Zusammenfassung
Hintergrund
Die Anzahl alter Patienten in der Strahlentherapie steigt mit der zunehmenden Alterung der Bevölkerung. Dennoch werden die damit verbundenen Fragen zur Verträglichkeit und Effektivität einer Strahlenbehandlung alter Menschen selten diskutiert.
Material und Methode
Die Ergebnisse einer Literaturrecherche zu epidemiologischen Daten, strahlenbiologischen Aspekten und Ergebnissen der Strahlentherapie alter Patienten werden dargestellt.
Ergebnisse
Mit zunehmendem Alter nimmt die Krebsinzidenz zu. Sie liegt bei Männern älter als 85 Jahre bei ca. 3,5%. Bei einer durchschnittlichen Lebenserwartung von mehr als vier Jahren ist auch in dieser Altersgruppe der Einsatz einer kurativen Strahlentherapie sinnvoll. Außerdem deuten verschiedene retrospektive Studien darauf hin, daß die Raten an lokaler Tumorkontrolle und krankheitsspezifischem Überleben nach Strahlentherapie mit denen jüngerer Patienten vergleichbar sind. Eine Ausnahme bilden unter anderem ältere Patienten mit Gliomen Grad III bis IV und mit Rektumkarzinom, die ein schlechteres Überleben aufweisen. Dieses ist eventuell auf eine weniger aggressive Kombinationstherapie (Tumorresektion) zurückzuführen.
Obwohl strahlen- und molekularbiologische Daten auf einen Anstieg der Strahlenempfindlichkeit mit zunehmendem Alter hinweisen, wie zum Beispiel das Nachlassen der Kapazität verschiedener DNA-Reparatur-Enzymsysteme, bestätigen Tierexperimente sowie retrospektive klinische Studien an bestrahlten Patienten dies nur partiell. Drei größere Untersuchungen zur Toxizität prospektiver EORTC-Studienprotokolle zeigen für einige Organsysteme altersabhängige Unterschiede in der Häufigkeit und Schwere der Nebenwirkungen: Ältere Patienten mit Strahlenbehandlung der Kopf-Hals-Region leiden häufiger an funktioneller (subjektiv erlebter) Mukositis. Im Falle einer thorakalen Bestrahlung weisen sie einen höheren Gewichtsverlust und eine erhöhte Rate an Spätschäden des Ösophagus auf. Nach Bestrahlung im Beckenbereich tritt bei Älteren häufiger eine sexuelle Dysfunktion auf, während bei Jüngeren akute Nebenwirkungen, wie Hautschäden, Übelkeit und Verschlechterung des Allgemeinzustands, überwiegen. Bei der Wahl der Intensität einer Strahlentherapie sind langjährige Erkrankungen, die zu ausgeprägten arteriosklerotischen Gefäßveränderungen führen können, zu berücksichtigen. Aufgrund der schlechten Kompensation einer möglichen Entgleisung des Elektrolyt- und Flüssigkeitshaushalts ist eine engmaschige Überwachung der Strahlentherapie älterer Patienten erforderlich.
Schlußfolgerung
Die Indikation zur Bestrahlung älterer Krebspatienten sollte in Abhängigkeit von Allgemeinzustand und Begleiterkrankungen getroffen werden. Das chronologische Alter an sich ist selten eine Kontraindikation zur Bestrahlung. Eine Dosisreduktion speziell bei kurativen Konzepten allein wegen des Alters erscheint nicht gerechtfertigt. Radiation Therapy in Old Patients. Side Effects and Results of Radiation Therapy in Old Patients
Abstract
Background
Despite a growing number of elderly patients receiving radiation therapy little is known about side effects and outcome of irradiation in this section of the population.
Methods
In a review article epidemiologic data, aspects of radiation-biology as well as side effects and outcome of radiation therapy of elderly patients are discussed.
Results
Cancer incidence rises with age (Figure 1) and is exceeding 3.5% for males older than 85 years. With a life expectancy of more than 4 years, curative therapy is indicated even at this age. Furthermore several retrospective studies indicate that local control and disease-Specific survival after radiation therapy of elderly patients is comparable with that of younger persons (Tables 3 and 4). The exception contains elderly patients with Grade-III to IV gliomas or with rectal carcinoma who show a reduced survival which is perhaps caused by less aggressive combined treatment (tumor resection).
Although some biological and molecular data indicate a rise in radiation sensitivity with growing age like the reduction of the capacity of some DNA-repair enzymes, there is no convincing evidence in animal studies or in retrospective clinical studies that radiation therapy is generally less well tolerated by older individuals (Tables 1 and 2). Some age-depending differences in organ toxicities are described in 3 large studies, which evaluate the data of patients who were enrolled in different EORTC-trials: Older patients suffer more of functional mucositis in case of radiation therapy to the head and neck, they have an increased weight loss and a higher frequency of late esophageal damage when irradiated in the thorax, and they show a higher prevalence of sexual dysfunction when treated with radiation therapy to the pelvis. On the other hand younger patients suffer more from acute toxicity like skin damage, nausea, and deterioration of the performance status during pelvic radiotherapy.
When discussing the dose intensity of radiation therapy concomitant disease which leads to extensive atherosclerotic vessel damage should be kept in mind. Old patients should be monitored closely during therapy, since the loss of electrolytes or fluid is often not very well tolerated.
Conclusion
The indication to radiation therapy of elderly cancer patients should take into account their performance status as well as the extent and the severity of comorbidity. Age per se is seldom a contraindication for radiation therapy. Regarding the available data in literature there is no indication for a dose reduction in radiation therapy only because of age, especially in the curative setting.
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Geinitz, H., Zimmermann, F.B. & Molls, M. Strahlentherapie des alten patienten. Strahlentherapie und Onkologie 175, 119–127 (1999). https://doi.org/10.1007/BF02742345
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DOI: https://doi.org/10.1007/BF02742345