Radiotherapy for Esophageal Cancer in Patients 80 Years of Age or Older: A 16-Year Experience

Abstract

Recently some studies showed that esophagectomy and (chemo-)radiation with curative intent were tolerable for older patients with EC, while octogenarian and nonagenarian are often excluded from these researches. The purpose of this study was to evaluate the tolerance and the long-term overall survival (OS) of patients, diagnosed at age ≥ 80, undergoing definitive radiotherapy (RT). 219 consecutive EC patients over 80 years old treated with curative intent RT between February 1999 and December 2015 at a single institution were retrospectively reviewed. Information on patients’ age, gender, tumor location, medical comorbidity, the length of lesion instead of T stage (T stage was not available as endoscopic ultrasound was performed for very few patients), lymph node status, histology, treatment regimen, acute toxicities and tumor response (judged by barium swallow X-ray performed after RT and categorized into 4 grades according to Zhengzhou Meeting criteria) were obtained from medical records. Patients had a follow-up visit every 3 months for the first 2 years and then every 6 months until to death. Clinical prognostic variables were analyzed against OS in univariable and multivariable Cox proportional hazards analysis. Among the patients, 155 were male and 64 were female. 196 patients (89.5%) finished the definitive RT (median: 60Gy,range: 50Gy – 70Gy) without grade 4 or higher acute toxicities including esophagitis, cardiac event, infections and sudden death. Tumor disappearance in barium swallow X-ray image was observed in 82 patients (37.4%) after RT. With a median follow up of 11 months (range: 0 –153 months), overall 171 deaths (78.1%) were observed. The OS rates were 50.6%, 17.7% and 13.3% at 1, 3 and 5-year, respectively. In the univariable analysis, significant prognostic factors were gender (female vs male), tumor location (upper vs middle and lower), length of lesion (continuous data) and treatment response (continuous data). In the multivariable analysis, tumor location, length of lesion and treatment response were significantly associated with OS. Rates of middle or lower EC patients hazard increased by 75% compared with upper EC (hazard ratio(HR), 1.75; 95% confidence interval (CI):1.11-2.75, p = 0.016) , while mortality increased by 15% with per centimeter longer length of lesion (HR, 1.15; 95%CI : 1.06-1.24 ,p = 0.001) and decreased by 48% per treatment response grade (HR, 1.48; 95%CI : 1.19-1.83 , p <0.001). Definitive RT could be considered as an effective treatment for EC patients older than 80 years and 50-60Gy seems to be the reasonable dose for them. Long-term OS can be expected once better tumor response is obtained for patients with upper EC, shorter tumor length and better tumor response to RT. These prognostic factors may improve clinicians' abilities to predict individualized survival and to make treatment recommendations for elderly EC patients.