i sessione “terapia come e quando” - progetto...
TRANSCRIPT
09,40 – 15,30
I Sessione“Terapia come e quando”
Moderatore:
Roberto Labianca
10,40 – 11,10
Trattamenti radioterapici
Isacco Desideri
RuolodellaradioterapianelpazienteanzianoDott.IsaccoDesideri
UniversitàdegliStudidiFirenzeSODc Radioterapia– Careggi
Firenze
Background:radiotherapy inelderly patients
Radiotherapyisakeycomponentofthemanagementofoldercancerpatients
Technologicalimprovementsinradiationoncologyfieldmaysignificantlycontributetoasubstantialimprovementinthemanagementofelderlypopulation.
Dataregardingcomprehensivegeriatricassessmentandtoxicityinthissubsetofpatientsarestillscarceandcontroversial.
Priorities for futureradiotherapy research
Kunkler IHetal.Ann Oncol 2014
Appropriateness
Doseandvolumereduction
Newtechnology implementation (SBRT,VMATetc.)
Updateinradiotherapy:Primary CNSTUMORS
Short-course radiotherapy apossible solutionfor frail/elderly patients affected by GBM?
• 98patients• Frail:age≥50yearsandKPSof50%to70%;• Elderlyandfrail:age≥65yearsandKPSof50%to70%;• Elderly :age≥65yearsandKPSof80%to100%)
• Short-courseRT(5x5Gy)vsstandardhypofractionated-RT(15x2.6Gy)
Roa Wet al.JCO2015
Anew paradigm of treatmentinHGG?
NOdifference interms of OSandPFSbetween shortcourseandstandardhypofractionated treatment
Roa Wet al.JCO2015
Updateinradiotherapy:Lung Cancer
Is SBRTsuitable for elderly patients?
• 70years orolder patients affected by early stageNSCLC(cT1-T3cN0)• 3147patients extracted from NationalUSDatabase• SBRTdelivered in289patients (8.2%)vsno-treatmentin2889(91.2%)• Nodifference interms of comorbidity between two groups
NandaRHetal.Cancer 2015
NandaRHetal.Cancer 2015
Updateinradiotherapy:Lung cancer
• Improvement of survival acrossall ages group dueto SBRT• Median OS:29.1vs10.1months(p<0.001)• Benefitof SBRTonOSnotinfluenced by thenumber ofcomorbidities,
How to identify predictors of lung toxicity inSBRT?
• Specific predictors of lungtoxicity inSBRTstill controversial• Age-only paramateris not asufficient predictor of lungtoxicity.• Functional parameters (SPECT)may provide informations onradiation pneumonitis risk.
Farr KPet al.Radiother Oncol 2015
Updateinradiotherapy:ProstateCancer
Managementof prostatecancer intheelderly
Bekelman JEet al.JCO2015
• Non-randomizedeffectivenessstudiesofADTplusRTversusADTinthreegroupsofpatientsdiagnosedbetween1995and2007andobservedthrough2009intheSEER-Medicaredataset:
• (1)therandomizedclinicaltrial(RCT)cohort:(age65-75yearswithlocallyadvancedprostatecancer)• (2)theelderlycohort :(age≥75yearswithlocallyadvancedprostatecancer)• (3)thescreen-detectedcohort:(age≥65yearswithhig-riskprostatecancer)
Should we always try to de-intensificatetreatments inelderly population ?
Adrogen-deprivation therapy alonehas adetrimental effect onOSeven inmen older than 75years with high-risk prostatecancer
Bekelman JEet al.JCO2015
Headandneck Cancer
Background
25%of all H&N patients arediagnosed >70years of age
Elderly population steadily increasing inwesternsocieties
Noprospective randomized dataexist regarding thepotentialbenefitofconcurrent chemoradiotherapy inelderly patientsaffected bylocally advanced disease
Theelderly population:aneasydefinition?
•Cut-offpoint ofelderly is still controversial:•Re-definition ofelderly ≥65years (NIH/NIA):• «young old»:65-74years• «older old»:74-85years• «oldest old»:above 85years
•Upto10comorbidity scores aredefined(+++Charlson Comorbidity index,ACE-27)
Characteristics ofelderly patients H&Ncancers patients
HPV-related tumors less commoninelderly
Incidence will increase inthefollowing years (34%@10years;64%@20years
Sexratio:Females >males
Oropharynx andlarynx most frequently involved
Gucic etalRepPract Oncol Radiother 2013
Where it all began
• CRTImprovessurvivalinlocallyadvancedheadandneckcancer• Decreasedsurvivalbenefitwithage,specifically≥71,seenonseminalmeta-analysis• Only6%ofpatientsonmeta-analysiswere>70yearsofage• Under-representedelderlypatientpopulationonclinicaltrials
Pignon etal.Radiother Oncol 2009
Does Agereally matter?NewdatafromH&Nsymposium2016
• TheNationalCancerDatabase(NCDB)• 1998-2011• 23%>70
• Patients:≥71years,receivingRT+/-CT• Oropharynx,larynx,hypopharynx• StageIIIandIV(T1-2,N(+)orT3-4,N0-3)• CRT:CTstarts14daysbeforeor14daysafterRT
KARAMSD,Multidiscipinary HeadandNeck Symposium2016
Summary
individualizedclinicaljudgmentand
personalizedmedicalcarearefundamental
Norandomizedtrialandchronic
underrepresentationofthesepatientsin
largetrials
Needtodefineoptimalsubpopulationof
elderlypatientswhowillbenefitthemost
fromCRT
Possible algorithm
Verma Vetal.JGeriatric Oncol 2016
functionalstatus
nutritionalstatus
comorbiditiesPatients
preference
Quality oflife
Updateinradiotherapy:BREASTCANCER
Currentquestionsaboutradiotherapyafterbreast-conservingsurgery:
IsabsolutebenefitfromRTgreaterforsomegroupsofwomenthanforothers?
DoallwomenneedRT?
RelationshipbetweeneffectsofRTonrecurrenceandonbreastcancerdeath
AdjuvantRTomissionintheelderly(1)
• 2003- 2009,1326 womenaged65yearsorolderearlyBC
• Hormonereceptor-positive,axillarynode-negative,T1–T2upto3cm,grade3orLVI,butnotboth,werepermitted
• 76centersinfourcountries
• whole-breastRT(40–50Gy in15–25fr)orNORT
• Primaryendpointwasipsilateralbreasttumorrecurrence(IBTR)Kunkler IH,etal.LancetOncol,2015
AdjuvantRTomissionintheelderly(2)
• Postoperativewhole-breastRTafterBCSandadjuvantendocrinetreatmentresultedinasignificantbutmodestreductioninlocalrecurrenceforwomenaged65yearsorolder
• 5-yearrateofIBTRisprobablylowenoughforomissionofRTtobeconsideredforsomepatients
Kunkler IH,etal.LancetOncol,2015
Evidences gained fromRTCs
SignificantimpactofradiotherapyomissiononIBTRrate
NOimpactofradiotherapyomissiononOS
NOidentificationofafavorablesubgroupofpatients
NODefinitionofaverylowriskgroupofpatientsinwhomRTcouldbesafelyavoided
Kunkler IH,etal.LancetOncol,2015FisherB,etal.JCO,2002HughesKS,etal.JCO,2013
● 5yearsOS:96.6%forWBRTgroupand99.4forIMRTgroup
● IBTR was 1.5%intheIMRTgroupvs 0.1-3%intheWBRTgroup(p=0.86)
● NostatisticaldifferenceintermsofIBTRat5yearsofFup
● ThefirststudyusingexclusivelyIMRTtechniquesforAPBIdelivery
Is APBIsuitable for elderly women?
Very lowrateof local recurrence across two treatmentarms
Nodifference interms of OSbetween APBIandWBI
Significant less toxicity inAPBIarm (possible gain inQoL?Datacoming soon…)
Meattini Iet al.Breast Cancer Res Treat 2015
Futureperspectives..toward atailored treatment
Primary EndpointQuality of Life
Exclusive surgery vs exclusive aPBI versus exclusive ET
Primary endpoint assessmentGlobal Health Status (GHS)
EORTC QLQ-C30/BR-23
Secondary endpointsIBTR, LRR, DM, OS, overall grade 3-4 AEs, contralateral BC, treatment compliance
EORTC1625
CONCLUSIONS
Tailoredandpersonalisedradiotherapytreatmentsforelderlypopulationareemerginginalmosteverycancertype
Technologicaladvancesinradiationoncologyrepresentanusefultoolfortreatingelderlypatientswhenappropriatelyadopted
Chroniclackofrandomizeddataregardingthispatientpopulation…
But trialsaddressing this issue areontheir way,at least inthemorefrequentcancer types (e.g.breast)