ESTRO 36 Abstract Book

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S297 ESTRO 36 2017
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SP-0563 Radiotherapy in older patients with GBM
G. Minniti 1
1 Azienda Ospedaliera Sant' Andrea, UOC Radioterapia,
Rome, Italy
The incidence of glioblastoma in the elderly population
has increased over the last few decades. Current
treatment includes surgery, radiotherapy (RT) and
chemotherapy, but the optimal management of disease
remains a matter of debate. RT remains an effective
treatment in elderly patients with GBM and either
standard RT or hypofractionated RT are associated with
longer survival than supportive care only. Randomized
studies comparing standard RT versus hypofractionated
radiation schedules show similar survival benefits,
although short-courses RT are associated with a better
safety profile. Hypofractionated RT should be chosen in
older patients with newly diagnosed GBM, especially in
those with poor performance status or older than 70 years
old. Temozolomide (TMZ) is a safe and effective treatment
option alternative to RT. Recent randomized studies
indicates that chemotherapy with the alkylating agent
temozolomide is a safe and effective therapeutic option
in patients of 60 years or older with newly diagnosed
glioblastoma. Decisions regarding the choice between RT
and TMZ chemotherapy should be based on the assessment
of O6-Methylguanine-DNA methyltransferase (MGMT)
promoter gene. Patients with MGMT methylated tumors
receive the most significant survival benefit from
treatment with TMZ; by contrast, chemotherapy produces
no benefit in patients with MGMT unmethylated tumors,
suggesting that RT is a better option in these patients. Few
studies have reported survival benefit in elderly patients
treated with a combination of standard RT with
concomitant and adjuvant TMZ. Although this may
represent a feasible therapeutic approach in selected
patients of 60-70 years old with good performance status,
the potential toxicity of standard RT and chemotherapy
for large irradiated brain volumes, and the modest survival
advantages in this age group as compared with younger
patients, do not support the use of aggressive treatments
in the majority of elderly patients. An abbreviated course
of RT plus TMZ may represent a feasible treatment
associated with similar survival benefit and improved
quality of life. Results from an EORTC large randomized
study comparing a short course of RT (40 Gy in 15 daily
fractions) with or without concomitant and adjuvant TMZ
in elderly patients older than 65 years old with newly
diagnosed GBM indicate that RT+TMZ is a safe and
effective treatment in older GBM patients. Currently,
several questions regarding the risks and benefit of
combined chemoradiation remains unanswered.
SP-0564 Lung
J. Van Loon1
1MAASTRO Clinic, Maastricht, The Netherlands
Lung cancer is a problem of the elderly: 30% of the lung
cancer patients are older than 75 years. Due to
underrepresentation of elderly patients in clinical trials
there is a lack of evidence to select the optimal treatment
strategy. For the subgroup of elderly presenting with stage
I peripheral lung cancer, stereotactic radiotherapy has
shown to be an effective and well tolerated treatment
option. For the other patients with stage I or II disease,
fractionated radiotherapy is generally offered for elderly
that are considered inoperable.
With respect to the 35% of elderly patients with stage III
disease, pulmonologists and radiation oncologists are
faced with the challenge to judge which treatment option
would be best for each individual patient. Although
concurrent radiochemotherapy (RCHT) is the standard
treatment for stage III disease, evidence for this
treatment was gained in clinical trials that mostly
excluded elderly patients. 1 Furthermore, the survival gain
obtained with combined RCHT comes with a significant
increase in toxicity. The lack of evidence on the optimal
treatment strategy in elderly stage III NSCLC patients
contributes to the difference between treatment
guidelines and the treatment offered in routine clinical
practice.
Subgroup analyses of the limited number of elderly stage
III NSCLC patients included in clinical trials indicate that
fit elderly patients may benefit from intensified treatment
such as concurrent RCHT, but their value is limited due to
a restricted number of patients and potential selection
bias. Data on the influence of age on treatment induced
toxicity are conflicting. A recent retrospective study
reflecting current clinical practice showed that despite
the fact that relatively fit and younger elderly were
assigned to concurrent RCHT, tolerance was worse and OS
was not significantly better compared to sequential
RCHT2. Since limited information on geriatric
characteristics was available in this retrospective study,
prospective studies including geriatric assessments are
urgently needed to gather evidence on treatment options,
quality of life and survival. Different geriatric
assessments have been developed to discern frail,
vulnerable and fit elderly patients that may help in the
selection of the most appropriate treatment3,4, but these
have not been validated for RCHT in elderly lung cancer
patients, are time consuming and difficult to implement
in routine oncology practice.
These issues are largely addressed in the multicentre
prospective randomized NVALT25-ELDAPT trial
(NCT02284308), which has recently started in the
Netherlands , focusing on treatment options for
unselected stage III NSCLC patients ≥ 75 years This trial
aims to incorporate geriatric assessment strategies to
guide treatment selection, build evidence on the
treatment resulting in the most optimal balance between
QoL and survival, and develop a short and clinically
applicable geriatric screening instrument to implement in
future lung cancer care. The results of ELDAPT can
facilitate treatment decision making in the elderly since
patient preferences and capacities can be collected more
precisely and interpreted in the light of a geriatric