Megyesi JF, Watling CJ, Macdonald DR. Hypofractionated radiotherapy with or without concurrent temozolomide in elderly patients with glioblastoma multiforme: a review of ten-year single institutional experience. J Neuro-Oncol. 2012;107:395–405.

    Article  CAS  Google Scholar 

  70. Lu VM, Kerezoudis P, Brown DA, Burns TC, Quinones-Hinojosa A, Chaichana KL. Hypofractionated versus standard radiation therapy in combination with temozolomide for glioblastoma in the elderly: a meta-analysis. J Neuro-Oncol. 2019;143:177–85 This meta-analysis compared elderly patients treated with hypofractionated RT (hRT) + temozolomide vs standard fractionation + temozolomide. They found that the hypofractionation had similar progression-free survival but a decreased overall survival. The authors suggest the combination of hRT + TMZ is feasible in well-selected elderly GBM cases.

    Article  CAS  Google Scholar 

  71. Arvold ND, Tanguturi SK, Aizer AA, Wen PY, Reardon DA, Lee EQ, et al. Hypofractionated versus standard radiation therapy with or without temozolomide for older glioblastoma patients. Int J Radiat Oncol Biol Phys. 2015;92:384–9.

    Article  CAS  PubMed  Google Scholar 

  72. Reifenberger G, Hentschel B, Felsberg J, Schackert G, Simon M, Schnell O, et al. Predictive impact of MGMT promoter methylation in glioblastoma of the elderly. Int J Cancer. 2012;131:1342–50.

    Article  CAS  PubMed  Google Scholar 

  73. Malmström A, Grønberg BH, Marosi C, Stupp R, Frappaz D, Schultz H, et al. Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomised, phase 3 trial. Lancet Oncol. 2012;13:916–26 This phase 3 trial evaluated the optimum palliative treatment glioblastoma as described in the study title. Overall survival was similar between TMZ and hRT. For age 70 or older, survival was better with TMZ and with hRT than with standard RT (HR for TMZ vs standard RT 0.35 [0.21–0.56], p < 0.0001; HR for hRT vs standard RT 0.59 [95% CI 0.37–0.93], p = 0·02). Patients treated with TMZ who had MGMT promoter methylation had longer survival than those without (p= 0.02).

    Article  PubMed  Google Scholar 

  74. Keime-Guibert F, Chinot O, Taillandier L, Cartalat-Carel S, Frenay M, Kantor G, et al. Radiotherapy for glioblastoma in the elderly. N Engl J Med. 2007;356:1527–35.

    Article  CAS  PubMed  Google Scholar 

  75. Atagi S, Mizusawa J, Ishikura S, Takahashi T, Okamoto H, Tanaka H, et al. Chemoradiotherapy in elderly patients with non-small-cell lung cancer: long-term follow-up of a randomized trial (JCOG0301). Clin Lung Cancer. 2018;19:e619–27 This phase III trial evaluated patients > 70 with stage III NSCLC and randomized them to chemoradiotherapy (CRT) or RT. CRT arm had better overall survival than the RT arm (p= 0.0239).

    Article  PubMed  Google Scholar 

  76. Dalwadi SM, Savjani RR, Bernicker EH, Butler EB, Teh BS, Farach AM. A matter of comprehensive informed consent: short-term mortality rates with definitive treatment options in elderly stage I NSCLC. Am J Clin Oncol. 2019;42:851–5.

    Article  PubMed  Google Scholar 

  77. Lee K, Kim HO, Choi HK, Seo GH. Real-world treatment patterns for patients 80 years and older with early lung cancer: a nationwide claims study. BMC Pulm Med. 2018;18:127.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Bezjak A, Paulus R, Gaspar LE, Timmerman RD, Straube WL, Ryan WF, et al. Efficacy and toxicity analysis of NRG Oncology/RTOG 0813 Trial of stereotactic body radiation therapy (SBRT) for centrally located non-small cell lung cancer (NSCLC). Int J Radiat Oncol Biol Phys Elsevier. 2016;96:S8 This paper evaluates phase II results of NRG/RTOG 0813 evaluating the use of SBRT for T1–2 (< 5 cm) N0M0 centrally located NSCLC in 71 patients treated in either a 12Gy/fraction or 11.5 Gy/fraction cohort. Late toxicities grade 3 or greater attributed to SBRT were acceptable. Two-year overall survival was 70%.

    Article  Google Scholar 

  79. Videtic GM, Suescun JAG, Stephans KL, Bogart JA, Tian L, Groman A, et al. A phase 2 randomized study of 2 stereotactic body radiation therapy (SBRT) regimens for medically inoperable patients with node-negative, peripheral non-small cell lung cancer. Int J Radiat Oncol Biol Phys Elsevier. 2016;96:S8–9.

    Article  Google Scholar 

  80. Chang JY, Senan S, Paul MA, Mehran RJ, Louie AV, Balter P, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015;16:630–7.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Nanda RH, Liu Y, Gillespie TW, Mikell JL, Ramalingam SS, Fernandez FG, et al. Stereotactic body radiation therapy versus no treatment for early stage non-small cell lung cancer in medically inoperable elderly patients: a National Cancer Data Base analysis. Cancer. 2015;121:4222–30.

    Article  PubMed  Google Scholar 

  82. Cassidy RJ, Patel PR, Zhang X, Press RH, Switchenko JM, Pillai RN, et al. Stereotactic body radiotherapy for early-stage non-small-cell lung cancer in patients 80 years and older: a multi-center analysis. Clin Lung Cancer. 2017;18:551–8.e6 This multicenter study investigated the efficacy, safety, and survival of patients ≥ 80 years old with NSCLC treated with definitive lung SBRT. The study found that definitive lung SBRT for early-stage non-small-cell lung cancer was efficacious and safe in patients ≥ 80 years old. Patients with a KPS of ≥ 75 derived the most benefit from therapy.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Cassidy RJ, Zhang X, Switchenko JM, Patel PR, Shelton JW, Tian S, et al. Health care disparities among octogenarians and nonagenarians with stage III lung cancer. Cancer. 2018;124:775–84.

    Article  PubMed  Google Scholar 

  84. Soni PD, Boonstra PS, Schipper MJ, Bazzi L, Dess RT, Matuszak MM, et al. Lower incidence of esophagitis in the elderly undergoing definitive radiation therapy for lung cancer. J Thorac Oncol. 2017;12:539–46.

    Article  PubMed  PubMed Central  Google Scholar 

  85. Miller ED, Fisher JL, Haglund KE, Grecula JC, Xu-Welliver M, Bertino EM, et al. Identifying patterns of care for elderly patients with non-surgically treated stage III non-small cell lung cancer: an analysis of the national cancer database. Radiat Oncol. 2018;13:196.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Strøm HH, Bremnes RM, Sundstrøm SH, Helbekkmo N, Aasebø U. How do elderly poor prognosis patients tolerate palliative concurrent chemoradiotherapy for locally advanced non-small-cell lung cancer stage III? A subset analysis from a clinical phase III trial. Clin Lung Cancer. 2015;16:183–92.

    Article  PubMed  Google Scholar 

  87. Vellekoop A, Loeb S. More aggressive prostate cancer in elderly men. Rev Urol. 2013;15:202–4.

    PubMed  PubMed Central  Google Scholar 

  88. Loeb S, Ross AE. Genomic testing for localized prostate cancer: where do we go from here? Curr Opin Urol. 2017;27:495–9.

    Article  PubMed  PubMed Central  Google Scholar 

  89. Daskivich TJ, Fan K-H, Koyama T, Albertsen PC, Goodman M, Hamilton AS, et al. Prediction of long-term other-cause mortality in men with early-stage prostate cancer: results from the Prostate Cancer Outcomes Study. Urology. 2015;85:92–100.

    Article  PubMed  Google Scholar 

  90. Mandel P, Chandrasekar T, Chun F, Huland H, Tilki D. Radical prostatectomy in patients aged 75 years or older: review of the literature [Internet]. Asian J Androl. 2019:32. Available from:. https://doi.org/10.4103/aja.aja_43_17.

  91. Kundu SD, Roehl KA, Eggener SE, Antenor JAV, Han M, Catalona WJ. Potency, continence and complications in 3,477 consecutive radical retropubic prostatectomies. J Urol. 2004;172:2227–31.

    Article  PubMed  Google Scholar 

  92. Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med. 2016;375:1415–24.

    Article  PubMed  Google Scholar 

  93. Catton CN, Lukka H, Gu C-S, Martin JM, Supiot S, Chung PWM, et al. Randomized trial of a hypofractionated radiation regimen for the treatment of localized prostate cancer. J Clin Oncol. 2017;35:1884–90.

    Article  CAS  PubMed  Google Scholar 

  94. Morgan SC, Hoffman K, Loblaw DA, Buyyounouski MK, Patton C, Barocas D, et al. Hypofractionated radiation therapy for localized prostate cancer: executive summary of an ASTRO, ASCO, and AUA evidence-based guideline. Pract Radiat Oncol. 2018;8:354–60.

    Article  PubMed  Google Scholar 

  95. Hamstra DA, Mariados N, Sylvester J, Shah D, Karsh L, Hudes R, et al. Continued benefit to rectal separation for prostate radiation therapy: final results of a phase III trial. Int J Radiat Oncol Biol Phys. 2017;97:976–85.

    Article  PubMed  Google Scholar 

  96. Dang A, Kupelian PA, Cao M, Agazaryan N, Kishan AU. Image-guided radiotherapy for prostate cancer. Transl Androl Urol. 2018;7:308–20.

    Article  PubMed  PubMed Central  Google Scholar 

  97. Kishan AU, Dang A, Katz AJ, Mantz CA, Collins SP, Aghdam N, et al. Long-term outcomes of stereotactic body radiotherapy for low-risk and intermediate-risk prostate cancer. JAMA Netw Open. 2019;2:e188006.

    Article  PubMed  PubMed Central  Google Scholar 

  98. Chang GJ, Skibber JM, Feig BW, Rodriguez-Bigas M. Are we undertreating rectal cancer in the elderly? An epidemiologic study. Ann Surg. 2007;246:215–21.

    Article  PubMed  PubMed Central  Google Scholar 

  99. Jung B, Påhlman L, Johansson R, Nilsson E. Rectal cancer treatment and outcome in the elderly: an audit based on the Swedish Rectal Cancer Registry 1995-2004. BMC Cancer. 2009;9:68.

    Article  PubMed  PubMed Central  Google Scholar 

  100. Choi Y, Kim JH, Kim J-W, Kim JW, Lee K-W, Oh H-K, et al. Preoperative chemoradiotherapy for elderly patients with locally advanced rectal cancer-a real-world outcome study. Jpn J Clin Oncol. 2016;46:1108–17.

    Article  PubMed  Google Scholar 

  101. François E, Azria D, Gourgou-Bourgade S, Jarlier M, Martel-Laffay I, Hennequin C, et al. Results in the elderly with locally advanced rectal cancer from the ACCOR12/PRODIGE 2 phase III trial: tolerance and efficacy. Radiother Oncol. 2014;110:144–9.

    Article  PubMed  Google Scholar 

  102. Shahir MA, Lemmens VEPP, van de Poll-Franse LV, Voogd AC, Martijn H, Janssen-Heijnen MLG. Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study. Eur J Cancer. 2006;42:3015–21.

    Article  CAS  PubMed  Google Scholar 

  103. Maas HAAM, Lemmens VEPP, Nijhuis PHA, de Hingh IHJT, Koning CCE, Janssen-Heijnen MLG. Benefits and drawbacks of short-course preoperative radiotherapy in rectal cancer patients aged 75 years and older. Eur J Surg Oncol. 2013;39:1087–93.

    Article  CAS  PubMed  Google Scholar 

  104. Gani C, Kirschniak A, Zips D. Watchful waiting after radiochemotherapy in rectal cancer: when is it feasible? Visc Med. 2019;35:119–23.

    Article  PubMed  PubMed Central  Google Scholar 

  105. Appelt AL, Pløen J, Harling H, Jensen FS, Jensen LH, Jørgensen JCR, et al. High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. Lancet Oncol. 2015;16:919–27.

    Article  PubMed  Google Scholar 

  106. Higuera O. Management of pancreatic cancer in the elderly [Internet]. World J Gastroenterol. 2016:764. Available from:. https://doi.org/10.3748/wjg.v22.i2.764.

  107. Hayman TJ, Strom T, Springett GM, Balducci L, Hoffe SE, Meredith KL, et al. Outcomes of resected pancreatic cancer in patients age ≥70. J Gastrointest Oncol. 2015;6:498–504.

    PubMed  PubMed Central  Google Scholar 

  108. Nagrial AM, Chang DK, Nguyen NQ, Johns AL, Chantrill LA, Humphris JL, et al. Adjuvant chemotherapy in elderly patients with pancreatic cancer. Br J Cancer. 2014;110:313–9.

    Article  CAS  PubMed  Google Scholar 

  109. Adjuvant chemoradiation therapy after pancreaticoduodenectomy in elderly patients with pancreatic adenocarcinoma. Int J Radiat Oncol Biol Phys Elsevier. 2011;80:1391–7.

    Article  Google Scholar 

  110. Frakes J, Mellon EA, Springett GM, Hodul P, Malafa MP, Fulp WJ, et al. Outcomes of adjuvant radiotherapy and lymph node resection in elderly patients with pancreatic cancer treated with surgery and chemotherapy. J Gastrointest Oncol. 2017;8:758–65.

    Article  PubMed  PubMed Central  Google Scholar 

  111. Morizane C, Okusaka T, Ito Y, Ueno H, Ikeda M, Takezako Y, et al. Chemoradiotherapy for locally advanced pancreatic carcinoma in elderly patients. Oncology. 2005;68:432–7.

    Article  CAS  PubMed  Google Scholar 

  112. Miyamoto DT, Mamon HJ, Ryan DP, Willett CG, Ancukiewicz M, Kobayashi WK, et al. Outcomes and tolerability of chemoradiation therapy for pancreatic cancer patients aged 75 years or older. Int J Radiat Oncol Biol Phys. 2010;77:1171–7.

    Article  PubMed  Google Scholar 

  113. de Geus SWL, Eskander MF, Kasumova GG, Ng SC, Kent TS, Mancias JD, et al. Stereotactic body radiotherapy for unresected pancreatic cancer: a nationwide review. Cancer. 2017;123:4158–67.

    Article  PubMed  Google Scholar 

  114. Zhong J, Patel K, Switchenko J, Cassidy RJ, Hall WA, Gillespie T, et al. Outcomes for patients with locally advanced pancreatic adenocarcinoma treated with stereotactic body radiation therapy versus conventionally fractionated radiation. Cancer. 2017;123:3486–93.

    Article  PubMed  Google Scholar 

  115. Sutera PA, Bernard ME, Wang H, Heron DE. Prognostic factors for elderly patients treated with stereotactic body radiation therapy for pancreatic adenocarcinoma. Front Oncol. 2018;8:282.

    Article  PubMed  PubMed Central  Google Scholar 

  116. Jiang W, Haque W, Verma V, Butler EB, Teh BS. Neoadjuvant stereotactic body radiation therapy for nonmetastatic pancreatic adenocarcinoma. Acta Oncol. 2019;58:1259–66.

    Article  PubMed  Google Scholar 

  117. Yechieli RL, Robbins JR, Mahan M, Siddiqui F, Ajlouni M. Stereotactic body radiotherapy for elderly patients with medically inoperable pancreatic cancer. Am J Clin Oncol. 2017;40:22–6.

    Article  PubMed  Google Scholar 

  118. Walter F, Böckle D, Schmidt-Hegemann N-S, Köpple R, Gerum S, Boeck S, et al. Clinical outcome of elderly patients (≥ 70 years) with esophageal cancer undergoing definitive or neoadjuvant radio(chemo)therapy: a retrospective single center analysis. Radiat Oncol. 2018;13:93.

    Article  PubMed  PubMed Central  Google Scholar 

  119. Zeng Y, Liang W, He J. Esophageal cancer in elderly patients: a population-based study [Internet]. J Clin Oncol. 2017:e15561–1. Available from:. https://doi.org/10.1200/jco.2017.35.15_suppl.e15561.

  120. Jain R, Yee J-L, Shaikh T, Au C, Handorf E, Meyer JE, et al. Treatment-related toxicity and outcomes in older versus younger patients with esophageal cancer treated with neoadjuvant chemoradiation. J Geriatr Oncol. 2020;11:668–74.

    Article  PubMed  Google Scholar 

  121. Song EY, Frakes JM, Extermann M, Klocksieben F, Mehta R, Saeed S, et al. Clinical factors and outcomes of octogenarians receiving curative surgery for esophageal cancer. J Surg Res. 2020;251:100–6.

    Article  PubMed  Google Scholar 

  122. Ruol A, Portale G, Castoro C, Merigliano S, Cavallin F, Battaglia G, et al. Management of esophageal cancer in patients aged over 80 years. Eur J Cardiothorac Surg. 2007;32:445–8.

    Article  PubMed  Google Scholar 

  123. Moreno AC, Verma V, Hofstetter WL, Lin SH. Patterns of care and treatment outcomes of elderly patients with stage I esophageal cancer: analysis of the National Cancer Data Base. J Thorac Oncol. 2017;12:1152–60.

    Article  PubMed  Google Scholar 

  124. Vlacich G, Samson PP, Perkins SM, Roach MC, Parikh PJ, Bradley JD, et al. Treatment utilization and outcomes in elderly patients with locally advanced esophageal carcinoma: a review of the National Cancer Database. Cancer Med. 2017;6:2886–96.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  125. Zhao Q, Hu G, Xiao W, Chen Y, Shen M, Tang Q, et al. Comparison of definitive chemoradiotherapy and radiotherapy alone in patients older than 75 years with locally advanced esophageal carcinoma: a retrospective cohort study. Medicine. 2017;96:e7920.

    Article  PubMed  PubMed Central  Google Scholar 

  126. Chen M, Liu X, Han C, Wang X, Zhao Y, Pang Q, et al. Does chemoradiotherapy benefit elderly patients with esophageal squamous cell cancer? A propensity-score matched analysis on multicenter data (3JECROG R-03A). BMC Cancer BioMed Central. 2020;20:1–9.

    CAS  Google Scholar 

  127. Fawaz ZS, Kazandjian S, Tsui JM, Devic DS, Lecavalier-Barsoum M, Vuong T, et al. What is the optimal radiation technique for esophageal cancer? A dosimetric comparison of four techniques. Cureus. 2018;10:e2985.

    PubMed  PubMed Central  Google Scholar 

  128. Chun SG, Hu C, Choy H, Komaki RU, Timmerman RD, Schild SE, et al. Impact of intensity-modulated radiation therapy technique for locally advanced non-small-cell lung cancer: a secondary analysis of the NRG Oncology RTOG 0617 randomized clinical trial. J Clin Oncol. 2017;35:56–62.

    Article  PubMed  Google Scholar 

  129. Hellman S, Weichselbaum RR. Oligometastases. J Clin Oncol. 1995;13:8–10.

    Article  CAS  PubMed  Google Scholar 

  130. Palma DA, Salama JK, Lo SS, Senan S, Treasure T, Govindan R, et al. The oligometastatic state—separating truth from wishful thinking [Internet]. Nat Rev Clin Oncol. 2014:549–57. Available from:. https://doi.org/10.1038/nrclinonc.2014.96.

  131. Ashworth A, Rodrigues G, Boldt G, Palma D. Is there an oligometastatic state in non-small cell lung cancer? A systematic review of the literature [Internet]. Lung Cancer. 2013:197–203. Available from:. https://doi.org/10.1016/j.lungcan.2013.07.026.

  132. Hong JC, Ayala-Peacock DN, Lee J, Blackstock AW, Okunieff P, Sung MW, et al. Classification for long-term survival in oligometastatic patients treated with ablative radiotherapy: a multi-institutional pooled analysis. PLoS One. 2018;13:e0195149.

    Article  PubMed  PubMed Central  Google Scholar 

  133. Palma DA, Olson R, Harrow S, Gaede S, Louie AV, Haasbeek C, et al. Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. Lancet. 2019;393:2051–8.

    Article  PubMed  Google Scholar 

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Dohm, A., Diaz, R. & Nanda, R.H. The Role of Radiation Therapy in the Older Patient. Curr Oncol Rep 23, 11 (2021). https://doi.org/10.1007/s11912-020-01000-y

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