Urologic Oncology: Seminars and Original Investigations
Seminar articleRadiation therapy for urologic malignancies in the elderly
Introduction
Radiation therapy (RT) has a long history in the treatment of patients with urologic cancers, with the first patient treated not long after the discovery of X-rays over a century ago. Today, RT occupies an important therapeutic role in a wide variety of urologic malignancies, including prostate, bladder, and testicular cancers. In these patients, RT may be delivered either alone, as definitive therapy, or in combination with surgery and/or systemic therapies (chemotherapy, hormonal therapy).
RT is particularly common in the treatment of the elderly urologic cancer patient in whom surgery is precluded by either medical co-morbidities or disease extent. Moreover, it is commonly delivered in older patients to palliate symptoms when cure is no longer possible. The purpose of this article is to provide an overview of the use of RT in the elderly urologic cancer patient. Our focus will be on published clinical studies; however, potential uses of novel emerging radiation technologies in the older patient will also be highlighted.
Section snippets
Prostate cancer
Prostate cancer is the most common cancer diagnosed in older men [1]. Currently, prognosis and treatment decisions in these patients are based on risk stratification using variables, such as tumor stage, Gleason score, and serum prostate-specific antigen (PSA). There is considerable variation in the treatment approach to the older cancer patient due to multiple confounding factors, such as age, life expectancy, medical comorbidities, performance status, and importantly bias among physicians
Selection of radiation therapy
Age alone should not be used as the criteria for selecting appropriate therapy and treatment modality in prostate cancer patients. Since screening approaches and the treatment employed in the elderly remain controversial and debatable [6], outcomes based on quality of life have significant implications. Definitive RT and radical prostatectomy (RP) are the most commonly employed treatment options for localized prostate cancer. HRQOL measures have recently been reported using these two modalities
Combined radiation and androgen deprivation
The use of RT in combination with androgen deprivation for high risk prostate cancer patients is clearly supported by multiple randomized trials [21], [22]. However, several questions remain unanswered, including the optimum sequencing and duration of androgen deprivation. The rationale for combining hormone therapy and RT is a synergistic enhancement of radiation-induced cell killing, possibly through promotion of apoptosis and decrease of hypoxia. The target coverage with RT is also improved,
Brachytherapy
Brachytherapy involves the insertion of radioactive seeds into the prostate gland, thereby delivering high radiation doses within the target with a rapid dose fall-off of dose sparing surrounding critical organs, notably the rectum and bladder. Brachytherapy may be performed with a permanent seed implant using low dose rate sources (iodine-125 or palladium-103). Alternatively, the use of temporary high dose rate brachytherapy approaches has also been reported.
Brachytherapy offers several
Post-prostatectomy radiation therapy
While the proportion of older prostate cancer patients treated with definitive surgery is small, it is important to carefully evaluate the pathologic features following surgery, offering adjuvant RT to select patients with adverse factors. Multiple prospective, randomized trials have shown that adjuvant RT following RP improves progression-free survival in men with high risk features such as a positive margin, seminal vesicle involvement or extra-capsular extension [28], [29], [30]. Moreover,
Emerging technologies
Over the past 20 years, several novel RT technologies have been introduced, improving the quality and delivery of RT in prostate cancer patients. All have important implications for elderly patients. Perhaps the most important of these technologies is intensity-modulated RT (IMRT). IMRT is a sophisticated radiation delivery technique achieving high conformity using optimization software [33]. With IMRT, radiation dose is conformed to the shape of the target in three dimensions, thereby limiting
Palliation
RT plays an important role in palliating symptoms in elderly prostate cancer patients due to progressive local and metastatic disease. Palliative RT is effective in relieving local pelvic symptoms, such as hematuria, pain, and obstructive symptoms. Hindson et al. treated 35 hormonally refractive prostate cancer patients with a median dose of 60 Gy in 20 fractions and noted complete and partial responses in 8.6% and 51.4% of patients, respectively [57].
Palliative RT is also commonly used in
Testicular tumors
Malignant neoplasms of testis have low incidence in the elderly. Overall, seminoma is the commonest type of germ cell tumor encountered. The spermatocytic type, which accounts for only 1% to 2% of seminomas, tends to occur in the elderly. Such tumors are usually confined to the testes and no adjuvant therapy is typically required. However, adjuvant RT has been traditionally employed for stage I classic seminomas. Given the rarity of these tumors in older population, the recommended treatment
Conclusions
There is an imperative need for the acquisition of quality data to formulate optimal treatment guidelines for elderly patients with prostate and other urologic cancers. The medical community should design clinical trials for older patients as well as to include this subgroup of patients in all prospective trials. Future trials should also incorporate measures of quality of care and treatment outcomes, including toxicity relevant to the older population. This would provide valuable information
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