NCCN: Continuing Education
Accreditation Statement
This activity has been designed to meet the educational needs of physicians, nurses, and pharmacists involved in the management of patients with cancer. There is no fee for this article. The National Comprehensive Cancer Network (NCCN) is accredited by the ACCME to provide continuing medical education for physicians. NCCN designates this journal-based CE activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
NCCN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center‘s Commission on Accreditation.
NCCN designates this educational activity for a maximum of 1.0 contact hour. Accreditation as a provider refers to recognition of educational activities only; accredited status does not imply endorsement by NCCN or ANCC of any commercial products discussed/displayed in conjunction with the educational activity. Kristina M. Gregory, RN, MSN, OCN, is our nurse planner for this educational activity.
National Comprehensive Cancer Network is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. NCCN designates this continuing education activity for 1.0 contact hour(s) (0.1 CEUs) of continuing education credit in states that recognize ACPE accredited providers. This is a knowledge-based activity. UAN: 0836-0000-16-011-H01-P
All clinicians completing this activity will be issued a certificate of participation. To participate in this journal CE activity: 1) review the learning objectives and author disclosures; 2) study the education content; 3) take the posttest with a 66% minimum passing score and complete the evaluation at http://education.nccn.org/node/79757; and 4) view/print certificate.
Release date: November 1, 2016; Expiration date: November 1, 2017
Learning Objectives:
Upon completion of this activity, participants will be able to:
Integrate into professional practice the updates to NCCN Guidelines for Older Adult Oncology
Describe the rationale behind the decision-making process for developing the NCCN Guidelines for Older Adult Oncology
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Categories of Evidence and Consensus
Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise noted.
Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Overview
Cancer is the leading cause of death in women and men aged 60 to 79 years.1 More than 50% of all cancers and more than 70% of cancer-related deaths in the United States occur in patients who are 65 years or older.2 It is estimated that by 2030 approximately 70% of all cancers will be diagnosed in adults aged 65 years or older.3 An aging US population and a greater life expectancy mean that cancer in older adults is becoming an increasingly common problem. Furthermore, older patients with cancer are underrepresented in clinical trials for new cancer therapies.4 Therefore, less evidence-based information exists to guide treatment of these patients. The challenge of managing older patients with cancer is to assess whether the expected benefits of treatment are superior to the risk in a population with decreased life expectancy and decreased tolerance to stress. There are unique issues to consider when caring for an older adult with cancer.
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
Surgery, radiation therapy (RT), chemotherapy, and targeted therapies should be considered as treatment options for all older patients who are able to tolerate curative treatment. RT can be offered either in the curative or palliative setting.8,9 Available data from the literature indicate that RT can be highly effective and well tolerated, so that age alone need not be a limiting factor.10–12 Advanced RT techniques (eg, intensity-modulated RT [IMRT], image-guided RT [IGRT], and stereotactic body RT [SBRT] or stereotactic ablative RT [SABR]) facilitate the delivery of large doses of radiation to small target volumes while limiting the risk of radiation-induced damage to normal surrounding tissues and organs at risk (OAR).13 Judicious application of these techniques may also help assuage concerns about the risks of RT in older adults. Hypofractionated RT may also help improve treatment tolerability by limiting overall treatment time without compromising clinical outcomes in some patients.14
The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults and provide an approach to decision-making with the application of comprehensive geriatric assessment (CGA). In addition, the NCCN Guidelines for Older Adult Oncology also provide age-specific recommendations for the use of surgery, RT, chemotherapy, and targeted therapies for different cancer subtypes. These NCCN Guidelines Insights focus on recent updates to the 2016 NCCN Guidelines for Older Adult Oncology specific to the use of RT in the management of older adults with cancer.
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
Breast Cancer
RT as a component of breast-conserving therapy after lumpectomy is not always necessary in selected older women with stage I breast cancer. In a study that randomized 636 women (aged ≥70 years) treated with lumpectomy for clinical stage I estrogen receptor–positive breast cancer to either tamoxifen with whole-breast RT or tamoxifen alone, locoregional recurrence was slightly higher among those who did not receive RT.15,16 At the median follow-up of 12.6 years, the 10-year local recurrence rates were 2% and 10%, respectively, for those who received tamoxifen with RT and those who received tamoxifen alone. However, there were no significant differences in time to mastectomy, time to distant metastasis, breast cancer–specific survival, or overall survival (OS) between the groups.16 The 10-year OS rates were 67% and 66%, respectively, and the estimated 10-year breast cancer–specific survival rates were 97% and 98%, respectively. In this study, all patients received adjuvant tamoxifen for 5 years. Results of the recently published PRIME II study led the authors to conclude that because the rate of ipsilateral recurrence is low, omission of whole-breast RT after breast-conserving surgery could be considered for some women aged 65 years or older with early-stage breast cancer.17 In this study, 1,326 women aged 65 years or older who had undergone breast-conserving surgery for early-stage, low-risk breast cancer (hormone receptor–positive, axillary node-negative, T1–T2 up to 3 cm at the longest dimension, and clear margins; either grade 3 tumors or lymphovascular invasion) and receiving adjuvant endocrine treatment were randomized to whole-breast RT and no further treatment. After median follow-up of 5 years, the ipsilateral recurrence rate was 1.3% in women assigned to whole-breast RT and 4.1% for those assigned no RT (P=.0002), with no difference in OS between the groups; the 5-year OS rate was 93.4% in both groups.
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
The NCCN Guidelines Panel concluded that omission of RT can be considered in women aged 70 years or older with stage I estrogen receptor–positive breast cancer who undergo a lumpectomy with negative margins and who are likely to complete 5 years of endocrine therapy. Given that the PRIME study results are based on the 5-year follow-up,17 the panel concluded that currently there is not enough evidence to extrapolate these results to any patient aged 65 years or older with a life expectancy of greater than 5 years.
Central Nervous System Cancers
Surgery followed by RT in combination with concurrent and adjuvant temozolomide is the standard treatment for glioblastoma multiforme (GBM) in patients younger than 70 years.18 Recent reports from a global randomized phase III clinical trial confirmed that the addition of concurrent and adjuvant temozolomide to hypofractionated RT (40 Gy in 15 fractions over 3 weeks) is well tolerated and significantly improves OS and progression-free survival (PFS) in older patients with newly diagnosed GBM and good performance status.19 In this trial, 562 patients (aged ≥65 years) were randomized to short-course RT (40 Gy in 15 fractions over 3 weeks) either alone or in combination with concomitant temozolomide plus adjuvant temozolomide until progression or 12 cycles. The median OS and PFS for patients who received short-course RT with concurrent and adjuvant temozolomide were 9.3 and 5.3 months respectively, compared with 7.6 and 3.9 months for those who were treated with short-course RT alone (P<.0001).19 Patients with methylguanine DNA methyltransferase (MGMT) methylated tumors benefited the most from the addition of temozolomide to RT. Earlier reports from other investigators also suggest that the addition of temozolomide to standard RT (60 Gy) or short-course RT (40 Gy in 15 fractions over 3 weeks) can prolong survival with acceptable toxicity in older patients
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
Postoperative RT alone has also been shown to effectively improve clinical outcomes in older patients with GBM.24,25 In a randomized trial, older patients with GBM treated with surgery (≥60 years; n=100) were randomized to either standard-course RT (60 Gy in 30 fractions over 6 weeks) or an abbreviated course of RT (40 Gy in 15 fractions over 3 weeks).24 The median OS was similar for both treatment groups (5.1 months for standard-course RT and 5.6 months for abbreviated-course RT). However, among those who completed RT as planned, more patients who received standard RT
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
The NCCN Guidelines Panel recommends that postoperative hypofractionated accelerated-course RT (with the goal of completing treatment in 2–3 weeks) either alone or in combination with concurrent and adjuvant temozolomide is a reasonable treatment option for patients aged 70 years or older with newly diagnosed GBM. Hypofractionated accelerated-course RT with concurrent and adjuvant temozolomide has been shown to be superior to hypofractionated accelerated-course RT alone in older patients (≥65 years) with newly diagnosed GBM.19 The panel does not recommend withholding temozolomide for older patients with newly diagnosed GBM in the absence of a specific contraindication. MGMT gene promoter methylation status has been identified as a predictive marker for survival benefit in patients treated with temozolomide, which could be useful for the selection of older patients suitable for treatment with temozolomide in combination with RT.26–28
Hepatocellular Carcinoma
Older patients with hepatocellular carcinoma (HCC) may benefit from liver resection or transplantation.29–31 Available evidence (primarily from retrospective studies) has shown no major difference in outcomes between carefully selected older patients and younger patients with HCC.32–36
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
Available evidence (primarily from nonrandomized clinical trials and retrospective analyses) supports the use of SBRT in the management of patients with unresectable or locally advanced HCC. In a large prospective series of 102 patients with locally advanced HCC and Child-Pugh A liver function treated in sequential phase I and II trials, SBRT resulted in a 1-year local control rate of 87% and median survival of 17 months.37 Most of these patients were at high risk with relatively advanced-stage tumors. Limited safety data are available in patients with Child-Pugh B or poorer liver function.38–41 The safety of SBRT for patients with Child-Pugh C cirrhosis has not been established. In a retrospective analysis of 185 patients treated with SBRT at 2 different dose levels (40 Gy in 5 fractions for patients with Child-Pugh A liver function and 35 Gy in 5 fractions for those with Child-Pugh B liver function), the 3-year local control and OS rates were 91% and 70%, respectively, with no significant differences in outcomes between dose levels.41
The panel decided to include a section highlighting the benefit of SBRT for older patients with HCC who may not be able to tolerate liver resection or transplantation and locoregional therapies. The panel recommends that SBRT be considered for those who may not be suitable for liver resection or transplantation due to the presence of comorbidities or compromised performance status. Patients with good liver function (Child-Pugh A) and limited volume of disease are ideal candidates for SBRT, although those with Child-Pugh B cirrhosis can safely be treated with dose modifications and strict dose constraint adherence. Treatment toxicity can be minimized by careful patient selection, appropriate radiation dose, and optimized dosimetry to meet normal tissue constraints.
Lung Cancers
Non–Small Cell Lung Cancer
Surgical resection and mediastinal lymph node dissection is the standard treatment for patients with
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
In older patients with locally advanced NSCLC, combined modality therapy (concurrent chemotherapy with RT given once or twice daily) has resulted in disease control and survival rates similar to those observed in younger patients; however, toxicities (esophagitis, pneumonitis, and
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
Small Cell Lung Cancer
Combined modality therapy is the recommended treatment for patients with limited-stage disease, whereas chemotherapy alone is the standard treatment option for patients with extensive-stage disease. Prophylactic cranial irradiation (PCI) is effective in decreasing the incidence of cerebral metastases in patients with SCLC (limited and extensive stage) responding to initial chemotherapy. A recent report from a pooled analysis of 4 prospective trials showed that PCI was also associated with significant improvement in survival among older patients (aged ≥70 years) with SCLC, and the survival advantage was more significant in patients with extensive-stage SCLC.47 However, PCI is also associated with more adverse events and increased neurotoxicity in older patients compared with younger patients, with older age being the most significant predictor of chronic neurotoxicity.48,49
The panel concluded that patients aged 70 years and older with extensive-stage SCLC that responds to chemotherapy may benefit from PCI. However, given the strong relationship between declining cognitive function and age, the panel emphasized that patients with poor performance status or impaired neurocognitive functioning should not be treated with PCI.
Prostate Cancer
The use of long-term androgen deprivation therapy (ADT) in combination with RT is an effective treatment option (associated with improved cancer-specific survival and OS) for all patients with high-risk
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
NCCN Guidelines Insights: Older Adult Oncology, Version 2.2016
Version 2.2016 © National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 11; 10.6004/jnccn.2016.0146
Based on these findings, the panel concluded that for men of advanced age with high-risk prostate cancer and moderate-to-severe comorbidity, a shorter course (4–6 months) of ADT with RT can be considered over a longer course (28–36 months).
NCCN Recommendations
The decision to offer RT to older patients with cancer should be based on the following factors: (1) evaluation of the benefits and risks associated with RT; (2) careful consideration of the patient's underlying functional reserve; and (3) an understanding of the differences in the biology of cancers and their responsiveness to therapy in this patient population. Treatment should be individualized based on the nature of the disease and the performance status of the patient.
Omission of RT (after lumpectomy with negative margins) can be considered for selected older women with stage I estrogen receptor–positive breast cancer who are likely to complete 5 years of endocrine therapy.
Hypofractionated accelerated-course RT (either alone or in combination with concurrent and adjuvant temozolomide) is a reasonable treatment option for patients aged 70 years or older with newly diagnosed GBM. Hypofractionated accelerated-course RT with concurrent and adjuvant temozolomide is superior to hypofractionated accelerated-course RT alone in older patients (≥65 years) with newly diagnosed GBM.
SBRT should be considered for older patients with HCC, particularly for those with comorbidities or a compromised performance status, who may not be suitable for liver resection or transplantation and locoregional therapies.
SBRT is also recommended for early-stage NSCLC in older patients who are medically inoperable or who decline to have surgery after thoracic surgery evaluation.
Older patients with extensive-stage SCLC and response to chemotherapy may benefit from PCI; however, it should not be used for patients with poor performance status or impaired neurocognitive functioning.
Shorter-course ADT with RT can be considered over longer-course ADT in older men with high-risk prostate cancer and moderate-to-severe comorbidity.
References
- 2.↑
Altekruse SF KC, Krapcho M, Neyman N et al., eds. SEER Cancer Statistics Review, 1975-2007: National Cancer Institute. Bethesda, MD, based on November 2009 SEER data submission, posted to the SEER web site, 2010. Available at: http://seer.cancer.gov/csr/1975_2007/. Accessed October 12, 2016.
- 3.↑
Smith BD, Smith GL, Hurria A et al.. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009;27:2758–2765.
- 4.↑
Talarico L, Chen G, Pazdur R. Enrollment of elderly patients in clinical trials for cancer drug registration: a 7-year experience by the US Food and Drug Administration. J Clin Oncol 2004;22:4626–4631.
- 6.↑
Saltzstein SL, Behling CA. 5- and 10-year survival in cancer patients aged 90 and older: a study of 37,318 patients from SEER. J Surg Oncol 2002;81:113–116; discussion 117.
- 7.↑
Extermann M. Management issues for elderly patients with breast cancer. Curr Treat Options Oncol 2004;5:161–169.
- 8.↑
Zachariah B, Balducci L. Radiation therapy of the older patient. Hematol Oncol Clin North Am 2000;14:131–167.
- 9.↑
Smith GL, Smith BD. Radiation treatment in older patients: a framework for clinical decision making. J Clin Oncol 2014;32:2669–2678.
- 10.↑
Zachariah B, Balducci L, Venkattaramanabalaji GV et al.. Radiotherapy for cancer patients aged 80 and older: a study of effectiveness and side effects. Int J Radiat Oncol Biol Phys 1997;39:1125–1129.
- 11.
Mitsuhashi N, Hayakawa K, Yamakawa M et al.. Cancer in patients aged 90 years or older: radiation therapy. Radiology 1999;211:829–833.
- 12.↑
Wasil T, Lichtman SM, Gupta V, Rush S. Radiation therapy in cancer patients 80 years of age and older. Am J Clin Oncol 2000;23:526–530.
- 13.↑
Kunkler IH, Audisio R, Belkacemi Y et al.. Review of current best practice and priorities for research in radiation oncology for elderly patients with cancer: the International Society of Geriatric Oncology (SIOG) task force. Ann Oncol 2014;25:2134–2146.
- 14.↑
Donato V, Valeriani M, Zurlo A. Short course radiation therapy for elderly cancer patients. Evidences from the literature review. Crit Rev Oncol Hematol 2003;45:305–311.
- 15.↑
Hughes KS, Schnaper LA, Berry D et al.. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004;351:971–977.
- 16.↑
Hughes KS, Schnaper LA, Bellon JR et al.. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol 2013;31:2382–2387.
- 17.↑
Kunkler IH, Williams LJ, Jack WJ et al.. Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol 2015;16:266–273.
- 18.↑
Stupp R, Hegi M, Mason W et al.. Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomized phase III study: 5-year analysis of the EORTC-NCIC trial. Lancet Oncol 2009;10:459–466.
- 19.↑
Perry JR, Laperriere N, O'Callaghan CJ et al.. A phase III randomized controlled trial of short-course radiotherapy with or without concomitant and adjuvant temozolomide in elderly patients with glioblastoma (CCTG CE.6, EORTC 26062-22061, TROG 08.02, NCT00482677) [abstract]. J Clin Oncol 2016;34(18 Suppl):Abstract LBA2.
- 20.↑
Minniti G, Lanzetta G, Scaringi C et al.. Phase II study of short-course radiotherapy plus concomitant and adjuvant temozolomide in elderly patients with glioblastoma. Int J Radiat Oncol Biol Phys 2012;83:93–99.
- 21.↑
Behm T, Horowski A, Schneider S et al.. Concomitant and adjuvant temozolomide of newly diagnosed glioblastoma in elderly patients. Clin Neurol Neurosurg 2013;115:2142–2146.
- 22.↑
Minniti G, Scaringi C, Lanzetta G et al.. Standard (60 Gy) or short-course (40 Gy) irradiation plus concomitant and adjuvant temozolomide for elderly patients with glioblastoma: a propensity-matched analysis. Int J Radiat Oncol Biol Phys 2015;91:109–115.
- 23.↑
Arvold ND, Tanguturi SK, Aizer AA et al.. Hypofractionated versus standard radiation therapy with or without temozolomide for older glioblastoma patients. Int J Radiat Oncol Biol Phys 2015;92:384–389.
- 24.↑
Roa W, Brasher PM, Bauman G et al.. Abbreviated course of radiation therapy in older patients with glioblastoma multiforme: a prospective randomized trial. J Clin Oncol 2004;22:1583–1588.
- 25.↑
Keime-Guibert F, Chinot O, Taillandier L et al.. Radiotherapy for glioblastoma in the elderly. N Engl J Med 2007;356:1527–1535.
- 26.↑
Minniti G, Salvati M, Arcella A et al.. Correlation between O6-methylguanine-DNA methyltransferase and survival in elderly patients with glioblastoma treated with radiotherapy plus concomitant and adjuvant temozolomide. J Neurooncol 2011;102:311–316.
- 27.
Wick W, Platten M, Meisner C et al.. Temozolomide chemotherapy alone versus radiotherapy alone for malignant astrocytoma in the elderly: the NOA-08 randomised, phase 3 trial. Lancet Oncol 2012;13:707–715.
- 28.↑
Malmstrom A, Gronberg BH, Marosi C et al.. Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomised, phase 3 trial. Lancet Oncol 2012;13:916–926.
- 29.↑
Kim J, Ko ME, Nelson RA et al.. Increasing age and survival after orthotopic liver transplantation for patients with hepatocellular cancer. J Am Coll Surg 2014;218:431–438.
- 30.
Faber W, Stockmann M, Schirmer C et al.. Significant impact of patient age on outcome after liver resection for HCC in cirrhosis. Eur J Surg Oncol 2014;40:208–213.
- 31.↑
Fan HL, Hsieh CB, Chang WC et al.. Advanced age is not a contraindication for liver resection in cases of large hepatocellular carcinoma. Eur J Surg Oncol 2014;40:214–219.
- 32.↑
Thornton RH, Covey A, Petre EN et al.. A comparison of outcomes from treating hepatocellular carcinoma by hepatic artery embolization in patients younger or older than 70 years. Cancer 2009;115:5000–5006.
- 33.
Mirici-Cappa F, Gramenzi A, Santi V et al.. Treatments for hepatocellular carcinoma in elderly patients are as effective as in younger patients: a 20-year multicentre experience. Gut 2010;59:387–396.
- 34.
Kozyreva ON, Chi D, Clark JW et al.. A multicenter retrospective study on clinical characteristics, treatment patterns, and outcome in elderly patients with hepatocellular carcinoma. Oncologist 2011;16:310–318.
- 35.
Ozenne V, Bouattour M, Goutte N et al.. Prospective evaluation of the management of hepatocellular carcinoma in the elderly. Dig Liver Dis 2011;43:1001–1005.
- 36.↑
Peng ZW, Liu FR, Ye S et al.. Radiofrequency ablation versus open hepatic resection for elderly patients (> 65 years) with very early or early hepatocellular carcinoma. Cancer 2013;119:3812–3820.
- 37.↑
Bujold A, Massey CA, Kim JJ et al.. Sequential phase I and II trials of stereotactic body radiotherapy for locally advanced hepatocellular carcinoma. J Clin Oncol 2013;31:1631–1639.
- 38.↑
Tse RV, Hawkins M, Lockwood G et al.. Phase I study of individualized stereotactic body radiotherapy for hepatocellular carcinoma and intrahepatic cholangiocarcinoma. J Clin Oncol 2008;26:657–664.
- 39.
Cardenes HR, Price TR, Perkins SM et al.. Phase I feasibility trial of stereotactic body radiation therapy for primary hepatocellular carcinoma. Clin Transl Oncol 2010;12:218–225.
- 40.
Andolino DL, Johnson CS, Maluccio M et al.. Stereotactic body radiotherapy for primary hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2011;81:e447–453.
- 41.↑
Sanuki N, Takeda A, Oku Y et al.. Stereotactic body radiotherapy for small hepatocellular carcinoma: a retrospective outcome analysis in 185 patients. Acta Oncol 2014;53:399–404.
- 42.↑
Palma D, Visser O, Lagerwaard FJ et al.. Treatment of stage I NSCLC in elderly patients: a population-based matched-pair comparison of stereotactic radiotherapy versus surgery. Radiother Oncol 2011;101:240–244.
- 43.↑
Samuels MA, Kandula S, Koru-Sengul T et al.. Stereotactic body radiotherapy in patients with stage I non-small-cell lung cancer aged 75 years and older: retrospective results from a multicenter consortium. Clin Lung Cancer 2013;14:446–451.
- 44.↑
Chang JY, Senan S, Paul MA et al.. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol 2015;16:630–637.
- 45.↑
Schild SE, Stella PJ, Geyer SM et al.. The outcome of combined-modality therapy for stage III non-small-cell lung cancer in the elderly. J Clin Oncol 2003;21:3201–3206.
- 46.↑
Atagi S, Kawahara M, Yokoyama A et al.. Thoracic radiotherapy with or without daily low-dose carboplatin in elderly patients with non-small-cell lung cancer: a randomised, controlled, phase 3 trial by the Japan Clinical Oncology Group (JCOG0301). Lancet Oncol 2012;13:671–678.
- 47.↑
Rule WG, Foster NR, Meyers JP et al.. Prophylactic cranial irradiation in elderly patients with small cell lung cancer: findings from a North Central Cancer Treatment Group pooled analysis. J Geriatr Oncol 2015;6:119–126.
- 48.↑
Wolfson AH, Bae K, Komaki R et al.. Primary analysis of a phase II randomized trial Radiation Therapy Oncology Group (RTOG) 0212: impact of different total doses and schedules of prophylactic cranial irradiation on chronic neurotoxicity and quality of life for patients with limited-disease small-cell lung cancer. Int J Radiat Oncol Biol Phys 2011;81:77–84.
- 49.↑
Le Pechoux C, Laplanche A, Faivre-Finn C et al.. Clinical neurological outcome and quality of life among patients with limited small-cell cancer treated with two different doses of prophylactic cranial irradiation in the intergroup phase III trial (PCI99-01, EORTC 22003-08004, RTOG 0212 and IFCT 99-01). Ann Oncol 2011;22:1154–1163.
- 50.↑
Shahinian VB, Kuo YF, Freeman JL, Goodwin JS. Risk of fracture after androgen deprivation for prostate cancer. N Engl J Med 2005;352:154–164.
- 51.
Keating NL, O'Malley AJ, Smith MR. Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol 2006;24:4448–4456.
- 52.↑
Ehdaie B, Atoria CL, Gupta A et al.. Androgen deprivation and thromboembolic events in men with prostate cancer. Cancer 2012;118:3397–3406.
- 53.↑
D'Amico AV, Chen MH, Renshaw AA et al.. Androgen suppression and radiation vs radiation alone for prostate cancer: a randomized trial. JAMA 2008;299:289–295.
- 54.
Roach M, Bae K, Speight J et al.. Short-term neoadjuvant androgen deprivation therapy and external-beam radiotherapy for locally advanced prostate cancer: long-term results of RTOG 8610. J Clin Oncol 2008;26:585–591.
- 55.
Denham JW, Steigler A, Lamb DS et al.. Short-term neoadjuvant androgen deprivation and radiotherapy for locally advanced prostate cancer: 10-year data from the TROG 96.01 randomised trial. Lancet Oncol 2011;12:451–459.
- 56.↑
Jones CU, Hunt D, McGowan DG et al.. Radiotherapy and short-term androgen deprivation for localized prostate cancer. N Engl J Med 2011;365:107–118.
- 57.↑
D'Amico AV, Renshaw AA, Loffredo B, Chen MH. Duration of testosterone suppression and the risk of death from prostate cancer in men treated using radiation and 6 months of hormone therapy. Cancer 2007;110:1723–1728.
