SIOG 2015

Utilising radiotherapy to treat elderly cancer patients

Prof Lorenzo Livi - Careggi Hospital, Florence, Italy

Radiotherapy is a powerful way of treating patients and in many cancers, I’m thinking for instance breast cancer, it has some great effects in long-term survival. But looking at the elderly specifically, what are the new applications for radiotherapy, not only in breast cancer but other cancers, for older patients in your view?

In other cancers, especially in lung cancer or in brain tumours or also in prostate cancer, in elderly patients now we can offer an excellent treatment because we can concentrate radiotherapy in a week or sometimes in just one shot and obtain excellent results in terms of overall survival, progression free survival, without comorbidity. So this is a new scenario, it’s very important for these types of patients in which quality of life is very important.

Could I ask you, I’d like to ask you about that, but in the case of breast cancer it’s also interesting to be able to avoid radiotherapy in those patients who will not benefit from it. What have you got to say about that?

Now we have several studies published just some months ago in which you can demonstrate that radiotherapy in patients aged more than 65 years old is important to obtain local control but it’s not important for overall survival. The local control, the risk of local recurrence is too low. So we started to identify a subgroup of patients in which we can avoid radiotherapy. Maybe in luminal A cancer, it is a very low risk cancer, now from Florence but obviously with the help of EORTC we try to propose a new study in which we maybe obtain, we hope, the result in which we can have the avoiding of radiotherapy. So we have three different arms – only surgery, radiotherapy but not to the whole breast but to the inner quadrant, so partial breast, or only hormonal treatment.

There are, however, some patients with higher risk disease with whom you would go ahead with more radiotherapy. Which are those patients in breast cancer?

High risk cancer maybe like lung cancer or brain cancer.

But in the case of breast cancer what are the categories of breast cancer where you would still, nevertheless, go for radiotherapy?

Until now radiotherapy is a main treatment for this type of patient so now you cannot avoid the radiotherapy in high risk patients or in patients aged less than 75 years old. So radiotherapy is a very important part of the treatment. So obviously not avoiding radiotherapy outside of clinical trials in this moment.

But in the case of other cancers, lung cancer, prostate cancer and primary brain cancer, I gather that there’s a case for using radiotherapy instead of surgery?

Yes, now with hypofractionated radiotherapy we can give maybe a single shot or three radiotherapy or five radiotherapy, no more than five radiotherapy, and we can obtain excellent results similar to surgery without comorbidity. So it’s related to the new technical approach that radiation oncology now can use.

What are some of the outstanding examples of the efficacy of radiotherapy as an alternative to surgery in some of those cancers?

In lung cancer we can treat the primary lung cancer with five courses of radiotherapy, five fractions. Prostate cancer, we can treat prostate cancer with five fractions of radiotherapy. Primary tumours of the brain we can treat with five fractions, obviously in selected patients, especially in the elderly patients. There is a study that shows that elderly patients with a lot of comorbidity can receive radiotherapy in five fractions and we obtained an excellent result in terms of overall survival in respect to nothing. Obviously the surgeon cannot undergo these patients to surgery because they have a lot of comorbidity. So the choice now is nothing, it’s wrong. The choice now is radiotherapy, not nothing, and radiotherapy compared to surgery in fit patients obtains the same results. Somewhere in the next future radiotherapy can avoid surgery.

So you’re trying to do the surgeons out of a job but are there any checks and balances, is there a downside of using radiotherapy in those patients for whom it would do as well in terms of overall survival?

Yes, I think that the progression of medicine and biological knowledge is going to this type of approach, not because I’m working as a radiation oncologist but obviously also in prostate cancer. You have the same result using just five fractions, a week, with respect to surgery. So can you propose this type of treatment with a lot of comorbidity like surgery for prostate cancer when you have another treatment without comorbidity just that you can use everywhere and in a week? I don’t know, we need to study. In fact, now there is an ongoing trial, PACE, that is trying to demonstrate this possibility - new surgery with robotic surgery versus new radiotherapy with hypofractionation. So maybe we have to wait for this study.

As we go into the era of precision radiotherapy, what’s the take home message for doctors?

The take home message for doctors is believe in their work and start to use this possibility to improve the survival of the patient. So believe and use.