In 2011, among the three commonest cancers for which radiotherapy is the standard treatment, 22,000 women over the age of 65 were diagnosed with breast cancer, 32,000 men and women over 65 with lung cancer, and 31,000 men with prostate cancer.1 Delaney and coworkers2 estimated the ideal use of radiotherapy in these populations as 83%, 76% and 60%, respectively, amounting to 61,000 individuals for these three cancers alone. Other sites for which over half of patients were expected to receive radiotherapy included rectum, head and neck, oesophagus, stomach, pancreas, lymphoma, bladder and CNS. There is therefore a large pool of older patients for whom radiotherapy is likely to represent a component of their treatment pathway.
A number of studies have suggested lower rates of use of radiotherapy in older patients than would be expected, particularly when compared with younger populations.3-5 Even the use of palliative radiotherapy has been reported to be 25–44% lower in those aged over 80 years.5 This may relate to perceived benefit from and tolerance of radiotherapy. A Dutch study6 examined health-related quality of life after radiotherapy in patients over 80 years old. Quality of life was maintained until the end of radiotherapy. Six months after the completion of radiotherapy it had, however, deteriorated in general and in elderly-specific areas, indicating potentially limited benefit and also the need to develop specific supportive interventions for this age group.6
In older patients, the delivery of radiotherapy may be further complicated by the need to integrate chemotherapy with radiotherapy for locally advanced cancers for many tumour sites. De Ruysscher and coworkers7 looked at the eligibility for concomitant chemotherapy of 711 patients with stage III non-small-cell lung carcinoma (NSCLC) diagnosed between 2002 and 2005. One or more severe comorbidities were considered to exclude patients from this treatment. Approximately a quarter were over 75 years old and all of this age group had at least one major comorbidity. A similar number were aged between 70 and 74 years, of whom over half had at least one comorbidity.
This chapter describes examples of a number of possible solutions to these problems, including attempting to identify those at greatest risk of harm, avoiding radiotherapy where possible, modifying treatment and ameliorating side effects.7
Can we identify older people who are at increased risk of harm from radiotherapy?
Many instruments have been developed to identify patients with frailty. A systematic review of the literature from 2010 to 20128 identified 33 studies published in English and one in French that applied geriatric assessment tools to older people with newly diagnosed cancer. Treatment decisions were changed in a quarter of individuals so assessed. Performance status (PS) and reduced independence in activities of daily living (ADL) were associated with increased mortality. A range of different tools were used but none were clearly better than ...