Outcomes and Tolerability of Chemoradiation Therapy for Pancreatic Cancer Patients 75 years or Older

Abstract

Localized pancreatic cancer has poor outcomes despite aggressive combined modality treatment. Chemoradiation, both in the adjuvant and definitive settings, can be associated with high morbidity. Randomized trials include few elderly patients, and it is unknown whether very elderly patients can tolerate treatment and have similar outcomes. We reviewed the outcomes and tolerability of full dose chemoradiation therapy for pancreatic cancer in patients 75 years or older treated at two institutions over the last 5 years. Patients 75 years or older with non-metastatic pancreatic cancer treated at the Massachusetts General Hospital and the Brigham and Women's Hospital from 2002-2007 were reviewed on an IRB-approved protocol. Patients who received a radiation dose of at least 45 Gy with concurrent chemotherapy were analyzed for survival, local control, distant metastases, and treatment toxicity. Treatment toxicity was defined as hospitalizations, emergency room (ER) visits, radiation treatment breaks, and inability to complete treatment. Forty-two patients with a mean age of 78 (range, 75-90) who received full dose chemoradiation therapy for pancreatic cancer were identified. Twenty-four had locally advanced disease treated with definitive chemoradiation therapy, and 18 had disease treated with surgery and adjuvant chemoradiation therapy (17 postoperative and 1 preoperative). Prior to chemoradiation therapy, mean ECOG performance status was 1.0 ± 0.8, and mean weight loss over 6 months was 11.6 ± 8.3 pounds. A 3D conformal or IMRT technique was used, with a planned dose of 50.7 ± 1.9 Gy and a delivered dose of 48.1 ± 9.2 Gy. All patients received fluoropyrimidine-based chemotherapy concurrently with radiation therapy. During chemoradiation, 8 patients (19%) were hospitalized, 15 (36%) required a treatment break, 7 (17%) had an ER visit, 9 (21%) did not complete therapy, and 19 (45%) had at least one of these adverse events. The most common toxicities were nausea, pain, and failure to thrive. Median overall survival in patients who received definitive chemoradiation therapy was 7.9 months (95% CI, 5.7-11.1). Median overall survival in patients who underwent resection and chemoradiation therapy was 20.6 months (95% CI, 9.5-∞). In this dataset of very elderly patients with pancreatic cancer and good ECOG performance status, outcomes after chemoradiation therapy are similar to historic controls for locally advanced and resected patients. While their overall outcomes are comparable to that of younger patients, many patients experience substantial treatment-related toxicity. For elderly locally advanced patients in particular, we must find new strategies that acknowledge the limited survival and high toxicity of standard chemoradiation.