The number of people with cancer diagnosed at age 85 years or older — so-called super-elders — is increasing sharply, posing challenges for radiation oncology planning. Geriatric oncology evaluations and careful communication to identify patients’ goals and priorities for care will play important roles in personalizing treatment plans.

As the US population ages, radiation oncology will see increasing numbers of elderly and super-elder (older than 85 years) patients whose potential benefits, information needs, comorbidities, radiation dose regimens, and treatment toxicity vulnerabilities can differ importantly from those of younger patients, according to a collection of papers published in the International Journal of Radiation Oncology Biology Physics (known in the field as “the Red Journal”).1-7

The US Census Bureau predicts that by 2050 there will be as many super-elders as there are young children (younger than 5 years), and that by 2030, older adults will represent one-fifth of the US population and 70% of patients with newly diagnosed cancer.1,3

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“The elderly, and particularly those older than 85 [years], are the fastest-growing age demographic in most of the developed world,” noted Anthony L. Zietman, MD, FASTRO, the editor-in-chief of the Red Journal and a radiation oncologist at the Harvard Medical School and Massachusetts General Hospital Cancer Center, in Boston.

Super-elders are a “new and rapidly growing demographic, never previously encountered in our evolutionary past,” Dr Zietman noted.2


These patients tend to be frail. Their capacity to repair tissue damage and to recover from stressful events is not what it once was.2 Both cancer and its treatment can take a heavier toll on these patients than on younger populations. Treatment toxicity can “undermine dignity, independence, and the will to live,” Dr Zietman wrote.2 “Elders with neuropathy may be unable to dress themselves; muscle loss may render them bedbound; and those who become incontinent, or deaf, or blind, may become socially isolated.”

But clinical trials exclude patients with comorbidities that are typical in advanced older age, leading to an underappreciation of the real-world side effects of treatment in the oldest patients.3

“In medicine, we have an entire specialty — pediatrics — that is dedicated to children because of their distinctive biology and vulnerabilities,” Dr Zietman said. “I believe that we need to think about the elderly differently, also. There are pressing questions involved in cancer care for elderly, including both biological and philosophical considerations. Can we assess the elderly and tailor their cancer treatments in a way that saves their lives without ruining their lives? How little treatment can we give yet still be effective? How can we leverage new technologies to reduce the side effects of treatment?”

In the United States, more than half of patients with cancer undergo radiotherapy at some point during their care, Dr Zietman noted.1 Because older patients are more often not eligible for — or prefer to avoid — surgical interventions, radiotherapy seems likely to play a larger role in the care of these patients than in younger people.1 The emergence of more precise external-beam radiotherapy modalities such as stereotactic body radiotherapy (SBRT), stereotactic radiosurgery (SRS), and possibly, proton therapy, might reduce irradiation of healthy nontarget tissues in a manner that allows greater use in elderly patients than was possible with older radiotherapy technology.1 But the optimal role for radiotherapy in the treatment of very old patients is not yet entirely clear.