SHOULD ADULTS OVER 80 GET RADIATION OR CHEMO FOR CANCER? PROS, CONS AND OTHER CONSIDERATIONS

Older adults are at higher risk of contracting cancer and other lifestyle diseases. They are also more likely to succumb to treatment side effects and typically have comorbid conditions to consider. The risk and occurrence of such manifestations rise with age, with those over 80 being in the most vulnerable category. This time in one’s life raises several questions regarding the best course of action regarding healthcare, factoring in the quality of life and mortality.

With respect to treating cancer in those over the age of 80 and 90, it is important to weigh the benefits and risks of mainstay treatment. Is treatment in this age group worth it, and does it help to make the final years of life better? While there is no truly objective answer to these questions, the following article explores radiation and chemotherapy for cancer patients in their 80s and older to highlight key health considerations. Potential pros and cons are discussed, alongside recommendations for improving treatment.

Radiation Therapy

Radiotherapy is often considered more cost-effective and beneficial than chemo for treating terminally ill patients.

If you or someone you know over 80 are considering radiation therapy for cancer, the below points may be helpful.

Pros

• Often Less Toxic than Many Available Forms of Chemo. Radiation therapy is thought to be better tolerated than chemotherapy as it is usually a localized therapy and does not cause systemic issues. Due to this observation, many experts advocate that it is comparatively better tolerated overall in the elderly. However, it does exert toxicity in local tissues that may result in both short and long-term complications. If the patient is in good health and is expected to live longer than several months, radiotherapy may be a better treatment option than many available forms of chemotherapy.^[1]
• Pain Relief. For the end-of-life care of elderly cancer patients undergoing pain, radiotherapy may be an optimal treatment, particularly when treating metastatic cancers. It is used successfully to relieve pain related to bone metastases^[2] and may alleviate symptoms pertaining to brain and spinal tumors. Low-dose radiotherapy has also proven to be beneficial for lowering pain in the context of osteoarthritis^[3] and may help in managing similar painful comorbidities. Despite this benefit, it has been shown to promote pain attributable to other complications and has also been noted to induce bone metastases in rare cases.
• Better than Hormone Therapy in Prostate Cancer. In 19,920 men over 80 with prostate cancer, standalone radiation therapy was shown to respond better than a lack of treatment or androgen deprivation therapy (whether alone or in combination with radiation). Outcomes suggested a 50% reduction in overall mortality rates.^[4]
• May Be More Suitable for Treating Metastatic Cancer. Some studies suggest that radiotherapy may be most beneficial in the context of treating metastatic tumors in the elderly than chemotherapy. This is likely due to the nature of radiation-induced toxicity, with treatment of late-stage cancers being most able to take advantage of the benefits prior to long-term toxic effects and risk for metastases.

Cons

• Rapid Aging. Radiation therapy for cancer has been shown to promote rapid cell aging in normal cells, which has led to faulty cell functioning and decline in irradiated tissues. This contributes to most of the side effects associated with radiation therapy and can also increase adverse effects pertaining to chemo use. Patients that have advanced comorbid conditions or who have a shorter life expectancy will likely benefit more from opting out of radiotherapy.
• Localized Comorbid Disease Exacerbation and Mortality. Radiotherapy is usually performed at the site of the tumor and can weaken the functioning of nearby areas as well. There are both short-term and long-term toxic effects. The long-term effects usually take decades to manifest and are not usually problematic for this population. Short-term toxicity can be manageable in elderly patients over 80 if the health of the irradiated area is in reasonable condition. If not, the treatment is likely to exacerbate pre-existing problems in the area that may contribute to mortality. For example, treating lung cancer with radiation may exacerbate pre-existing heart conditions and lead to heart failure.
• Digestive Complaints. Appetite loss, diarrhea, dehydration and xerostomia (a severely dry mouth) may be side effects of radiation therapy in elderly individuals, which can contribute to digestive problems^[5]. This is related to increasing senescent cells in the salivary glands, resulting in lower output and reductions in stem cell reservoirs.^[6]
• Mucositis and Systemic Infections. Mucositis refers to the inflammation of the mucosal surfaces that line the gastrointestinal tract. This is the most common side effect of radiotherapy, particularly in those who receive treatment for head and neck cancers. If prolonged, it can result in the formation of ulcers, erosion of the mucosal lining of the tract and an increase in systemic toxicity and infections.^[7]
• Risk of Falls and Hospitalization. Radiotherapy may increase the risk of falls and resultant fractures due to increasing fatigue and weakness. This is especially true of those with brain tumors, where it is suspected that local neurotoxicity adds to the risk.^[8]

Other Considerations

Radiotherapy for Elderly Patients Post Cancer Surgery. Surgery is not often recommended for very elderly patients with cancer, as they are typically in the highest risk category for complications and mortality. In most cases, radiation treatment conveys a far better prognosis than surgery.

Hypofractionation refers to therapy where the total dose is administered in larger amounts over shorter periods of time^[9]. Some studies suggest it may be more beneficial for the elderly patient due to less time spent at the radiologist as well as less toxicity observed in cancerous tissue. Other studies suggest it may increase systemic toxicity. Benefits have been observed for patients with breast cancer, glioblastomas, as well as head and neck cancer. However, the precise dosing and number of sessions are usually tailored by the healthcare provider and require frequent monitoring for side effects.

Chemotherapy

Chemotherapy is considered the best option for those diagnosed with cancer in the early stages, who have a higher life expectancy, and who are on a minimal prescription list.

If you are considering chemo for yourself or a loved one over 80, the following pros and cons may apply to you.

Pros

• Improves Survival Rates When Treating Primary Cancers. Many studies have confirmed that chemotherapy can increase the average rate of survival in the context of cancers that have not metastasized. These results have been shown for small cell lung carcinoma^[10], colon cancer^[11], and breast cancer. Metastases, low albumin count and kidney dysfunction were shown to be predictors of chemo toxicity and adverse effects in the elderly.^[12]
• Possibly Less Travel Time. Patients may prefer chemotherapy using medication as opposed to other treatment options that may require several weekly appointments and travel time.
• May Pose Anti-Aging Benefits. Some chemo drugs serve as senotherapeutics which means they target both tumors and aged cells. Notably, these chemo and senolytic strategies target the aged immune system, which allows for the detection of faulty cells and improves their ability for destruction and removal. Consulting with the oncologist about the senolytic properties of the available chemotherapy options can help to tailor the treatment plan and enhance final results. Read more about chemo senotherapeutics here.

Cons

• Toxicity. In many studies assessing the efficacy of chemo for those over 80, the main reason treatment was discontinued was due to toxic side effects, even after repeated dose adjustments^[13]. By comparison to radiotherapy, many forms of chemo appear to be far less tolerated and have also been implicated in spurring adverse events that lead to mortality. Those with comorbidities or on other medication may wish to avoid chemo for this reason. ^[14] This is especially true for elderly individuals with cardiovascular diseases where many common chemo drugs contribute towards cardiac toxicity, heart attack risk and associated mortality.^[15] In some studies, cardio medications such as beta-blockers helped to decrease toxicity risks^[16], while in other studies, the result was negligible. If side effects are severe and persist despite dose reductions, treatment should be stopped immediately.
• Cytopenia. A frequently observed complication of chemotherapy includes cytopenia, which refers to a drastic reduction in various cells, the most common being red blood cells. Lower levels of thrombocytes have also been observed in patients on chemo, with older patients being at a higher risk. Cytopenia often results in the need for blood transfusions.
• Fatigue, Weakness and Falls. As one of the main side effects of chemotherapy, fatigue can be related to many other factors, such as cytopenia, blood sugar anomalies, hypertension, and weakness, which may contribute to the risk of falls. Neurotoxic chemo drugs can also increase the risk of falls and hospitalization due to eliciting motor and sensory symptoms.
• Functional Decline and Life Quality. Other studies highlight that chemo promotes functional decline in roughly 30% of elderly patients, which notably affects their daily activities.^[17] Other common symptoms that may affect the quality of life include pain, muscle cramps, and edema.^[18]
• Hidden Hospital Costs. Due to the high risk for toxicity, cytopenia and other adverse effects in those over 80 on chemo, hidden hospitalization costs ought to be factored in. For this reason, chemo is often thought to be more expensive than radiotherapy in the long term, even when travel costs are taken into account.

Other Considerations

Minimizing Polypharmacy. Those over 80 are often prescribed multiple other medications for comorbid conditions. It is becoming increasingly more recognized that polypharmacy in this age group is especially inappropriate and that the side effects of many common prescriptions may converge, promoting toxicity, adverse effects and hospitalization. In this context, chemo drugs may (yet not always) exacerbate the already toxic effects of other prescription medications or vice versa^[19]. Healthcare physicians and providers ought to screen the prescriptions of the patient to make sure there are no drugs with duplicate effects, unnecessary medications or those with clashing side effects.

Symptoms vs Survival. While chemo has been shown to reduce cancer-related symptoms in the elderly, which may enhance the quality of their final years, it has also been shown to substantially reduce survival rates in those with metastatic cancer.^[20] Therefore, those who find their symptoms manageable without chemo may wish to avoid chemo in exchange for prolonged survival. On the other hand, targeted therapies may not affect survival risks, to which therapy may be the best option. These are considerations that patients ought to think about before undergoing therapy.

Combined Radiation and Chemotherapy

Radiation and chemo may be complementary or highly deleterious for treating cancer in elderly patients.

Combined radiation with chemotherapy may not be advisable in some instances as it may increase the toxicities associated with both protocols and spur mortality. In a small study, two patients over 90 years with Non-Hodgkin Lymphoma died of chemodrug-induced pneumonitis while on radiation therapy.^[21] Mucositis, cardiotoxicity and other symptoms that frequently intensify as a result of combined therapy often lead to hospitalization and fatality.

Elderly patients who are fit for their age, more mobile and with few comorbidities have been shown to benefit from this therapy combination similarly to their younger counterparts. The right combination of therapies may also help to lower the risk of metastases and pain while improving symptoms, prognosis and survival rates.

Additional Treatment Considerations for Both Chemo and Radiotherapy

After taking the above into consideration, it is important to consult with an oncologist regarding therapy. You will likely also need the help of a nutritionist who can assist with optimizing a diet plan for an elderly individual undergoing either chemo or radiotherapy.

• Overall Functionality Assessment. Radiologists and oncologists are encouraged to assess each elderly patient based on the degree of functionality, the site of their cancer(s) and the degree of comorbidity. Treatment may not be worth it if it lowers functional independence and leaves the patient more prone to weakness, falls, hospitalization, reduced food intake, dehydration or similar scenarios that may increase mortality risk and are too costly for little benefit. Factors that should be reviewed include vision and hearing, balance, mobility and physical aptitude, cognition, overall health status, the degree of care received (if any), their home environment, daily routine and finances.
• Nutrition Counseling. Nutritional deficiencies may be associated with reduced mobility and greater chemo and radiation side effects in the elderly. For example, low vitamin D status has been associated with promoting esophagitis and emesis in elderly patients receiving radiation therapy^[22]. Polypharmacy is associated with lowered nutritional absorption and reduced food intake, which may exacerbate the side effects of both chemo and radiotherapy. While supplementation may improve treatment outcomes, it is not often advised as it may interfere with the efficacy of treatment. On the other hand, senolytic nutritional supplements can often enhance the effects of chemotherapy and minimize the side effects of chemo-radiotherapy. Nutritional counseling is recommended for those undergoing treatment as it can optimize the absorption of nutrients and tends to take the individual needs of the patient into consideration.^[23]

Conclusion

Whether an elderly individual should opt for chemo or radiation therapy for their cancer depends on their overall health, life expectancy, financial situation and what they hope to achieve with treatment.

Radiation may be a better treatment for painful cancers and those that have metastasized, while chemo may be better in the context of stage I-III cancers, particularly where caution is taken to minimize polypharmacy, toxicity and metastasis risk. The oncologist ought to assess whether the patient would benefit from either chemo or radiotherapy. Minimizing prescription medications and choosing chemotherapy that provides additional senotherapeutic benefits is advisable. A nutritionist or dietician ought to be consulted as well in order to optimize nutrition during treatment.

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