Kate Johnson

April 29, 2013

GENEVA, Switzerland — Elderly patients with painful bone metastases should be offered palliative radiotherapy just like their younger counterparts, according to new research.

"The literature shows that [older people] are frequently not asked because clinicians think it's too much for them — they are elderly, they have more comorbidities, they are frail," said Paulien Westhoff, MD, from the Department of Radiotherapy at the University Medical Centre Utrecht in the Netherlands.

"We've proven that this is not true," she told Medscape Medical News after her presentation here at the 2nd European Society for Radiotherapy & Oncology Forum.

Dr. Westhoff and colleagues analyzed data from the Dutch Bone Metastasis Study, which demonstrated that, in 1157 patients, a single fraction of 8 Gy of radiotherapy and 6 fractions of 24 Gy provided equal pain relief (Radiother Oncol. 1999;52:101-109).

In the study cohort, 520 patients were 32 to 64 years of age (younger group); 410 patients were 65 to 74 years of age (intermediate group), and 227 patients were 75 years or older (older group).

Patients completed questionnaires before palliative radiotherapy (baseline) and at regular follow-ups to measure response in terms of pain and quality of life (using the Rotterdam Symptom Checklist to evaluate psychological distress, physical symptom distress, and activity level impairment).

At baseline, patients in the older group had worse scores on the Karnofsky Performance Status Scale than patients in the intermediate and younger groups (39% vs 29% vs 26%; P =.004), and were less likely to have visceral disease (17% vs 24% vs 35%; P < .001).

There were also significant differences in terms of primary tumors; patients in the older group more frequently had prostate cancer (42%), and those in the younger group more frequently had breast cancer (53%).

Median survival was 35 weeks in the younger group and 27 weeks in the intermediate and older groups (P = .05).

Overall, 71% of the study cohort experienced a response to palliative radiotherapy, defined as a decrease of at least 2 points from the initial pain score, at some time during the first year.

Although significant, response to radiotherapy was less in the older group than in the younger group (67% vs 78%; P = 0.07) and than in the intermediate group (67% vs 74%; P =.36).

Overall, response to palliative radiotherapy was meaningful in patients in the older group, "so we should consider palliative radiotherapy in these patients," Dr. Westhoff explained.

Some studies show that elderly patients are referred less often for palliative radiotherapy and receive different treatments than younger patients, "even though it's known that radiotherapy is a good, effective, and quite an easy treatment," she added.

Important Treatment, Underused in Elderly

"Palliative radiotherapy is an important treatment modality that can greatly impact a patient's quality of life. Unfortunately, in the United States and in other countries, elderly patients are less likely to receive it," said James Murphy, MD, from the Department of Radiation Medicine and Applied Sciences at the University of California, San Diego, who was asked Medscape Medical News to comment on the findings.

Dr. Murphy is the lead author of a study that highlights this disparity (J Oncol Pract. Published online April 16, 2013). Using Medicare data to explore patterns of palliative radiotherapy use in the United States, Dr. Murphy's team found that "the use of palliative radiotherapy decreases substantially as patients grow older, even after controlling for other confounding factors such as geographic location, income level, and comorbidity," he said.

They found that patients older than 85 years had one third the odds of receiving palliative radiotherapy as patients 65 to 70 years. This age-related difference in treatment has been reported previously in the United States (Int J Radiat Oncol Biol Phys. 2007;69:1001-1007) and in Canada (J Clin Oncol. 2001;19:137-144).

Dr. Murphy said that the Dutch Bone Metastasis Study "helps to dispel the commonly held belief that older patients benefit less from palliative radiation."

Other factors contributing to this discrepancy include "patient beliefs or biases and concerns about patient performance status deserve mention," he added. "The true barriers that older patients face are not clearly defined. Our field needs more research to identify the barriers that the underserved face, especially given the benefit that palliative radiotherapy offers," Dr. Murphy noted.

Dr. Westhoff and Dr. Murphy have disclosed no relevant financial relationships.

2nd European Society for Radiotherapy & Oncology (ESTRO) Forum: Abstract PD-0533. Presented April 22, 2013.


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