Treatments for elderly head and neck cancer patients

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Published: 15 Nov 2017
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Dr Ronald Maggiore - University of Rochester, New York, USA

Dr Maggiore talks to ecancer at SIOG 2017 in Warsaw about the potential benefits of using geriatric assessment tools to incorporate better treatment for elderly patients with head and neck cancer. 

He deduces that there needs to be better selection of patients for aggressive treatments because of the toxicity costs.

He also discusses more mindful use of the G8 screening tool in order to provide a more personalised treatment.

Dr Maggiore considers how ongoing trials should shed more light and fill in current knowledge gaps around head and neck cancer treatment. 

This service has been kindly supported by an unrestricted grant from Janssen Oncology.

I spoke on the role of the geriatric assessment in older adults with head and neck cancer. Mainly I focussed on reviewing the current literature available of studies that have incorporated geriatric assessment and outcomes for older adults with head and neck cancer. We’re starting to get more information about the potential role and benefits of utilising geriatric assessment tools in evaluating and potentially risk stratifying patients who are older, particularly with locally advanced disease for more intensive treatment such as chemoradiation with curative intent. The theme for the whole discussion this morning was we all need better selection of patients for more aggressive treatments such as concurrent chemoradiation because we can still cure patients with that but of course there’s the cost of the toxicities, both short and late term. Some of my co-discussants emphasised some of the late term toxicities that were probably not as focussed on such a stroke risk as particularly in the older survivors. That goes up significantly at ten years compared to younger patients. From the geriatric assessment studies I reviewed, particularly the Belgian study, that we can use tools like the G8 that’s more conducive time-wise for evaluating older adults, that patients who are deemed fit or unfit based on that do have remarkably different trajectories in terms of their quality adjusted survival as well as patient reported outcomes.

How many patients were studied?

They had a fair number of patients, I think it was over 100. Some of the other studies that we reviewed were only in the 30-40 range but I’m pretty confident that study had a much larger sample size. Those patients were predominantly, up to 70% or so, were getting definitive chemoradiation or radiation as opposed to many patients getting surgery and then additional treatment. So it was a little more homogeneous in terms of treatment type. So in terms of the patients we’re typically addressing with some of the long-term quality of life issues, from the medical oncology side we’re going to be more involved with chemoradiation patients. So it’s definitely a more germane study to look at to gain some insights about the potential use of G8 and comprehensive G8 in that population.

Could you give a consensus based on this analysis?

I don’t think we have a consensus yet. As opposed to patients with more advanced stage disease where many of these tools have been used to predict chemotherapy toxicity and survival in general, head and neck patients were generally not included in any of those earlier studies. It is helpful, based on a review that we discussed, that utilising a G8 to be more mindful of patients who may have poor self-reported functional outcome issues or potentially worse survival overall, whether we should look at either modifying the treatment recommendations but the group as a whole didn’t recommend any dose adjustment. So what it will boil down to is that single modality versus combined modality treatment based on the geriatric assessment results or the G8 score at baseline as well as tailoring that to the frequency of visits and the amount of supportive care that will be necessary to support that more vulnerable patient through whatever treatment intensity is deemed most appropriate for a given patient. But I don’t think we’re at the point yet of being able to use the tools yet to decide what type of treatment necessarily or dosage. Because a lot of the landscape, as we all allude to in our talks, especially with immunotherapy on the horizon and that being incorporated both in the early stage as well as the recurrent metastatic setting, the paradigm shifting in general for all patients. But for our older patients who might be more vulnerable functionally or because of comorbidity it’s, at least so far, useful to use these tools to help guide general treatment decisions in terms of overall intensity and how to better approach supportive care during and after treatment.

Anything else to add in the realm of head and neck cancer?

Other than we’re definitely eagerly awaiting some of the geriatric assessment embedded trials being done right now in France, adapting chemotherapy choice for the patients with recurrent metastatic setting as well as the general overarching trial looking at the geriatric assessment and functional status disability and nutrition and similar outcomes in a much larger cohort of older adults with head and neck cancer to help fill in some of these knowledge gaps.