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is it inadequately investigated and treated?
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CANCER IN ELDERLY
- Jeremic Branislav (10 August 1999)
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The benefits in local control may be outweighted lower quality of life
- Ian Kunkler (18 August 1999)
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Jeremic Branislav
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Dear Sir, In their elegant publication, Turner et al 1 summarise current problems in the diagnos-tic and therapeutic approaches in cancer in elderly. While all treatment modalities used in this population are discussed separately, there is also a possibility of using concurrent radiotherapy (RT) and chemotherapy (CHT). Although this approach increasingly used in a number of tumours is usually considered toxic, even in non-elderly, our recent studies clearly showed opposite 2-4. The outcome of treatment of elderly with a variety of lung tumours treated that way was shown to be similar to that obtained with more aggressive approach in non-elderly. Although results of our phase II studies should not be seen as a definitive conclusion about its utility, our detailed pattern of toxicity clearly showed that if appropriately selected, elderly may be a suitable target group for investigational treatment. The selection criteria, similar to that we and other usually use in the non- elderly entering clinical studies, were accompanied with careful selection of both RT and CHT parameters. In all these studies we have used al-tered fractionated regimens, depending on the indication. While in stage IV non- small-cell lung cancer (NSCLC) 4 we used two large single fraction given with one week split, in stage III NSCLC and in limited disease small-cell lung cancer 2,3 we used accelerated hyperfrac-tionated RT. In all studies carboplatin and etoposide were used. With concurrent approach we did not observe an increase in the incidence of both acute and late high-grade (> 3) toxicity, that was mostly described as mild to moderate. Furthermore, toxicity profile ensured us that there was a room for intensification of the treatment, although every caution should be sug- gested when one intend to embark on such policy. Careful selection of patients, thus, must be performed because it is eventually rewarding. Because there is unequivocal fact that elderly are undercared (both diagnostically and therapeutically), we should move from this point as Turner et al 1 suggest. If I am allowed to slightly change the order of their suggestions, maybe we should start first with getting an-swers about optimal management of particular tumours in elderly as a community of oncologists. Only then, other medical professionals (GPs, non- oncologists, etc) and elderly patients themselves will be assured that they are suggested the "optimal care". The turn of the century is the right time to do so, moving from compassion to adequate medical care we have to offer this patient population. REFERENCES 1. Turner NJ, Haward RA, Mulley GP, Selby PJ. Cancer in old age - is it inadequately investigated and treated. BMJ 1999; 319 : 309-312. 2. Jeremic B, Shibamoto Y, Acimovic Lj, Milisavljevic S. Carboplatin, etoposide, and accelerated hyperfractionated radiotherapy for elderly patients with limited small cell lung cancer. A phase II study. Cancer 1998; 82 : 836-841. 3. Jeremic B, Shibamoto Y, Milicic B, Milisavljevic S, Nikolic N, Dagovic A, Aleksan-drovic J, Radosavljevic-Asic G. Concurrent accelerated hyperfractionated radiation therapy and carboplatin/oral etoposide in elderly patients with stage III non-small-cell lung cancer. a phase II study. Int J Radiat Oncol Biol Phys 1999; 44 : 343-348. 4. jeremic branislavJeremic B, Shibamoto Y, Milicic B, Milisavljevic S, Nikolic N, Dagovic A, Aleksan-drovic J, Radosavljevic-Asic G. Short-term chemotherapy and palliative radiotherapy for elderly patients with stage IV non-small cell lung cancer. A phase II study. Lung Cancer 1999; 24 : 1 -9. |
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Ian Kunkler
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In their paper discussing the management of cancer in old age, Turner et al (1) report a decline in the delivery of treatment for cancer among older patients. A similar trend is seen in Scotland (2) where older people are less likely to be treated outside their area of residence and more likely to be admitted to hospitals with small numbers of admissions. This implies that these patients are less likely to be referred to a cancer centre and may reflect, in part, reluctance of general practitioners to submit older patients for investigation and treatment. While ageism among health care professionals may account for some of the poorer outcomes of the elderly, we would submit that, at least in breast cancer, the lack of randomised trials among older patients to underpin rationale treatment choice may also play an important part. The issue is an important one in Scotland since here a 12% rise in cases of breast cancer has been predicted among women over 75 from 1996 to 2006. In women over the age of 70, the value of adjuvant breast irradiation, for example, following wide local excision for small tumours is largely inferred from randomised trials whose eligibility criteria exclude women over the age of 70. There is evidence from a randomised trial of quadrantectomy, axillary clearance and appropriate systemic therapy with or without breast irradiation that the risk of recurrence diminishes with increasing age (3). Since there is no evidence from randomised trials (4,5) that survival is compromised by the omission of breast irradiation, the gains in local control have to be balanced against impaired quality of life from radiation induced morbidity (breast pain, pneumonitis, rib fractures) and the social disruption from 4-6 weeks of inpatient/outpatient treatment. In older women treated by breast conservation at low risk of breast recurrence (e.g. completely excised, low/intermediate grade, axillary node negative), it is unknown whether the benefits in local control may be outweighed from the patient's perspective by the adverse impact of treatment on quality of life. To test this hypothesis a randomised trial, PRIME (Post-operative Radiotherapy In Minimum-risk Elderly), in Scotland, funded by the Department of Health (Health Technology Assessment) will be recruiting 240 older women at low risk of local recurrence treated by breast conserving surgery and tamoxifen. They will be randomised to receive or not receive breast irradiation. The primary end-points are quality of life, anxiety and depression, and cost-effectiveness. Quality of life will be assessed using questionnaires completed by a research nurse with patients in their own home. Comorbidity will be prospectively documented. Hopefully the results of this and similar trials in older women will provide a sounder basis for management decisions in this group with operable breast cancer. Dr. Ian Kunkler Dr. Robin Prescott Mr. Michael Dixon Dr. Susan Shepherd Ms. Linda Williams Mrs. Celia King Medical Statistics Unit References: 1. Turner NJ, Haward RA, Mulley GP, Selby PJ. Cancer in old age - is it adequately investigated and treated? BMJ 1999;319:309-12 2. Cancer in older persons in Scotland. Health Bulletin 1996;54:375- 389 3. Veronesi U, Luini A, Del Vecchio M, Greco M et al. Radiotherapy after breast conserving surgery in women with localized cancer of the breast. N Eng J Med 1993;328:1587-91. 4. Forrest APM, Stweart HJ, Everington D et al. Randomised controlled trial of conservation therapy for breast cancer: 6 year analysis of the Scottish trial. Lancet 1996;348:708-13. 5. Fisher B, Anderson S, Redmond CK et al. Reanalysis and results after 12 years of follow up in a randomised clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Eng J Med 1996;333:1456-61. |
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