Management of advanced head and neck squamous cell carcinoma in elderly patients

Abstract

We face an increasing number of elderly patients diag-nosed with head and neck squamous cell carcinoma(HNSCC), probably due to the increased life expectancyand also to the higher frequency of HNSCC with increas-ing age, though not at all subsites [1]. Considering thenatural history of HNSCC and the specific anatomicalsites of these tumors, their locoregional involvementusually leads to denutrition, anemia, pain, swallowingdifficulties, respiratory discomfort and disfiguration,among other symptoms. Indeed, if we take into accountthe tobacco and alcohol-related comorbidities (e.g. pul-monary obstructive diseases, cirrhosis, and cardiac pro-blems), many HNSCC patients present to themultidisciplinary oncology team with low performancestatus, potentially irreversible from the medical point ofview. Moreover, the frequency of second neoplasia(around 7%) in these patients is not negligible [2]. Theirmanagement, therefore, represents a truly difficultchallenge.There is no standard treatment for elderly HNSCCpatients. They are usually not eligible for clinical trialsdue to age, among other reasons. Those presenting withlocally advanced, unresectable HNSCC, for instance, arenot able to tolerate any of the cisplatin-based chemor-adiotherapy regimens used nowadays. Analyzing thepopulation included in trials evaluating concurrent che-moradiation, considered today the standard treatment forunresectable HNSCC according to metaanalyses andphase III randomized trials, only young patients andthose with (very) good performance status can benefitfrom this toxic therapy [3]. In other words, there is a lackof studies directed to this ‘frail’ population of elderlypatients.Another issue is that elderly patients with HNSCC areprone notto receive standard treatments.In the survey byDerks et al. [4], in the 45–60-year age group, 89% of the105 patients received a treatment considered as standard,compared with 62% of the patients aged 70 years or over.Unfortunately, this study showed that age itself indepen-dently influenced treatment choices. In the adjuvantsetting, Airoldi et al. [5] evaluated chemoradiation(54 Gy to all risk volumes plus 10 Gy to high-riskvolumes, concurrent to carboplatin 30 mg/m