New Horizons in Radiotherapy for Older People

Anthea Cree; Anita O'Donovan; Shane O'Hanlon

Disclosures

Age Ageing. 2019;48(5):605-612. 

In This Article

Abstract and Introduction

Abstract

Radiotherapy is an effective, albeit underutilised, treatment for cancer in older adults, especially for those who are surgically inoperable or for whom chemotherapy poses too great a risk. It is estimated that approximately half of patients with cancer could benefit from radiotherapeutic management. This article synthesises the basics of how radiotherapy works, recent developments in the field and considers how this treatment modality may be adapted in an older patient population or may evolve in the future.

Technological advances of relevance include Intensity Modulated Radiotherapy (IMRT), Volumetric Modulated Arc therapy (VMAT), Stereotactic Ablative Body Radiotherapy (SABR), proton therapy, MR guided radiotherapy, as well as better image guidance during irradiation in order to improve precision and accuracy.

New approaches for better integration of geriatric medicine principles into the oncologic assessment and workup will also be considered, in order to provide more age attuned care. For more informed decision making, a baseline assessment of older radiotherapy patients should encompass some form of Comprehensive Geriatric Assessment. This can facilitate the optimal radiotherapy regime to be selected, to avoid overly toxic regimes in patients with frailty.

The review discusses how these new initiatives and technologies have potential for effective oncologic management and can help to reduce the toxicity of treatment for older adults. It concludes by highlighting the need for more evidence in this patient population including better patient selection and support for treatment to enhance person-centred care.

Introduction

Radiotherapy is an effective treatment for many cancers, both in a curative and palliative setting.[1] It is estimated that around half of patients with cancer would benefit[2] but even in well-resourced countries, a proportion of those eligible are not treated.[3] Lower regional rates of access to radiotherapy have been associated with worse outcomes, e.g. in patients with non-small cell lung cancer.[4]

Rates of radiotherapy usage decline in older patients, especially those over 85 years. This is in keeping with other cancer treatments such as chemotherapy and surgery.[5] There is considerable geographic variation both in access to treatment and cancer outcomes, which is so great it is unlikely to be explained by population differences alone.[6,7]

A recent multivariate analysis of patients treated with radiotherapy showed no association between survival and age in patients with palliative intent, and only small variation in those treated with radical intent.[8,9] Historically, selection for intensive treatments, such as concurrent chemoradiotherapy, was based on strict age cut offs.[10] Older patients remain under represented in clinical trials and therefore evidence regarding optimum treatment is limited.[11]

Many patients have limited knowledge of radiotherapy prior to treatment and may have negative perceptions based on stories from friends, family and the press.[12] In patients with breast cancer, the majority found that their fears were unfounded.[13] These misperceptions can also occur amongst medical students and other doctors, who often have limited experience of radiotherapy.[14] Radiotherapy delivery has significantly improved over the last 50 years, from the routine use of linear accelerators (Linacs) to stereotactic radiotherapy (high dose, highly localised radiotherapy).

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