ESTRO 37 Abstract book

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ESTRO 37

Abstract text Radiation therapy is a cancer modality that can be an excellent option for older patients due to its limited systemic toxicities, especially where surgery and chemotherapy are deemed unsuitable. Approximately 50- 60% percent of all cancer patients receiving treatment will require radiotherapy at some stage of their treatment trajectory, and the majority of these will be older patients. Most European countries are currently faced with a major demographic shift that will see increasing numbers of older patients. This represents a corresponding increase in the number of older patients presenting for radiation therapy. It is recognised that this will require “age attuning” of our cancer treatment services to provide more integrated care for these patients. Traditionally the disciplines of Oncology and Geriatric Medicine have worked independently of each other in many countries. This is beginning to change, as it’s recognised that most older patients have complex medical profiles, and that information provided by the specialised discipline of Geriatric Medicine may help treatment decisions and rehabilitation of older cancer patients, providing a more holistic care option. Comprehensive Geriatric Assessment (CGA) or Geriatric Assessment (GA) as used in the oncology literature, can identify risk factors for adverse outcomes in older cancer patients. CGA was designed to more accurately detect frailty in older patients, and both the National Comprehensive Cancer Network (NCCN) and International Society of Geriatric Oncology (SIOG) recommend its use in Oncology. CGA includes a compilation of reliable and valid tools to assess geriatric domains such as comorbidity, functional status, physical performance, cognitive status, psychological status, nutritional status, medication review, and social support. The aim of this presentation is to present a critical overview of the current literature on GA in radiation oncology, and previous research by the authors in this field. It will also incorporate aspects of feasibility and requirements for a geriatric oncology service. The latter will include educational aspects and the need for adapted curricula in radiation oncology to incorporate aspects of aging, optimal treatment and attitudes towards aging. SP-0669 Clinical perspective I. Kunkler 1 1 Western General Hospital- Edinburgh Cancer Centre, Clinical Oncology, Edinburgh, United Kingdom Abstract text Implications of the ageing population for radiation oncology: clinical perspective Professor Ian Kunkler Despite the rising incidence in the older age group, the evidence base for elderly specific radiation treatment strategies remains weak with a dearth of level 1 evidence. Greater longevity, associated with multiple comorbidities, and impaired treatment tolerance have to be taken into account while maximizing cure rates and quality of life (QoL) and minimizing toxicity. Advanced techniques eg intensity-modulated radiation therapy and precision tools (genomics, radiomics and mathematical modelling) offer possibilities of personalised, adaptive radiotherapy (1). Genomic signatures may, if validated, identify patients likely to benefit from RT (2) Older patients with a variety of solid tumours may benefit from primary, adjuvant or palliative radiotherapy (RT). Recommendations for RT were drawn up by the International Geriatric Oncology Society (SIOG) (3) and by Pfeffer & Blumenfeld (4). Hypofractionated treatment schedules are more convenient for older patients. Nearly half of non small cell lung cancer (NSCLC) occurs in patients =/> 70 years. Stereotactic body RT (SBRT) provides about 90% short term local control for

medically inoperable stage I NSCLC and 79% 5 year local control (5,6). SBRT is feasible both for peripheral and central lung tumours (7, 8) as well as tumours >5cm diameter. In patients =/>70 years 30 day mortality was lower with SBRT (1.7%) compared to surgery (8.3%) but with similar 1 and 3 year survival rates (9). The omission of postoperative whole breast RT (WBRT) after breast conserving surgery in older patients with early breast cancer remains controversial and guidelines vary. The PRIME 2 trial showed a modest but statistically significant reduction in local control (local recurrence 4.1% RT- vs 1.3% RT+) at 5 years from the omission of WBRT in patients =/> 65 years with T1-2 (up to 3cm),pNO, hormone receptor positive tumours (10). The CALGB 9343 (11) in a lower risk group (T1, NO, ER positive) treated with tamoxifen showed WBRT reduced the risk of local recurrence by 7% at 10 years (2% vs 9%). Of head and neck (HN) cancer patients, 25% are aged > 70 years. Better overall survival and loco-regional control is achieved with hyperfractionated RT in RCTs and metanalyses. In a large retrospective study of HN patients undergoing radical RT (12), 238 patients =/> 75 years showed no difference in therapy related mortality, interruption in treatment or completion rates. However 2 year cause specific survival was lower in elderly patients. An analysis of 1589 patients in 5 EORTC trials showed that increasing age did not compromise overall survival (13).The ability of intensive modulated radiotherapy to reduce toxicity has been confirmed in a study comparing IMRT to conventional/3D techniques (14). Nearly half of patients with glioblastoma multiforme (GBM) are > 65 years. Aggressive RT regimes are associated with a high risk of neurological toxicity and impaired QoL (15). The utility of RT in patients in patients with GBM =/> 70 years has been demonstrated with median survival 29.1 weeks (50 Gy in 5 weeks) vs 16.9 weeks for supportive care only (16). The EORTC-NCIC trial which included good performance status patients =/> 70 years established RT plus concomitant temozolamide as standard of care for GBM. MGMT gene methylation predicts for benefit from combination therapy and is the most important prognostic factor in older patients. Older patients with localised locally advanced prostate cancer (PC) should be offered therapy. An NCIC RCT (78% > 65 years) showed significantly greater overall survival from a combination of androgen deprivation therapy (ADT) and RT (HR 0.70) compared to ADT alone (HR 0.46) (17). References: 1. Caudell JJ et al. Lancet Oncol 2017;18:e266-73;2.Speers C et al. Clin Cancer Res 2015;21:3667-77;3. Kunkler IH et al. Ann Oncol 2014;25:2134-2146; 4.Pfeffer MR, Blumenfeld P. Cancer J 2017:23:223-230; 5. Timmerman R et al. JAMA 2010;303:1070-1076; 6. Lagerwaard FJ et al. IJRBOP 2008;70:685-692; 7. Modh A et al. IJRBOP 2014;90:1168-1176; 8. Rowe BP et al. J Thorac Oncol 2012;&;1394-1399; 9.Palma D et al.. J Clin Oncol 2010;28:5153-5159; 10.Kunkler IH et al. Lancet Oncology 2015;16(3):266-73;11.Hughes KS et al.. J. Clin Oncol 2013;31:2382-2387;12.Huang SH et al. IJRBOP 2011; 79:46-51;13.Pignon T et al. Eur J Cancer 1996;32:2075- 81; 14.Nutting CM et al. Lancet Oncol 2011;12:127- 136;15.Minniti G et al. Rad Oncol 2017;12:101;16. Keime-Guibert F et al. N Engl J Med 2007;356:1527- 1535;17.Mason MD et al J Clin Oncol 2015;33:2143-2150. SP-0670 Implications of the ageing population for radiation oncology: cost-effectiveness J. Van Loon 1 1 MAASTRO Clinic, Radiation Oncology, Maastricht, The Netherlands Abstract text In view of the growing numbers of elderly cancer patients and the increasing demand from healthcare decision makers for economic evidence, measures to evaluate cost-effectiveness of radiotherapy in the elderly