HNC are treated by combined modalities – surgery, radiation, and chemotherapy, and therefore can be associated with high treatment-related morbidity.
By Dr Mrs Mukul Roy
The number of patients with cancer aged 65 years and older will increase in the next several decades. Approximately 25% of patients with head and neck cancer (HNC) are aged 70 years and older. HNC in older patients is a major health burden. They also have multiple comorbidities like diabetes, hypertension, etc which can lead to reduced treatment tolerance and hence they are a unique cohort of patients. ICMR-NCDIR National Cancer Registry Programme estimates a 12% increase in cancer cases in India by 2025. It is interesting to note that a significant percentage of men and women in India use some form of tobacco – urban as well as rural areas.
Most scientific studies include a relatively young and healthier population. For example, less than 25% of patients enrolled in National Cancer Institute Cooperative Group Clinical Trials are between 65 to 74 years and less than 10% are aged 75 years and older. Hence the efficacy and safety data of cancer drugs, especially in vulnerable older adults are limited.
HNC are treated by combined modalities – surgery, radiation, and chemotherapy, and therefore can be associated with high treatment-related morbidity. Oncologists need to rationalize treatment in this age group. There is less data in older patients with HNC. The performance status less than or equal to 80 and weight loss >5% are associated with higher mortality. Patients with suboptimal kidney function and low body mass index & poor nutrition are more likely to be hospitalized during treatment.
The choice between single vs. multi-agent chemotherapies is often made based on chronological age, which does not necessarily reflect the patient’s underlying physiologic age. Hence proper assessment of physiologic age and functioning is extremely essential otherwise it can lead to overtreatment or under treatment in fit older adults.
From the perspective of radiation, the modern advanced techniques of Volumetric arc radiotherapy/RapidArc techniques are excellent modalities for radiation in the head and neck region. They are better tolerated with lower risk of acute and late side effects. Common late effects such as dryness of mouth are less common. These modalities are better at sparring neck muscles and those for swallowing, thereby helping in better swallowing function after radiation. In oral cavity cancers, it is also associated with a lower risk of oral ulcers and altered taste sensations.
More than 90% of HNC survivors who are treated with chemo radiation may develop one or more nutrition-related syndromes that negatively influence survivorship after the active phase of treatment. Therefore, post-treatment surveillance and close follow-up are important to reduce the risk of malnutrition and weight loss and improve quality of life.
Immune checkpoint inhibitors like anti-PD-1 agents (e.g., nivolumab) have less side effects and are often the drug of choice for treating vulnerable older patients with HNC.
Treatment decisions need to be individualized always. It is important to consider comprehensive palliative care and social services also early in the management of older patients with HNC, especially in case of recurrent or metastatic disease (stage IV).
To conclude, proper assessment using medical tools is important for personalized treatment care. It can also guide supportive care interventions (e.g., social services, palliative care) and promote shared decision-making. Older adults with HNC are a unique cohort and need special care and attention for optimum outcome and survival.
(The author is MBBS, DNB, MBA, Consultant Radiation Oncologist, Jaslok Hospital & Research Centre, Mumbai. Email – [email protected]. The article is for informational purposes only. Please consult medical experts and health professionals before starting any therapy, medication and/or remedy. Views expressed are personal and do not reflect the official position or policy of TheSpuzz Online.)
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