- Email: [email protected]
Lung cancer radiation treatment in the elderly
Critical Reviews in Oncology/Hematology 32 (1999) 45 – 48 www.elsevier.com/locate/critrevonc
Lung cancer radiation treatment in the elderly Alessandro Gava* Radiotherapy Department, Tre6iso Hospital, Tre6iso, Italy Accepted 14 April 1999
Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
2. Non small cell lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
3. Small cells lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
4. Palliative treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
5. Discussion and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
Biography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
1. Introduction More than 900 000 new cases of lung carcinoma are diagnosed every year in the world, making this malignancy one of the major health problems in western countries [1–3] and more than one third of lung carcinomas occur after 70 years of age [4,5].Lung cancer represents the most common smoking-related cause of mortality and the percentage of lung cancer in the elderly is expected to increase within the next decade not only as a consequence of increased life expectancy in the general population but also because a great amount of people started smoking in the 1940s and 1950s; those who were still young at the time will have more pack-years than those who started at an older age, therefore, the incidence will continue to increase and especially in older people. [6,7] As elderly patients with lung cancer undergo radical treatment less frequently than younger patients, the age represents an important clinical parameter in order to make any therapeutic decisions [8 – 11]. However, it has * Present address: Dipartimento di Oncologia, Unita` Operativa di Radioterapia Oncologica, Ospedale Regionale di Treviso, Piazzale Ospedale, 31100 Treviso, Italy. Tel.: + 39-422-322201; fax: + 39-422322651. E-mail address: [email protected] (A. Gava)
recently been shown that when the clinical selection is accurate, both the clinical outcomes and the therapy-related toxicity exhibited by elderly patients undergoing standard treatment, are similar to those observed in younger subjects [12,13].Radiotherapy (both radical and palliative) is the most widely used treatment in elderly patients with non small cell lung cancer [13,14], and when combined with chemotherapy plays an important role also in the management of small cell lung cancer.
2. Non small cell lung cancer Surgery represents the standard treatment for the patients classified as stage I–II non small cell lung cancer (NSCLC), and when the preoperative evaluation of cardiopulmonary function is thorough, both the 5-year survival and the complication rate observed in elderly patients are similar to those of younger patients.In inoperable patients (as a result of poor general conditions or refusal of surgery) radical radiation therapy is an effective treatment and exhibits satisfactory outcomes. In fact the 5-year cancer specific survival rate approaches 31% when dealing with small tumors (3–4 cm in diameter) ([14–16], Table 1).
1040-8428/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 0 4 0 - 8 4 2 8 ( 9 9 ) 0 0 0 2 7 - X
A. Ga6a / Critical Re6iews in Oncology/Hematology 32 (1999) 45–48
46 Table 1 Results of radiotherapy alone
3. Small cells lung cancer
Author
Year
N° patients
Stage
3-Y survival (%)
Nordjik Krol Talton
1988 1996 1990
40 108 77
I–II I–II II–III
32 31 21
Doses ] 65 Gy with continuous fractionation are recommended and as the target volume of the radiation therapy usually encloses only the location of tumor volume with the ipsilateral hilum and the immediate adjacent mediastinum, both early and late toxicity tends to be very low ([17]). For patients classified as stage III NSCLC (which represents the majority of the patients with lung cancer) surgery is the treatment of choice only for a limited number of patients with stage IIIA and, therefore, radiotherapy appears to be the therapeutic procedure most frequently adopted [18]. It is only in patients affected by tumors of the superior pulmonary sulcus that the neoadjuvant radiotherapy associated with surgery obtains a 5-year survival rate of :40% [19]. Unfortunately, in other stage III cases the clinical results are poor, because radiotherapy alone cures less than 10% of patients [20].The clinical result of radiotherapy is unsatisfactory for several reasons: 1. it is difficult to eradicate large volumes with conventional doses; 2. larger tumours shows greater tendency for metastatic spread; 3. randomized trials with either concomitant cisplatinbased chemotherapy or neoadjuvant chemotherapy, which have proved beneficial on long-term outcomes when combined with radiation in younger patients, have not been undertaken in stage III NSCLC elderly patients as yet [21 – 23]. Nevertheless the clinical outcome is similar to that observed in younger patients: according to the experience of the geriatric radiotherapy oncology group, the 1-year survival rate observed in a group of 38 patients with stage III NSCLC treated with radiotherapy alone approached 44% [24]. As the size field of radiotherapy includes a large part of the lung and mediastinum, the incidence of both acute and late toxicity is higher than that observed in patients treated for stage I – II lung cancer. An accurate evaluation of stage III patients to be treated by radical radiotherapy is therefore mandatory. In stage IV lung cancer patients, palliative radiotherapy represents the best therapeutic option in many clinical conditions.
As far as small cell lung cancer (SCLC) is concerned, the effectiveness of radiation therapy alone appears to be of short duration, mainly because of the rapid development of systemic disease observed in almost all patients. When dealing with elderly patients with SCLC, chemotherapy achieves the best survival rates and therefore remains the treatment of choice [25]. Yet, it must be stressed that the tolerance to aggressive chemotherapy protocols required for SCLC still represent the most relevant limiting factor. Dajczman et al. [26] have demonstrated that 81 elderly patients, despite suboptimal treatment, did not show any significant difference both in terms of clinical response rates and overall survival in comparison with younger patients [26]. Also, in these patients, the combination of radiotherapy with chemotherapy (concurrent or sequential), improves both local control and clinical outcome [27] and those older patients who obtain complete objective response with chemotherapy can be considered for further treatment with radiotherapy [28]. Preliminary data from a randomized study demonstrated promising long-term results with combined accelerated hyperfractionated radiotherapy and chemotherapy in elderly patients staged as limited disease [29]. The real value of prophylactic cranial irradiation for those elderly patients who obtain complete response with chemo-radiotherapy is controversial [26].
4. Palliative treatment It should be remembered that radiation therapy plays an important role in palliative treatment of many clinical situations related to lung cancer. Since the doses delivered range between 20 and 40 Gy, radiotherapy is generally well tolerated in elderly patients. In many conditions, such as hemophtysis, dyspnea, mediastinal syndrome, chest or bone pain, spinal cord compression or brain metastases, palliative radiotherapy obtains a relief of symptoms in a proportion of cases ranging from 60 to 87%, thus improving the quality of life in most patients [30–33].
5. Discussion and conclusions In elderly patients with lung cancer radiation therapy permits to obtain clinical results and acute/late toxicity comparable with those observed in younger subjects [34]. However, in order to reduce the incidence of pneumonia and other complications, it is necessary that a thorough selection of older patients be treated radically. The main prognostic predictors to consider when
A. Ga6a / Critical Re6iews in Oncology/Hematology 32 (1999) 45–48
selecting patients for radical treatment are: stage, comorbidity (above all cardiopulmonary diseases), performance status and activity life index, low pulmonary function test and smoking history [35]. An accurate evaluation of the post-radiotherapy potential residual lung function is also of paramount importance. In patients with regionally extended NSCLC, the computed-guided 3-D treatment planning, which avoids the part of lung not involved by malignancy, can be useful in order to reduce the complications of radiotherapy [36]. Regarding stage III patients, in view of the high frequency of extended disease, it would be necessary to find new neoadjuvant chemotherapy schedules to add to radiation therapy, which could be enhanced by using radiosensitizer drugs and/or accelerated fractionation. New and interesting agents, such as vinorelbine, gemcytabine and taxoter, are currently being tested in many clinical trials [37,38]. In elderly patients, the addition of radiotherapy to chemotherapy improves local control and clinical results. The older patients who obtain a good objective response with chemotherapy can be considered for further treatment with radiotherapy. It must be stressed that eventually palliative radiotherapy is extremely effective in many clinical situations of advanced diseases and should always be considered as an important tool in order to reduce pain and to improve the quality of life.
References [1] Parkin DM, Piasni P, Ferlay J. Estimates of the world-wide frequency of eighteen major cancers. Int J Cancer 1993;54:594 – 606. [2] Shephered FA. Future directions in the treatment of non small cell lung cancer. Semin Oncol 1994;21(3 Suppl. 4):48–62. [3] Lamont DV, Gillis CR, Caird FI. Epidemiology of cancer in the elderly. In: Chaird FI, Thurstan BB, editors. Cancer in the Elderly. Guildford, UK: Butterworth, 1990. [4] Fry WA, Menck HR, Whinchester DP. The national cancer data base report in lung cancer. Cancer 1996;77:1947–55. [5] Samet JM. The epidemiology of lung cancer. Chest 1993;103:20 – 9. [6] Yancik R, Ries LA. Cancer in older person: magnitude of the problem — how do we apply what we know? Cancer 1994;74:1995 – 2003. [7] Monfardini S, Aapro M, Ferrucci L, et al. Commission of the European communities ‘Europe against cancer’ program: European school of oncology advisory report cancer treatment in the elderly. Eur J Cancer 1993;29A:2325–30. [8] Brown JS, Eraut D, Davison AG. Age and treatment of lung cancer. Thorax 1996;51:564–8. [9] Zagonel V, Tirelli U. Age as a risk factor for inadequate treatment. J Am Med Assoc 1988;41:259. [10] Yellen SB, Cella DR, Leslie WT. Age and clinical decision-making in oncology patients. J Nat Cancer Inst 1994;86:1766 – 70. [11] Pignon T, Scalliet P. Radiotherapy in the elderly. Crit Rev Oncol/Hematol 1998;27:129–30.
47
[12] Perez CA, Pajak TF, Rubin P, et al. Long-term observation of the patterns of failure in patients with unresectable non-oat cell carcinoma of the lung treated with definitive radiotherapy, report by the radiation therapy oncology group. Cancer 1987;59:1874 – 81. [13] Pignon T, Gregor A, Schaake Koning C, et al. Age has no impact on acute and late toxicity of curative thoracic radiotherapy. Radiother Oncol 1998;46:239 – 48. [14] Krol AD, Aussems P, Noordijk EM, et al. Local irradiation alone for peripheral stage I lung cancer: could we omit the elective regional nodal irradiation? Int J Radiat Oncol Biol Phys 1996;34:297 – 302. [15] Noordijk EM, Poest CE, Hermans J, et al. Radiotherapy as an alternative to surgery in elderly patients with resectable lung cancer. Radiother Oncol 1988;13(2):83 – 9. [16] Talton BS, Constable WC, Kersh CR. Curative radiotherapy in non-small cell carcinoma of the lung. Int J Radiat Oncol Biol Phys 1990;19:15 – 21. [17] Dosoretz DE, Galmarini D, Rubenstein JH, et al. Local control in medically inoperable lung cancer: an analysis of its importance in outcome and factors determining the probability of tumor eradication. Int J Radiat Oncol Biol Phys 1993;27:507– 16. [18] Zagonel V, Pinto A, Serraino D, et al. Lung Cancer in the elderly. Cancer Treat Rev 1994;20:315 – 29. [19] Arcasoy S, Jett J. Superior pulmonary sulcus tumors and Pancoast’s syndrome. New Engl J Med 1997;337:1710 – 7. [20] Lynch TJ. Management of stage III non-small-cell lung cancer. Educational book ASCO 1998; 265 – 275. [21] Fentiman IS, Tirelli U, Monfardini S, et al. Cancer in the elderly: why so badly treated. Lancet 1990;335:1020– 2. [22] Schaake-Koning C, Van den Bogaert W, Dalesio O, et al. Effects of concomitant cisplatin and radiotherapy on inoperable non small-cell lung cancer. New Engl J Med 1992;326:524 –30. [23] Dillman RO, Stephen LS, Propert KJ, et al. Randomized trial of induction chemotherapy plus high-dose radiation versus radiation alone in stage III non-small-cell lung cancer. New Eng J Med 1990;323:940 – 5. [24] Gava A. Lung cancer radiotherapy update in the elderly. Annals of Oncology 1998;9(Suppl 3):34 – 5. [25] Shepered FA, Amdemichael E, Evans WK, et al. Treatment of small cell lung cancer in the elderly. J Am Geriatr Soc 1994;42:64 – 70. [26] Dajczman E, Yi Fu L, Small D, et al. Treatment of small cell lung carcinoma in the elderly. Cancer 1996;77:2032 – 8. [27] Jeremic B, Shibamoto Y, Acimovic L, et al. Carboplatin, etoposide and accelerated hyperfractionated radiotherapy for elderly patients with limited small cell lung carcinoma: a phase II study. Cancer 1998;82(5):836– 41. [28] Repetto L, Granetto C, Venturino A, et al. Lung Cancer. Crit Rev Oncol/Hematol 1998;27:133 – 4. [29] Murray N, Grafton C, Shah A, et al. Abbreviated treatment for elderly and infirm patients with limited stage small cell lung cancer (LSCLC). Lung Cancer 1994;11(Suppl.1):171– 5. [30] Slawson RG, Scott RM. Radiation therapy in bronchogenic carcinoma. Radiology 1979;132:175 – 6. [31] Gava A, Bertossi L, Zorat PL, et al. Radiotherapy in the elderly with lung carcinoma: the experience of the Italian ‘Geriatric radiation oncology group’. Rays 1997;22(Suppl. 1):61 –5. [32] Sen M, Demiral AS, Cetingoz R, et al. Prognostic factors in lung cancer with brain metastasis. Radiother Oncol 1996;46:33–8. [33] Mandoliti G, Polico C, Capirci C, et al. Radiation therapy of bone metastases in the elderly: a multicentric survey of the Italian ‘Geriatric radiation oncology group’. Rays 1997;22(Suppl. 1):57 – 60.
48
A. Ga6a / Critical Re6iews in Oncology/Hematology 32 (1999) 45–48
[34] Veronesi A, Zagonel V, Serraino D, et al. Clinical characteristics, diagnosis and treatment of elderly patients with lung cancer at non-surgical institution: a multicenter study. Tumori 1990;76:429 – 33. [35] Monson JM, Stark P, Reilly JJ, et al. Clinical radiation pneumonitis and radiographic changes after thoracic radiation therapy for lung carcinoma. Cancer 1998;82:842–50. [36] Graham MV, Purdy JA, Emami B, et al. Preliminary results of a prospective trial using three dimensional radiotherapy for lung cancer. Int J Radiat Oncol Biol Phys 1995;33(5):993– 1000. [37] Elias A. Chemotherapy and radiotherapy for regionally advanced non-small-cell lung cancer. Chest 1993;103(Suppl. 4):362 – 6.
.
[38] Gridelli C. Treatment of advanced non small cell lung cancer in the elderly: an update. Ann Oncol 1998;9(Suppl 3):36–7.
Biography I am a Medical Doctor and have been working in the Radiotherapy and Oncology Department of Treviso Hospital since 1981. I specialize in Radiotherapy Oncology and in Medical Oncology. I am among the founders of GROG (Geriatric Radiotherapy Oncology Group) and am interested, above all, in radiation therapy of lung cancer.
Lung cancer radiation treatment in the elderly Alessandro Gava* Radiotherapy Department, Tre6iso Hospital, Tre6iso, Italy Accepted 14 April 1999
Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
2. Non small cell lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
3. Small cells lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
4. Palliative treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
5. Discussion and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
Biography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
1. Introduction More than 900 000 new cases of lung carcinoma are diagnosed every year in the world, making this malignancy one of the major health problems in western countries [1–3] and more than one third of lung carcinomas occur after 70 years of age [4,5].Lung cancer represents the most common smoking-related cause of mortality and the percentage of lung cancer in the elderly is expected to increase within the next decade not only as a consequence of increased life expectancy in the general population but also because a great amount of people started smoking in the 1940s and 1950s; those who were still young at the time will have more pack-years than those who started at an older age, therefore, the incidence will continue to increase and especially in older people. [6,7] As elderly patients with lung cancer undergo radical treatment less frequently than younger patients, the age represents an important clinical parameter in order to make any therapeutic decisions [8 – 11]. However, it has * Present address: Dipartimento di Oncologia, Unita` Operativa di Radioterapia Oncologica, Ospedale Regionale di Treviso, Piazzale Ospedale, 31100 Treviso, Italy. Tel.: + 39-422-322201; fax: + 39-422322651. E-mail address: [email protected] (A. Gava)
recently been shown that when the clinical selection is accurate, both the clinical outcomes and the therapy-related toxicity exhibited by elderly patients undergoing standard treatment, are similar to those observed in younger subjects [12,13].Radiotherapy (both radical and palliative) is the most widely used treatment in elderly patients with non small cell lung cancer [13,14], and when combined with chemotherapy plays an important role also in the management of small cell lung cancer.
2. Non small cell lung cancer Surgery represents the standard treatment for the patients classified as stage I–II non small cell lung cancer (NSCLC), and when the preoperative evaluation of cardiopulmonary function is thorough, both the 5-year survival and the complication rate observed in elderly patients are similar to those of younger patients.In inoperable patients (as a result of poor general conditions or refusal of surgery) radical radiation therapy is an effective treatment and exhibits satisfactory outcomes. In fact the 5-year cancer specific survival rate approaches 31% when dealing with small tumors (3–4 cm in diameter) ([14–16], Table 1).
1040-8428/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 1 0 4 0 - 8 4 2 8 ( 9 9 ) 0 0 0 2 7 - X
A. Ga6a / Critical Re6iews in Oncology/Hematology 32 (1999) 45–48
46 Table 1 Results of radiotherapy alone
3. Small cells lung cancer
Author
Year
N° patients
Stage
3-Y survival (%)
Nordjik Krol Talton
1988 1996 1990
40 108 77
I–II I–II II–III
32 31 21
Doses ] 65 Gy with continuous fractionation are recommended and as the target volume of the radiation therapy usually encloses only the location of tumor volume with the ipsilateral hilum and the immediate adjacent mediastinum, both early and late toxicity tends to be very low ([17]). For patients classified as stage III NSCLC (which represents the majority of the patients with lung cancer) surgery is the treatment of choice only for a limited number of patients with stage IIIA and, therefore, radiotherapy appears to be the therapeutic procedure most frequently adopted [18]. It is only in patients affected by tumors of the superior pulmonary sulcus that the neoadjuvant radiotherapy associated with surgery obtains a 5-year survival rate of :40% [19]. Unfortunately, in other stage III cases the clinical results are poor, because radiotherapy alone cures less than 10% of patients [20].The clinical result of radiotherapy is unsatisfactory for several reasons: 1. it is difficult to eradicate large volumes with conventional doses; 2. larger tumours shows greater tendency for metastatic spread; 3. randomized trials with either concomitant cisplatinbased chemotherapy or neoadjuvant chemotherapy, which have proved beneficial on long-term outcomes when combined with radiation in younger patients, have not been undertaken in stage III NSCLC elderly patients as yet [21 – 23]. Nevertheless the clinical outcome is similar to that observed in younger patients: according to the experience of the geriatric radiotherapy oncology group, the 1-year survival rate observed in a group of 38 patients with stage III NSCLC treated with radiotherapy alone approached 44% [24]. As the size field of radiotherapy includes a large part of the lung and mediastinum, the incidence of both acute and late toxicity is higher than that observed in patients treated for stage I – II lung cancer. An accurate evaluation of stage III patients to be treated by radical radiotherapy is therefore mandatory. In stage IV lung cancer patients, palliative radiotherapy represents the best therapeutic option in many clinical conditions.
As far as small cell lung cancer (SCLC) is concerned, the effectiveness of radiation therapy alone appears to be of short duration, mainly because of the rapid development of systemic disease observed in almost all patients. When dealing with elderly patients with SCLC, chemotherapy achieves the best survival rates and therefore remains the treatment of choice [25]. Yet, it must be stressed that the tolerance to aggressive chemotherapy protocols required for SCLC still represent the most relevant limiting factor. Dajczman et al. [26] have demonstrated that 81 elderly patients, despite suboptimal treatment, did not show any significant difference both in terms of clinical response rates and overall survival in comparison with younger patients [26]. Also, in these patients, the combination of radiotherapy with chemotherapy (concurrent or sequential), improves both local control and clinical outcome [27] and those older patients who obtain complete objective response with chemotherapy can be considered for further treatment with radiotherapy [28]. Preliminary data from a randomized study demonstrated promising long-term results with combined accelerated hyperfractionated radiotherapy and chemotherapy in elderly patients staged as limited disease [29]. The real value of prophylactic cranial irradiation for those elderly patients who obtain complete response with chemo-radiotherapy is controversial [26].
4. Palliative treatment It should be remembered that radiation therapy plays an important role in palliative treatment of many clinical situations related to lung cancer. Since the doses delivered range between 20 and 40 Gy, radiotherapy is generally well tolerated in elderly patients. In many conditions, such as hemophtysis, dyspnea, mediastinal syndrome, chest or bone pain, spinal cord compression or brain metastases, palliative radiotherapy obtains a relief of symptoms in a proportion of cases ranging from 60 to 87%, thus improving the quality of life in most patients [30–33].
5. Discussion and conclusions In elderly patients with lung cancer radiation therapy permits to obtain clinical results and acute/late toxicity comparable with those observed in younger subjects [34]. However, in order to reduce the incidence of pneumonia and other complications, it is necessary that a thorough selection of older patients be treated radically. The main prognostic predictors to consider when
A. Ga6a / Critical Re6iews in Oncology/Hematology 32 (1999) 45–48
selecting patients for radical treatment are: stage, comorbidity (above all cardiopulmonary diseases), performance status and activity life index, low pulmonary function test and smoking history [35]. An accurate evaluation of the post-radiotherapy potential residual lung function is also of paramount importance. In patients with regionally extended NSCLC, the computed-guided 3-D treatment planning, which avoids the part of lung not involved by malignancy, can be useful in order to reduce the complications of radiotherapy [36]. Regarding stage III patients, in view of the high frequency of extended disease, it would be necessary to find new neoadjuvant chemotherapy schedules to add to radiation therapy, which could be enhanced by using radiosensitizer drugs and/or accelerated fractionation. New and interesting agents, such as vinorelbine, gemcytabine and taxoter, are currently being tested in many clinical trials [37,38]. In elderly patients, the addition of radiotherapy to chemotherapy improves local control and clinical results. The older patients who obtain a good objective response with chemotherapy can be considered for further treatment with radiotherapy. It must be stressed that eventually palliative radiotherapy is extremely effective in many clinical situations of advanced diseases and should always be considered as an important tool in order to reduce pain and to improve the quality of life.
References [1] Parkin DM, Piasni P, Ferlay J. Estimates of the world-wide frequency of eighteen major cancers. Int J Cancer 1993;54:594 – 606. [2] Shephered FA. Future directions in the treatment of non small cell lung cancer. Semin Oncol 1994;21(3 Suppl. 4):48–62. [3] Lamont DV, Gillis CR, Caird FI. Epidemiology of cancer in the elderly. In: Chaird FI, Thurstan BB, editors. Cancer in the Elderly. Guildford, UK: Butterworth, 1990. [4] Fry WA, Menck HR, Whinchester DP. The national cancer data base report in lung cancer. Cancer 1996;77:1947–55. [5] Samet JM. The epidemiology of lung cancer. Chest 1993;103:20 – 9. [6] Yancik R, Ries LA. Cancer in older person: magnitude of the problem — how do we apply what we know? Cancer 1994;74:1995 – 2003. [7] Monfardini S, Aapro M, Ferrucci L, et al. Commission of the European communities ‘Europe against cancer’ program: European school of oncology advisory report cancer treatment in the elderly. Eur J Cancer 1993;29A:2325–30. [8] Brown JS, Eraut D, Davison AG. Age and treatment of lung cancer. Thorax 1996;51:564–8. [9] Zagonel V, Tirelli U. Age as a risk factor for inadequate treatment. J Am Med Assoc 1988;41:259. [10] Yellen SB, Cella DR, Leslie WT. Age and clinical decision-making in oncology patients. J Nat Cancer Inst 1994;86:1766 – 70. [11] Pignon T, Scalliet P. Radiotherapy in the elderly. Crit Rev Oncol/Hematol 1998;27:129–30.
47
[12] Perez CA, Pajak TF, Rubin P, et al. Long-term observation of the patterns of failure in patients with unresectable non-oat cell carcinoma of the lung treated with definitive radiotherapy, report by the radiation therapy oncology group. Cancer 1987;59:1874 – 81. [13] Pignon T, Gregor A, Schaake Koning C, et al. Age has no impact on acute and late toxicity of curative thoracic radiotherapy. Radiother Oncol 1998;46:239 – 48. [14] Krol AD, Aussems P, Noordijk EM, et al. Local irradiation alone for peripheral stage I lung cancer: could we omit the elective regional nodal irradiation? Int J Radiat Oncol Biol Phys 1996;34:297 – 302. [15] Noordijk EM, Poest CE, Hermans J, et al. Radiotherapy as an alternative to surgery in elderly patients with resectable lung cancer. Radiother Oncol 1988;13(2):83 – 9. [16] Talton BS, Constable WC, Kersh CR. Curative radiotherapy in non-small cell carcinoma of the lung. Int J Radiat Oncol Biol Phys 1990;19:15 – 21. [17] Dosoretz DE, Galmarini D, Rubenstein JH, et al. Local control in medically inoperable lung cancer: an analysis of its importance in outcome and factors determining the probability of tumor eradication. Int J Radiat Oncol Biol Phys 1993;27:507– 16. [18] Zagonel V, Pinto A, Serraino D, et al. Lung Cancer in the elderly. Cancer Treat Rev 1994;20:315 – 29. [19] Arcasoy S, Jett J. Superior pulmonary sulcus tumors and Pancoast’s syndrome. New Engl J Med 1997;337:1710 – 7. [20] Lynch TJ. Management of stage III non-small-cell lung cancer. Educational book ASCO 1998; 265 – 275. [21] Fentiman IS, Tirelli U, Monfardini S, et al. Cancer in the elderly: why so badly treated. Lancet 1990;335:1020– 2. [22] Schaake-Koning C, Van den Bogaert W, Dalesio O, et al. Effects of concomitant cisplatin and radiotherapy on inoperable non small-cell lung cancer. New Engl J Med 1992;326:524 –30. [23] Dillman RO, Stephen LS, Propert KJ, et al. Randomized trial of induction chemotherapy plus high-dose radiation versus radiation alone in stage III non-small-cell lung cancer. New Eng J Med 1990;323:940 – 5. [24] Gava A. Lung cancer radiotherapy update in the elderly. Annals of Oncology 1998;9(Suppl 3):34 – 5. [25] Shepered FA, Amdemichael E, Evans WK, et al. Treatment of small cell lung cancer in the elderly. J Am Geriatr Soc 1994;42:64 – 70. [26] Dajczman E, Yi Fu L, Small D, et al. Treatment of small cell lung carcinoma in the elderly. Cancer 1996;77:2032 – 8. [27] Jeremic B, Shibamoto Y, Acimovic L, et al. Carboplatin, etoposide and accelerated hyperfractionated radiotherapy for elderly patients with limited small cell lung carcinoma: a phase II study. Cancer 1998;82(5):836– 41. [28] Repetto L, Granetto C, Venturino A, et al. Lung Cancer. Crit Rev Oncol/Hematol 1998;27:133 – 4. [29] Murray N, Grafton C, Shah A, et al. Abbreviated treatment for elderly and infirm patients with limited stage small cell lung cancer (LSCLC). Lung Cancer 1994;11(Suppl.1):171– 5. [30] Slawson RG, Scott RM. Radiation therapy in bronchogenic carcinoma. Radiology 1979;132:175 – 6. [31] Gava A, Bertossi L, Zorat PL, et al. Radiotherapy in the elderly with lung carcinoma: the experience of the Italian ‘Geriatric radiation oncology group’. Rays 1997;22(Suppl. 1):61 –5. [32] Sen M, Demiral AS, Cetingoz R, et al. Prognostic factors in lung cancer with brain metastasis. Radiother Oncol 1996;46:33–8. [33] Mandoliti G, Polico C, Capirci C, et al. Radiation therapy of bone metastases in the elderly: a multicentric survey of the Italian ‘Geriatric radiation oncology group’. Rays 1997;22(Suppl. 1):57 – 60.
48
A. Ga6a / Critical Re6iews in Oncology/Hematology 32 (1999) 45–48
[34] Veronesi A, Zagonel V, Serraino D, et al. Clinical characteristics, diagnosis and treatment of elderly patients with lung cancer at non-surgical institution: a multicenter study. Tumori 1990;76:429 – 33. [35] Monson JM, Stark P, Reilly JJ, et al. Clinical radiation pneumonitis and radiographic changes after thoracic radiation therapy for lung carcinoma. Cancer 1998;82:842–50. [36] Graham MV, Purdy JA, Emami B, et al. Preliminary results of a prospective trial using three dimensional radiotherapy for lung cancer. Int J Radiat Oncol Biol Phys 1995;33(5):993– 1000. [37] Elias A. Chemotherapy and radiotherapy for regionally advanced non-small-cell lung cancer. Chest 1993;103(Suppl. 4):362 – 6.
.
[38] Gridelli C. Treatment of advanced non small cell lung cancer in the elderly: an update. Ann Oncol 1998;9(Suppl 3):36–7.
Biography I am a Medical Doctor and have been working in the Radiotherapy and Oncology Department of Treviso Hospital since 1981. I specialize in Radiotherapy Oncology and in Medical Oncology. I am among the founders of GROG (Geriatric Radiotherapy Oncology Group) and am interested, above all, in radiation therapy of lung cancer.