Role of Radiotherapy

• Approximately 50% of all cancer patients

require radiotherapy as part of their disease

management

• An attractive treatment option for older

patients, especially where surgery or

chemotherapy pose too great a risk

• Radical versus Palliative versus Prophylactic

versus Abscopal

Questions to Ask for Older Patients

• Will this patient be able to tolerate a course of

radiotherapy and associated toxicity?

• Or is a more palliative approach suitable?

• Are there alternative treatment schedules that might be

more suitable for an older patient?

• Is every possible attempt being made to reduce toxicity?

• Will the patient be able to attend radiotherapy every day?

• Does the patient have adequate support?

• Does the patient have capacity to consent to treatment?

• What are the patient’s wishes if treatment will result in

functional decline?

The Importance of Patient Wishes

Fried, T.R., et al., Understanding the Treatment Preferences of Seriously Ill Patients. New England Journal of

Medicine, 2002. 346(14): p. 1061-1066.

Case Study: Rectal Cancer

Why use Radiotherapy?

• Reduce the risk of local recurrence

– Involvement of the circumferential margin

– Lymph node status

– Extramural venous invasion

• Neoadjuvant

– Induce tumour response prior to Surgery (Sx)

– Increase the chances of sphincter sparing Sx: *not supported by evidence

– Potentially less small bowel toxicity as bowel adhesions more common

after Sx

– Surgically naïve tissue is better oxygenated…..therefore more responsive

to radiotherapy

� But not proven to increase survival*Bujko, Krzysztof, et al. Does rectal cancer shrinkage induced by preoperative radio (chemo) therapy increase the

likelihood of anterior resection? A systematic review of randomised trials. Radiotherapy and oncology 2006; 80: 4-12

Long Course vs Short Course RT

Long Course

• 45-50.4Gy in 25-28 fractions

delivered in 5 days/week, one

fraction/day

• 1.8 Gy/#

• Trend toward increased pCR with

higher doses. A statistically

significant increase in LRFS, DFS,

and OS was seen with radiation

doses of 46 and greater, but there

was no difference between 46 Gy

and 50 Gy. 2Gy/#

Short Course

25Gy in 5 fractions delivered in 1

week

• 5 Gy/#

Wiltshire et al. Preoperative radiation with concurrent chemotherapy for resectable rectal cancer: Effect of dose escalation on pathologic

complete response, local recurrence-free survival, disease-free survival, and overall survival

International Journal of Radiation Oncology*Biology*Physics, 2006; 64 (3):709-716

Case Study: Prostate Cancer

Hypofractionation: Less is More

• CHHiP (Conventional or Hypofractionated High-dose Intensity Modulated Radiotherapy in Prostate Cancer) (Lancet Oncol 2016;17[8]:1047-1060, PMID: 27339115),

• NRG Oncology 0415 trial (J ClinOncol 2016;34[20]:2325-2330, PMID: 27044935)

• Ontario Clinical Oncology Group/Trans-Tasman Radiation Oncology Group trial, PROFIT (PROstateFractionated Irradiation Trial) (J Clin Oncol 2017 Mar 15. [Epub ahead of print], PMID: 28296582).

4/5 weeks versus 7/8 weeks

Case Study: Head and Neck Cancer

CGA in Older H&N RT Patients

• Deterioration during

treatment supports

continuous assessment

• Screening tools are no

substitute for full CGA

• CGA deficits closely

associated with HRQOL

Pottel, L., Lycke, M., Boterberg, T., Pottel, H., Goethals, L., Duprez, F., Van Den Noortgate, N., De Neve, W., Rottey, S., Geldhof, K., Buyse, V.,

Kargar-Samani, K., Ghekiere, V. and Debruyne, P.R. (2014), Serial comprehensive geriatric assessment in elderly head and neck cancer patients

undergoing curative radiotherapy identifies evolution of multidimensional health problems and is indicative of quality of life. European Journal of

Cancer Care, 23: 401–412. doi: 10.1111/ecc.12179

Key Questions to Ask the RO

• Is this the only radiotherapeutic option for this patient?

• Is a different fractionation schedule possible/feasible/effective?

• What is the anticipated toxicity of treatment?

• What efforts can be made to reduce toxicity and manage pre-existing concerns?

• What supportive care options will the patient have access to during radiotherapy and during follow-up?

Role of CGA

An Integrated Approach

“broader than a restricted definition of technical

maintenance and quality control of equipment and

treatment delivery ….should encompass a comprehensive

approach to all activities in the radiotherapy department

from the moment a patient enters it until the moment they

leave, and also continuing into the follow-up period”(ESTRO,

1998)

“Quality geriatric care has been defined as aging-sensitive, evidence-based, individualised care that

promotes informed decision-making and is continuous across settings” (Barba, 2012)