Ældre kræftpatienter og strålebehandling. Jesper Grau Eriksen

Transkript

1 Ældre kræftpatienter og strålebehandling 1 Jesper Grau Eriksen

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4 Strålebehandling er velegnet til ældre! 70 år 2 onco-geriatriske centre n=643 CRC 28% CM 23% ØGI 20% C. prost. 11% 47% DM 4 Laurent M, The Oncologist 2014

5 Laurent M, The Oncologist

6 Strålebehandling er velegnet til ældre! Treatment No DM (n=204) + DM (n=181) Overall plan 87% 66% Surgery 96% 82% Chemotherapy 72% 59% Hormone therapy 98% 85% 6 Radiotherapy 96% 100% Laurent M, The Oncologist 2014

7 Alligevel får mange ældre kræftpatienter ikke den optimale strålebehandling: Afstanden til behandlingsstedet afskrækker nogle ældre fra relevant behandling For uoverskueligt med mange fraktioner 7 Frygten for bivirkninger Co-morbiditet Ældre er mindre bekymret over ventetider Athas, J NCI 2000; Punglia, IJROBP 2006; Boje, Acta Oncol 2013; Paul, Eur J Cancer Care

8 Disse forhold kan hver for sig eller tilsammen influere på udredningstiden og forsinke starten på 8 strålebehandlingen

9 Der er således næppe en aldersrelateret begrundelse for at udelade ældre fra aktiv 9 cancerdiagnostik

10 Old - YES...but fit or frail? 10

11 Atagi S, Lancet Oncol 2012 Randomize JCOG phase III: RT vs. CRT in unresectable st. III NSCLC Eligibility criteria: NSCLC Age 71 years Unresectable st. IIIA/B RT 60Gy/30Fx, 6wks (not T3N1M0, contralat. hilar nodes, atelectasis of the entire lung, mal. pleural or pericardial effusion. 200 pts from Sept to May 2010 RT 60Gy/30Fx, 6wks and carboplatin 30 g/m² per day, 5 days a week for 20 days

12 Atagi S, Lancet Oncol 2012 JCOG phase III: Primary endpoint - overall survival Median FU 19.4 months Comparable groups RT C-RT Grade 3 4 haematological toxicity more frequent in CRT than in RT. Grade 3 infection more common with CRT (12.5% vs. 4.1%).

13 Raske ældre: Funktionelt intakt; ingen alvorlig comorbiditet. Beh. som yngre (ca.½ af årige) Sårbare ældre: Reduceret funktion <2 comorbiditet; samme behandling som de yngre? Skrøbelige ældre reduceret funktion; : 3 comorbiditeter; modificeret/pallierende beh. I n t e r v e n t i o n S t a n d a r d b e h 13 For syg : Ingen behandling Balducci; The Oncologist 2000

14 Meta-analysis of radiotherapy in head and neck carcinomas: an update P. Blanchard 1, B. Lacas 1, J. Bourhis 2, A.M. Trotti 3, J.A. Langendijk 4, J. Overgaard 5, J.P. Pignon 1, on behalf of the MARCH Collaborative Group 1 Institut Gustave Roussy, Villejuif, France, 2 CHUV, Lausanne, Switzerland, 3 Moffit Cancer Center, Florida, USA, 4 University of Groningen, Groningen, Netherlands, 5 Aarhus Universitet Hospital, Aarhus, Danemark 14 With permission from P. Blanchard

15 Bourhis et al, Lancet

16 Age Hazard Ratio [95% CI] Overall Survival < [0.73;0.92] 0.97 [0.90;1.05] 0.96 [0.89;1.04] 0.97 [0.87;1.07] Test for trend : p=0.19 Test for heterogeneity : p=0.48 Progression-Free Survival < [0.71;0.88] 0.91 [0.84;0.98] 0.91 [0.85;0.98] 0.97 [0.88;1.07] Test for trend : p=0.03 Test for heterogeneity : p= Loco-Regional Control < [0.67;0.89] 0.80 [0.72;0.89] 0.86 [0.77;0.96] 0.92 [0.79;1.08] Test for trend : p=0.09 Test for heterogeneity : p= Experimental RT better With permission from P. Blanchard Conventional RT better

17 Adaptere behandlingen? Vil pt dø af eller med cancer? Er restlevetiden så længe at canceren vil påvirke pt? Kan pt. tolerere evt. cancerbehandling? 17 Hvad er langtids konsekvenserne af cancerbehandling? Behandlers opfattelse

18 Oral cavity cancer in patients 80 years old 18 Ortholan et al R&O 2009

19 Ortholan et al R&O

20 Ortholan et al R&O

21 Raske ældre: Funktionelt intakt; ingen alvorlig comorbiditet. Beh. som yngre (ca.½ af årige) Sårbare ældre: Reduceret funktion <2 comorbiditet; samme behandling som de yngre? Skrøbelige ældre reduceret funktion; : 3 comorbiditeter; modificeret/pallierende beh. I n t e r v e n t i o n S t a n d a r d b e h 21 For syg : Ingen behandling Balducci; The Oncologist 2000

22 Måder at adaptere behandlingen på Reducere fremmødebelastningen: hypofraktionering 22 Reducere toxiciteten: reduceret volumen undlade elektive områder

23 START B trial 23 Haviland; Lancet Oncol 2013

24 Breast-conserving treatment in the elderly : long-term results of adjuvant hypofractionated and normofractionated radiotherapy 367 women >70 y BCS + RT for T1-T2 CM, (median 73 y): NF-RT (50Gy/25 fx) +/- boost 50 (median 80 y): HF-RT (32.5 Gy/6 f), no boost Median FU : 93 months Kirovay IJROBP 2009

25 5 Y 7 Y Kirovay IJROBP 2009 NF RT (317) HF RT (50) 5% 7% 6% 9%

26 5 Y 7 Y Kirova IJROBP 2009 NF RT (317) HF RT (50) 96% 93% 95% 87%

27 Stereotaktisk stråleterapi - SBRT 27

28 SBRT allows for: Delivery of very high doses of radiation (hypofractionated) by multiple co-planar and noncoplanar beams and guided by coordinates ( stereotactic )

29 SBRT requires: Precise definition of the target Management of target motion, Identification of a small PTV Conformal RT planning High quality set-up verification prior to each treatment

30 SBRT can provide: Precise delivery High dose to the target Low dose to normal tissues Potentially sparing critical organs

31 Comparing treatment options: IA-IB NSCLC SEER database ; 10,923 patients 66 years Median age 75 years 29% moderate-severe co-morbidity Median FU 3.2 years Lobectomy, Sublobular resection, SBRT, EBRT, BSC Shirvani SM, IJROBP 2012

32 Shirvani SM, IJROBP 2012 Matched cohorts: surgery vs. SBRT N=99 N=99 N=112 N=112

33 SBRT for early-stage lung cancer Overall survival Local faliure Jeppesen, Acta Oncol 2013

34 SBRT for T1-2N0M0 lung cancer Jeppesen, Acta Oncol 2013

35 Perceptions of use of SBRT 43 countries ASTRO, ESTRO JASTRO and TROG 1007 responders Lewis Am J Clin Oncol 2015

36 Perceptions of use of SBRT 61% treat 3 oligometastases Lung, liver and spine most frequent Lewis Am J Clin Oncol 2015

37 Primary setting 44Gy/5fx PTV Oral cavity Spinal Vargo, Front Oncol 2014 Mandible

38 Primary setting Author Type of study No pts Median age SBRT Kawaguchi Retrospective Gy 3-5 fx Karam Retrospective Gy 3-5fx Khan Retrospective Gy 5-6 fx Vargo Retrospective Gy 5fx Median follow-up PFS 36 Mo 71.4% 36 Mo OS 78.6% 36 Mo 24 Mo 18 Mo 20 Mo - 87% 12 Mo 6 Mo 69% 12 Mo 60% 12 Mo 64% 12 Mo Different (or unknown) margins used

39 SEER: Risiko for apoplexi hos ældre efter RT for HNSCC? HNSCC pts. Non-met. sygdom 65 år Smith JCO 2008

40 Relevante emner for forskning hos ældre med cancer Type Problem Brystkræft Lungekræft Hoved-hals kræft Identifikation af en low-risk gruppe der ikke har glæde af post-kir. RT Rolle for partial bryst RT og IORT Prospektive (randomiserede?) studier af SBRT vs. kirurgi Gating og adaptive RT Forfining af organ-besparende IMRT Concomitant terapi...andre muligheder? 40

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