Chemoradiotherapy for elderly oesophageal sufferers

1 Dec 2008

Study demonstrates the benefit of using chemoradiotherapy in elderly patients with locally advanced oesophageal cancer
Chemoradiotherapy (CRT) can be considered an “effective” treatment for elderly patients with locally advanced oesophageal cancer, reports the British Journal of Cancer.  The French study, involving 109 consecutive patients with oesophageal cancer, suggests that characterising patients first with the 'Charlson' score may provide useful criteria for deciding which subjects are suitable for treatment.
Oesophageal cancer represents the eighth most common cancer world-wide, and the sixth most common cause of cancer mortality. Currently, definitive CRT based on the 5-fluorouracil–cisplatin (5FU–CDDP) regimen is used with curative intent in locally advanced or inoperable non-metastatic oesophageal cancer.  Improvements in general health care and increased life expectancy have resulted in more elderly patients developing oesophageal cancer. CRT is considered as a feasible non-surgical treatment for patients with a locally advanced OC, but questions remain over its use in older patients. In two recent randomised trials the mean ages of the subjects were 59.1 and 57 years respectively. Previous studies have produced contradictory results, with those undertaking careful selection of elderly patients producing good results, while others have shown reduced survival and higher CRT discontinuation and toxicity among the elderly.
David Tougeron and colleagues, from the Department of Gastroenterology at Rouen University Hospital (France), set out to evaluate the tolerance and outcome of treatment with CRT in elderly non-metastatic oesophageal cancer patients.  In the study 109 consecutive patients, aged between 70 and 88 years, were treated with definitive CRT between January 1994 and June 2007 at the Digestive Oncology Unit of Rouen University Hospital. Patients were followed up clinically with upper digestive endoscopy with biopsy and chest and abdominal CT scans every three months.
As part of the assessment, Tougeron and colleagues included the Charlson score, a means of assessing co-morbidity and overall mortality by accounting for the presence or absence of 19 different conditions. Conditions in the score included coronary artery disease, congestive heart failure, chronic pulmonary disease, peptic ulcer disease, peripheral vascular disease, liver disease, cerebrovascular disease, connective tissue disease, diabetes, dementia, renal disease, prior tumour and AIDS.
Results showed that a clinical complete response, defined as the disappearance of all signs of cancer, was observed in 63 patients (57.8 %) and that 26 patients (23.8 %) showed no recurrence at the median follow up of 20.5 months.  Furthermore, the two year survival was 35.5 % and the 12 year survival was 12.8%.
The median overall survival was 15.2 +- 2.8 months and the disease free survival was 8.3 +-7.3 months. Adverse events greater than grade 3 were observed in 26 (23.8%) of patients, and grade 4 toxicity was observed in three patients (2.7%), with two treatment related deaths (1.8%).
Overall 24 patients had an initial dose reduction due to their age or co-morbidities, with chemotherapy doses that were 50 or 70 % of complete dose. In the study, planned treatment was achieved in only 38.5 % of patients and 53.5% required dose adjustment.
The multivariate analysis showed that a clinical complete response to CRT (P<0.01), a dose of radiotherapy greater than 80 % (p=0.02) and a Charlson score less than 2 (p=0.0046) could all be identified as independent prognostic factors of overall survival. Tumour stage and being older or younger than 75 years were not found to be predictive factors of overall survival.
“The study suggested that definitive CRT in elderly patients with an oesophageal cancer was an effective treatment without a major increase in adverse events,” concluded the authors, adding that the results showed CRT in elderly patients produced similar results to those seen in younger patients.
One reason, they add, that the overall median survival of 15.2 months in the current study may be lower than that found in previous studies (17 to 26 months), is that a selection bias may have existed in the earlier trials. The current study reflects outcomes for non selected patients.
“Although age and co-morbidity were associated with higher difficulties encountered during treatment, no significant association was found between these factors and survival in our study,” write the authors.




Article: D Tougeron, F Di Fiore, S Thureau, et al. Safety and outcome of definitive chemoradiotherapy in elderly patients with oesophageal cancer. British Journal of Cancer 2008; 99:1586-1592.