Japanese Journal of Clinical Oncology

Characteristics of the Patients

Fifty-seven records of nonagenarian cancer patients were collected, representing 0.24% of all patients treated at the institutions (57/23 752). The age ranged from 90 to 98 years (median: 91) and the ratio of male to female was 16:41, with a strong female preponderance. There were 42 patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0-2 and 15 with PS 3 and 4 (Table 1).

Table 1. Characteristics of the surveyed patients

Rate of nonagenarians	0.24% (57/23 752)
Age range (years)	90-98 (median 91)
Gender: female:male	41:16
ECOG performance status before treatment: PS 0-2:PS 3,4	42:15
Histopathology:
Squamous cell carcinoma	34
Adenocarcinomas	8
Non-Hodgkin's lymphomas	3

Table 2. Distribution of the patients by site

Head and neck*	16
Skin and adnexae	11
Uterine cervix	7
Esophagus	6
Others[dagger]	17
Total	57

*Oral cavity, 10; pharynx (oro-/hypo-), 2; larynx, 1; ethmoid sinus, 1; thyroid, 1; parotid, 1. ^[dagger]Breast, 3; lymphomas, 3; gallbladder/bile duct, 3; bladder, 2; brain tumor, 1; soft tissue sarcoma, 1; eyelid, 1; stomach, 1; vulva, 1, bone tumor, 1.

The distribution by primary site of the disease is listed in Table 2. Head and neck cancer comes first, followed by cancer of the skin and adnexae. The prevailing histopathological diagnosis was squamous cell carcinoma (34 patients), followed by adenocarcinomas (8), as shown in Table 1.

The highest age of the patients at radiotherapy was 98 years [female, skin cancer, squamous cell carcinoma, died of senility with no evidence of the disease (NED) 2 years after treatment) and the longest survivor is 102 years old (female, glottic cancer, T2N0, age at radiotherapy 93 years, alive with NED for 8 years]. A 93-year-old female patient finally succumbed to her fifth cancer (the gums) 2 years 2 months after treatment, after surviving cancers of the rectum, tongue, anus and buccal mucosa. There were four other patients who had undergone treatment for malignancies previously, i.e., colon cancer in two patients, prostate cancer in one patient and lip cancer in one patient.

Comorbidity and Mental Status

The comorbidity associated with the cancers is as follows: ischemic or arrhythmic cardiac disease was found in 12 patients, hypertension in nine, cerebral vascular disease in seven, diabetes mellitus in two, chronic lung disease in two and others (Table 3). Hearing loss was noted in 10 patients; however, it did not seem to affect mental deterioration in eight patients. Other physical handicaps associated with the patients were wheelchair status (3) and bedridden status after fracture of the femur neck (1).

In addition to disorientation due to severe dementia in eight patients, the understanding of the disease and treatment by the patients was poor in nine other patients because of hearing loss, mild dementia and obstinacy (hesitancy) prior to the treatment. Most of the other patients did not consider their disease to be severe or fatal.

Radiotherapy

The strategy of RT was individually planned, depending on the stage and performance status of the patient; however, it was not modified based solely on age. The technique of radiotherapy was not altered because of age; however, in most of the patients the treatment field was intended to be limited to the primary site only and the dose per fraction and the total dose delivered were the least possible, to obtain palliation as the first aim, followed by radical cure of the local disease. A split course was effectively adopted at times, when necessary. No patient received radiotherapy as a combination with chemotherapy.

The rate of completion of treatment was 75% (43/57), if the treatment field was limited to the primary gross tumor volume only and if the cumulative dose was above 80% of the tolerable adult dose.

Specific Disease Sites

There were 16 patients with head and neck cancer, with squamous cell carcinoma in 14. The most common disease site was the oral cavity in 10 patients, followed by the pharynx in two, ethmoid sinus in one, larynx in one, thyroid in one and the parotid in one. The mucosal reaction was generally more severe than in younger adulthood, but they tolerated acute reactions fairly well. The treatment was completed in most of the patients; however, in two patients the treatment was stopped earlier in the treatment course, in one owing to her strong wish to return home and in the other owing to the motion of the patient during his treatment. Split treatment was adopted with three patients, owing to the severe mucosal reaction. For those in whom the treatment was not completed, the dose delivered ranged from 8 to 34 Gy in total. For those in whom the treatment was completed, the dose delivered ranged from 56 to 78 Gy, according to the specific tumor site. Good palliation was obtained in most of the patients as the achievement of the main aim; however, in nine patients the tumor recurred or regrew after considerable intervals. Complete response was obtained in four patients with cancer of the tongue, lower gum, soft palate and larynx. Eleven of 12 patients with head and neck cancers with PS of 0-2 completed RT, whereas two of four with PS of 3 and 4 completed RT.

Table 3. Status of comorbidity and mental status

Comorbidity
Cardiovascular	21
Cerebrovascular	7
Diabetes mellitus	2
Chronic lung disease	2
Mental status
Dementia	8
Poor understanding	9

The second prevailing cancer was cancer of the skin and adnexae, including hemangiosarcomas. In seven patients the skin cancer arose in the face, pinna, scalp and hand and treatment was necessary. Surgery was abandoned because of their age and radiotherapy was selected. The dose ranged from 32.5 Gy/5 fractions to 76 Gy/38 fractions with electrons. Nine out of nine patients showed complete response by external RT. The hemangiosarcoma was difficult to control, but good palliation was obtained with RT, with cessation of bleeding in two patients. Both of the patients with hemangiosarcoma died of metastatic lung disease. All the patients with cancers of the skin and adnexae, 10 with PS of 0-2 and one with PS of 3, eventually completed RT.

For the patients with uterine cervix cancer, the distribution by stage was 1B through 2B (3 patients) and 3B (4). The standard external and intracavitary radiotherapy was sufficiently completed in two patients. The doses delivered were 39.6-45 Gy by a fraction dose of 1.8 Gy by external radiotherapy and 31 Gy/4 fractions to 15 Gy/3 fractions at point A by intracavitary radiotherapy. However, four other patients received either high dose rate intracavitary (IC) radiotherapy only (owing to an outpatient basis and because of the fear of adverse reactions about which they had been informed prior to the treatment) in two (dose to point A: 20 Gy/5 fractions to 30 Gy/5 fractions), or external radiotherapy alone (because of their strong hesitancy towards IC treatment) in the other two (the dose ranged from 58.6 to 60 Gy). In one patient the reaction of the intestine was so severe that the treatment had to be abandoned at a dose of 12.6 Gy. Two of four patients with uterine cervix cancer with PS of 0-2 completed RT, whereas none of three with PS of 3 and 4 completed RT.

In many patients with cancer of the esophagus the aim of the treatment was the alleviation of dysphagia. The aim was achieved in four patients, even after the delivery of a radical dose of 55.2-70 Gy in 5-7 weeks. One patient abandoned the treatment at a dose of 41 Gy because of no response and another one with his family desired to return home because of no improvement of the symptoms after delivery of a full dose of 60 Gy. Even for the patients who completed the treatment, the median survival was 6 months and the longest 1 year 2 months. One of two patients with cancer of the esophagus with PS of 0-2 completed RT, whereas four of four with PS of 3 and 4 completed RT.

Other sites included in this survey were breast cancer in three patients, lymphomas in three, gallbladder/bile duct cancer in three, urinary bladder cancer in two and brain tumor, soft tissue sarcoma, eyelid cancer, stomach cancer, vulva cancer and bone tumor each in one patient. In most of the patients the primary aim of the treatment was the relief of persistent pain by treating the primary site. Ten of 14 patients with cancer of other sites with PS of 0-2 completed RT, whereas one of three with PS of 3 and 4 completed RT. However, in all three patients with cancer of the gallbladder/bile duct the RT dose delivered was far less than intended.

Prognostic Outcome

Follow-up of the patients could be done with most of the patients, but there were five patients for whom we could not make direct contact within 1 year, because of the movement of their family, and two others for whom the cause of death was not determined as being due to their tumor or to another cause.

Of the 42 patients with PS 0-2, 10 were alive at the time of last follow-up, 21 patients died of malignant disease or unknown cause and 11 died of intercurrent disease including senility. Of the six patients who survived more than 4 years, five have been alive and well and only one died of the tumor, 7 years after the treatment. Of 15 patients with PS 3 and 4, 13 died of malignant disease or unknown cause, whereas two died of intercurrent disease. The median survival time for 42 patients with PS 0-2 was 1 year and 10 months and that for 15 patients with PS 3 and 4 was only 6 months (Table 4).

Social Issues

Currently in Japan, the care of the elderly has been supported mainly by their families. In most of the patients an escort was invariably provided by their families, whether they were willing or not. Only one patient was admitted from a nursing home. The treatment was conducted mainly on an outpatient basis or with frequent hospital visits by their family, to adapt to the mental and physical status of the patients and familial situations. A granddaughter escorted her grandmother because the patient's son or daughter had died beforehand.

Table 4. Prognosis

ECOG PS 0-2	42 patients
Alive	10
Died of disease	21
Died of intercurrent disease	11
Median survival time	22 months
ECOG PS 3,4	15 patients
Died of disease	13
Died of intercurrent disease	2
Median survival time	6 months

Table 5. Proportion of nonagenarian patients among the whole group at each institution, 1990-95

Institute	No. of new patients	No. of nonagenarian patients (%)
A	1300	6 (0.46%)
B	2593	10 (0.39)
C	1274	5 (0.39)
D	6191	23 (0.37)
E	2652	4 (0.15)
F	1373	2 (0.15)
G	4513	2 (0.11)
H	3856	2 (0.05)
Total	23762	57 (0.24)