Supporting older people with cancer, implementing geriatric oncology in the radiotherapy setting

Rising life expectancy is perhaps the single most powerful metric charting the successes of modern living. Our ageing population is testament to better healthcare but simultaneously one of medicine’s greatest challenges. In this special geriatric oncology in radiotherapy edition of TipsRO, we have invited papers exploring the care of older adults with cancer across multiple elements of the radiotherapy treatment pathway. This edition augments the already growing recognition within the global radiation oncology community that we must urgently seek to improve outcomes for older adults with cancer who may benefit from radiotherapy. To echo a radiation oncologist pioneering research in geriatric oncology “we know we will see more and more patients in their 80s and 90s and we are convinced that we can do better” [1]. We hope this edition serves to highlight ways this can be achieved.

Pertinent issues in care of older adults are those of access, equity, efficacy and tolerability. The radiotherapy pathway illustrates of all these themes.

With respect to equity and access, Mackenzie et al present factors affecting Radiotherapy Utilisation (RTU) for older adults in NSW, Australia. This important work is the first time that geriatric oncology RTU across multiple cancer sites using a large cancer registry has been reported in the literature and the authors highlight that older adults are less likely to receive radiotherapy than their younger counterparts. It may be tempting to attribute this to differences in life expectancy and comorbidity but other evidence shows that if radiotherapy is withheld, prognosis may be worse and that inferior clinical outcomes are associated with the underutilisation of radiotherapy. Given that radiotherapy is often an excellent treatment option for older adults due to its limited systemic toxicity and avoidance of the morbidity and mortality of surgery and chemotherapy, Mackenzie et al. rightly argue that the appropriate utilisation of radiotherapy is potentially more important in older adults. Brachytherapy is a technique with both good efficacy and tolerability in older adults. Thiruthaneeswaran et al review the role of brachytherapy in common malignancies affecting older adults. The paper highlights that brachytherapy (especially HDR) is a relatively simple but effective technique and explores reasons why it is often overlooked as a treatment option in older patients. One reason for underutilisation is a likely bias that the patient is too frail for therapy. That bias requires challenge with formal assessment and recording of frailty. In terms of the workflow within radiation oncology departments, there is great potential to optimise care of older patients by harnessing the power of information systems and real time data interpretation, in particular to undertake Comprehensive Geriatric Assessments (CGA). VanderWalde et al. discuss various elements of this opportunity and share a local experience of efficiently integrating and recording electronic CGA into the patient care pathway across a large cancer care network. In order to be better geriatricians whilst still being radiotherapy professionals more education and training is required. From this education perspective, O’Donovan outlines the core principles of frailty screening, a well-recognised and evidence based approach in the clinical assessment of older adults, but which is not widely understood or adopted in radiation oncology practice. One marker of frailty is weight loss and specifically muscle loss (sarcopenia). Anjanappa et al. provide an overview of sarcopenia and its significance in older adults with cancer. Routine CT simulation data sets can be re-purposed to measure sarcopenia. These measurements can than effectively triage nutritional intervention and support as well as adding prognostic depth. This is an elegant example of using the resources we already have to enhance care.

Whilst we innovate and build system wide approaches to safety net our radiotherapy practice for older adults we must also look to establish with patients their core values and their aims and ambitions in undergoing cancer therapy. As the surgeon and author Atul Gawande writes: “As people become aware of the finitude of their life, they do not ask for much… They ask only to be permitted, insofar as possible, to keep shaping the story of their life in this world-- to make choices and sustain connections to others according to their own priorities”. As cancer professionals we must enable the discussions that help define those priorities. Developing personalised approaches for radiotherapy is part of that commitment as discussed by O’Donovan.

Ultimately we cannot approach the care of older adults by “rigidly adhering to algorithms, but must tread with caution, with flexibility, and with creativity” [2]. Fundamental to this is acknowledging the likely significant gaps in RTU for older adults and reflecting on the potential causes for this and seeking solutions to address it. Within our own departments, we must examine the radiotherapy treatment planning and workflow process and identify ways to efficiently tailor our approach for the specific needs of older adults. Lastly, the improvement of geriatric oncology specific training and education for all radiation oncology professionals (inclusive of oncologists, radiation therapists, physicists, nurses and allied health) will ensure the entire multidisciplinary team is empowered to provide access to high quality and appropriate care and support for older adults prior, during and after their radiotherapy.