CHANGING PRIORITIES
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When cancer is diagnosed in young people, it is likely to be the most immediate threat to their long-term survival and quality of life. That is not always the case with the very old.
“Prostate cancer is probably the best studied in this regard,” Dr Zietman noted.2 “Most low-risk cancer will not threaten a patient’s life within the decade, and probably not within 2. Restraint is clearly preferred, and the evidence suggests that this is now commonly the case.”
Even treatment of high-risk prostate tumors can be deferred for the very old, Dr Zietman added.2 These patients can be treated with androgen deprivation alone.
Once a decision is made to treat the very old more aggressively, however, treatment de-escalation or fractionation alternatives to the standard of care for younger patients are important considerations.2
“Experienced physicians are as aware of the risks of overreach as they are of undertreatment, and often limit radiation dose, shrink fields, or de-intensify chemotherapy in a patient-tailored fashion,” Dr Zietman explained.2 “If we plan treatment, can we make it better match the elder’s life: their immobility, their reliance on rides, their propensity to fatigue?”
Hypofractionation is one “low-hanging fruit” in treatment planning for very old patients, Dr Zietman argued.2 Truncated hypofractionated radiotherapy regimens offer comparable clinical effectiveness and quality of life for super-elder men with prostate cancer as standard regimens, and similar findings have been found for women with breast cancer, noted Benjamin Movsas, MD, FASTRO, of the Henry Ford Health System in Detroit, Michigan.3
Approximately 1 in 5 older cancer patients have an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher.4 Geriatric assessments such as the abbreviated Comprehensive Geriatric Assessment or Onco-Geriatric Screening Tool need to be used more widely, say experts in geriatric radiation oncology, to better tailor integrated treatment plans in light of patient functional status, vulnerabilities, and goals.3,4
Patients’ priorities can differ importantly from those typical among younger patients facing cancer, Dr Zietman noted.2 Shared decision-making that includes patients can be more challenging with older patients, who are more likely to have cognitive impairment and communication issues. Most older women with breast cancer report that they themselves are the primary decision-maker when it comes to whether or not they will undergo radiotherapy.5 Effectively communicating with elderly patients requires confirming that patients understood what they were told; members of the cancer care team should reiterate information about prognosis, disease progression, and treatment goals, using qualitative rather than quantitative descriptions where possible.6 The “ask-tell-ask” approach involves asking the patient for her understanding, followed by clarifying or providing additional information in simple language, before confirming her understanding.6
“Older women desire information and have more agency and input in the decision-making process than prior literature would suggest,” reported Shi-Yi Wang, MD, PhD, and coauthors from Yale University School of Medicine and School of Public Health in New Haven, Connecticut.5
References
1. Cancer research journal devotes special issue to radiation therapy and the elderly [news release]. Arlington, VA: American Society for Radiation Oncology; June 15, 2017.
2. Zietman AL. Frailty is our destiny: an introduction to the Red Journal’s special edition on radiation therapy in the elderly. Int J Radiat Oncol Biol Phys. 2017;98(4):713-714.
3. Movsas B. Radiation therapy in elderly persons: an old issue with new approaches. Int J Radiat Oncol Biol Phys. 2017;98(4):715-717.
4. Extermann M. Cancer in the elderly: moving the needle toward evidence-based personalized oncology. Int J Radiat Oncol Biol Phys. 2017;98(4):718-720.
5. Wang SY, Kelly G, Gross C, et al. Information needs of older women with early-stage breast cancer when making radiation therapy decisions. Int J Radiation Oncol Biol Phys. 2017;98(4):733-740.
6. Fakhreddine MH, Galvan E, Pawlowski J, Jones WE III. Communicating effectively with elderly cancer patients. Int J Radiat Oncol Biol Phys. 2017;98(4):741-742.
