TREATMENT OF ELDERLY CANCER PATIENTS: A PLANET IN EVOLUTION

Abstract

To the Editor: There is an outstanding interest in the treatment of elderly cancer patients, and many things have changed in the last decades in this setting. The number of studies conducted in elderly cancer patients has increased. New “elderly friendly” drugs have been added to our armamentarium, and we have better supportive treatments to reduce toxicity. Considering the three “big killer” cancers, older patients are better treated today than they were a few years ago.1 For example, the approach to the management of breast cancer in older people is slowly being reassessed. As far as surgery is concerned, mastectomy has been used as a standard treatment for older women, because it was believed that changes in body image would not bother them, although evidence shows that older women also suffer problems with body image after mastectomy. Moreover, several studies have examined the consequences of omitting axillary surgery in older women with breast cancer,2, 3 and in most of these studies, the results are in favor of axillary dissection. Given the considerable improvements in the detection and treatment of early breast cancer, several factors compel the clinician to assess the benefits and risks of adjuvant treatment in older patients with breast cancer.4 The wider use of screening mammograms is causing the tumor stage at diagnosis to shift toward increasingly smaller, low-risk tumors. Consequently, clinicians are increasingly treating older patients with small tumors and must determine whether an adjuvant treatment should be prescribed and, if so, what kind. Studies of women with metastatic breast cancer have shown that older women in good health tolerate chemotherapy reasonably well compared with younger women.5 Surgical resection offers the only hope of cure in patients with colorectal cancer. Therefore, older patients with colorectal cancer should not be denied surgery on the basis of age alone.6, 7 Most people aged 75 and older are independent, and their life expectancy without cancer is 10 to 12 years. Because colorectal cancer typically recurs within 5 years after diagnosis, it is reasonable to consider adjuvant chemotherapy to prevent recurrence whenever needed, irrespective of age, considering that elderly patients have no more toxic effects than younger patients, except for leukopenia.8 Despite the observation that no age-related difference was found in the effectiveness of chemotherapy, the number of elderly patients receiving palliative chemotherapy for colorectal cancer is still limited because of the still-diffuse concern about adherence to and tolerability of chemotherapy in such patients. Age is sometimes still used as an excuse not to resect lung cancer, although lung cancer resection in elderly patients is justified and has shown decreasing morbidity and mortality rates. During the last few years, there has been a revolution in the development of minimally invasive chest surgery, with smaller incisions and dramatic reductions in the overall operative risk. Elderly patients with lung cancer may benefit the most from these new techniques. The evaluation of cytotoxic therapies for older patients with non-small-cell lung cancer has recently become a major focus of clinical research and randomized controlled trials have established that single-agent chemotherapy is the standard treatment for non-small-cell lung cancer in older people. Although randomized trials are not available in older people that directly compare more-aggressive with less-aggressive chemotherapy, retrospective specific subgroup analyses of cisplatin combinations have been performed with results comparable with those in younger age groups.9 On the hematological malignancies side, studies on the treatment of aggressive non-Hodgkin's lymphoma have been conducted according to two opposite approaches: the first focused on minimizing toxicity, using regimens specifically designed for elderly patients, the second in favor of standard treatments.10 Lately, it has been shown that cyclophosphamide, doxorubicin, vincristine, and prednisone, with the addition of rituximab, is the standard treatment for non-Hodgkin's lymphoma in older people. In conclusion, despite the perceived barriers to including elderly cancer patients in clinical trials, there are few data to support excluding them. The increasing use of a complete geriatric assessment can lead to a more individualized patient treatment plan. Furthermore, the enormous advances in supportive treatments over recent years enable adverse effects to be minimized. Moreover, the implementation of prospective trials is strongly recommended to assess properly the quality of life of elderly patients undergoing chemotherapy. In this way, it could be possible to counteract an unjustified “ageism”: a prejudice that denies opportunities of treatment or even cure for patients that, as far as we know, may have the same chance as younger patients. Financial Disclosures: There are no grants or any financial ties with any of the authors of this letter. Author Contributions: All authors participated in the design and the preparation of this letter. Sponsor's Role: There was no sponsor for this letter.