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Cancer in patients of and above 90 years: A hospital-based retrospective study


1 Department of Gynecologic Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Pathology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
3 Departments of Population-based Cancer Registry (Kamrup-Urban), Dr. B Borooah Cancer Institute, Guwahati, Assam, India
4 Hospital-Based Cancer Registry, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
5 Department of Radiation Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
6 Department of Cancer Epidemiology and Biostatistics, Dr. B Borooah Cancer Institute, Guwahati, Assam, India

Correspondence Address:
Manigreeva Krishnatreya,
Room 2, OPD Building, Department of Cancer Epidemiology and Biostatistics, Dr. B Borooah Cancer Institute, Guwahati - 781 016, Assam
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_28_18

 > Abstract 


Background and Objective: Cancers in a nonagenarian patient are rarely seen, and there is always a moral dilemma for the family members and patient of whether to opt for the treatment or not. The main objective was to identify the survival differences between treated and not treated nonagenarian cancer patients.
Materials and Methods: This was a retrospective study of Hospital-Based Cancer Registry data from 2010 to 2016. The data of all nonagenarian cancer patients were analyzed for gender distribution, leading sites of cancer, stage distribution, types of treatment received, and survival. The survival was calculated from the date of the first diagnosis. Kaplan–Meier analysis was done to present the survival.
Results: Of 60,087 patients, 146 (0.2%) patients were of 90 years and above. Hypopharynx in males (20.5%) and tongue (20.5%) in females were the top cancer sites, 60% patient data were in Stages III and IV, 37 (25.3%) patients received treatment, and 86% patients were treated by radiotherapy. The overall survival (OS) was 14.3%. OS in the treatment group was 21.3% versus 7.7% (P = 0.001) in the no treatment group. The unadjusted hazard ratio for no treatment group was 3.8 (P = 0.003, confidence interval = 1.5–9.7).
Conclusion: Selected nonagenarian cancer patients from our population with a good performance status should receive curative treatments in all possible ways.

Keywords: Cancer pattern, nonagenarian, survival, treatment



How to cite this URL:
Kataki AC, Sharma JD, Kalita M, Baishya N, Bhattacharyya M, Krishnatreya M. Cancer in patients of and above 90 years: A hospital-based retrospective study. J Can Res Ther [Epub ahead of print] [cited 2019 Sep 15]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=264693




 > Introduction Top


With increase in life expectancy and use of prolonged medications for chronic diseases leading to improvement of health, the number of elderly cancer patients is rising. Nonagenarians are individuals over 90 years of age and most nonagenarians are the frail population of our society. Recent study on nonagenarians patients with prostate cancer showed major causes of mortality was due to noncancer causes.[1] Although rarely seen in day-to-day clinical patient setup, very little information is available to guide the oncologists in going forward with a firm decision for treatment of cancer patients above 90 years of age. Furthermore, a study has shown that minority of treated cancer patients above 90 years will derive long-term benefit.[2] Thus, oncologists should identify “fit” patients who can receive the same treatment as that offered to young patients, also identify “vulnerable” patients who need a tailored treatment, and finally identify “frail” patients who will probably not tolerate a radical therapy proper to their diseases.[3] The objective of this article was to identify the various types and pattern of care and survival in nonagenarian cancer patients treated or not in our settings.


 > Materials and Methods Top


We retrospectively analyzed the Hospital-Based Cancer Registry (HBCR) data of a tertiary care cancer center as part of the ongoing pattern of care and survival study. The pattern of care and survival study has been approved by the Institutional Ethics Committee of the institute. Patients registered from January 1, 2010 to December 31, 2016 (7 years) were included for the analysis. The data of nonagenarian cancer patients were identified. The data of all nonagenarian cancer patients were analyzed for gender distribution, leading sites of cancer, stage distribution, types of treatment received, and survival. The survival was calculated from the date of the first diagnosis. The survival was compared between the group that has received treatment versus not received, abandoned, and incomplete (NRAI) treatment group. Not received group refers to patients who have not received any form of cancer-directed treatment. Abandoned group refers to patients who were advised treatment, but the treatment was not accepted. Incomplete group of patients were those who did not tolerate the full course of treatment or optimum dosage of radiotherapy due to side effects of the treatment and noncompliance to the treatment. The treatment received group comprised nonagenarian cancer patients who have had received curative treatment only. Patients who received palliative or only symptomatic treatment were categorized in the not received group. The hazard ratio (HR) was estimated for the NRAI treatment group in comparison to the group of patients who have had received treatment.

Patient follow-up

The follow-up for survival was an active one that included searching of case records, hospital mortality/death records, and telephonic follow-up. For this present study, other methods of active follow-up such as sending self-addressed postal cards and home visit to patient addresses were not carried out. The data of patients where vital status information such as of death and alive were not available in the data set, these patients were considered as censored at variable length of time, and the censored date was the day of the last hospital visit as noted in the patient's hospital cases records. Furthermore, patients who have had survived for longer than 5 years were censored at 60 months. The closing date of follow-up was August 31, 2017.

Statistical analysis

Descriptive statistics was used to present the results and presented up to the single decimal place. Kaplan–Meier analysis was done to present the overall survival (OS) results, and Cox regression analysis was done to estimate the unadjusted HR. P value for significance was set at <0.05. SPSS v17.0 (IBM Inc, Chicago, Illinois) was used for carrying out the analysis.


 > Results Top


A total of 60,087 patients were registered during the study period, and 146 (0.2%) patients were of 90 years and above. One hundred and seven (73.3%) and 39 (26.7%) patients were male and female, respectively. In males, hypopharynx in 19 (20.5%), lungs in 11 (10.3%), and esophagus in 9 (8.4%) patients were top three leading sites [Figure 1]a, and in females, tongue in 8 (20.5%), mouth in 5 (12.8%), and hypopharynx in 4 (10.3%) patients were the top leading sites [Figure 1]b. [Figure 2] shows the top ten leading sites of cancer in males and females in all age groups as per our registry data for the year 2015.
Figure 1: (a) The bar diagram shows the top 5 leading sites in males, (b) it shows the top 5 leading sites of cancer in females

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Figure 2: It shows the top ten leading sites of cancer in all age groups in the relative proportion

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Stage distribution was as follows: Stage I in 1 (0.7%), Stage II in 25 (17.1%), Stage III in 44 (30.15), and Stage IV presentation was seen in 44 (301%) patients. Staging information was absent in 32 (21.9%) nonagenarian patient data. Thirty-seven (25.3%) patients received treatment, of which, 32 (86.4%) received radiotherapy alone. Five patients (13.5%) received combined modality of treatment. Two (5.4%) patients each received chemotherapy alone and surgery followed by radiotherapy for their cancer. Only 1 (2.5%) patient received concurrent chemoradiotherapy.

The year-wise number, proportion of patients followed up, median follow-up period, and vital status of nonagenarian cancer patient are shown in [Table 1]. On an average 27.1% of nonagenarian patients in our study, cohort could be successfully followed up for their vital status. Majority were censored at variable length of time from the date of the first diagnosis. Thirty-seven patients were only included for the survival analysis, of which 24 (64.8%) patients were from the treated group and 13 (11.9%) patients from the NRAI group. A total of 11 (29.7%) patients were alive or censored at variable length of time as shown in [Table 2]. One (9.0%) patient was censored at 60 months in the closing period of follow-up.
Table 1: The year-wise distribution of nonagenarian cancer patients

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Table 2: The follow-up details of alive or censored patients

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The median survival was 9 months (confidence interval [CI] = 4.5–13.4). The OS was 14.3% [Figure 3], and the OS in the treatment group was 21.3% versus 7.7% in the NRAI group (Log Rank [Mantel–Cox], P = 0.001) [Figure 4]. The unadjusted HR for NRAI group was 3.8 (P = 0.003, CI = 1.5–9.7).
Figure 3: Kaplan–Meier curve showing the overall survival probability of the nonagenarian cancer patients

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Figure 4: It shows the differences in the overall survival are not received, abandoned, and incomplete (no) group versus treatment received (yes) group

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 > Discussion Top


In our setting, 0.2% of all cancer patients were nonagenarians. This is similar to one report from Japan (0.24%),[4] where the life expectancy is higher than our population. The gender and site distribution of cancers in nonagenarian varies significantly in comparison to cancer patients in the other age groups in our setting [5] and can be also seen in [Figure 2]. In differing population, gender distribution of nonagenarian cancer patients would vary. As in our study, there was male predominance compared to a study from the US.[2] The choice of treatment in this group of patients should be based primarily on the expected symptomatic benefit, and treatment should not compromise the quality of life.[6] In our study, radiotherapy was the single most important treatment modality in nonagenarian patients treated in our setting. Furthermore, of 146 patients, only 25% patients did receive treatment or completed treatment in our study. The role of geriatrician in the decision making of the oncologist has been highlighted.[7] However, in our settings, the clinical decisions are being made by the concerned oncology specialist. In our study, leading sites of cancer in both males and females were head-and-neck cancers, more so in females. This highlights the fact that there is a reduction of hormonal influence of female-centric cancers such as breasts and ovary in nonagenarian. Interesting to note was the absence of prostate cancer among males in the top five leading sites. In females of the studied population, incidence of gallbladder cancer is very high.[5] However, it was absent among the top five leading sites in females, also suggesting the decline of the influence of hormone.

The World Health Organization performance status grading of a patient is an important guide for oncologist on deciding the type of treatment, especially when it comes to deciding treatment for a nonagenarian cancer patient. The pattern of types of treatment instituted for nonagenarian cancer patients seen from this study underscores the importance of radiotherapy in the treatment of this group of patients in our setting. In our study, the median survival was 9 months; this is much lower than that of developed settings which was as high as 4.8 years.[2] This could be attributed to the facts that 60% or majority of patient with staging information in the data set were in advanced stages (Stage III and Stage IV). The 5-year survival of nonagenarians in the Surveillance Epidemiology End Results registry was 12%.[8] In our study, the OS was around 14%. However, the 5-year survival from this study would be lower, as we estimated the cumulative OS of patients diagnosed from 2010 to 2016 and not followed all the patients for the full 5 years. Furthermore, follow-up information was present in only 25% of nonagenarian cancer patients in our study and was included in the survival analysis. There was a significant improvement in the OS in patients who have had received treatment in comparison to the NRAI group (21.3% versus 7.7%, P < 0.005). Furthermore, our study had shown a significant risk of dying in the NRAI group, which was almost four times.

Limitation of the study

As a tertiary cancer center, the nonagenarian patients in our study were selected referred patients from our population, and in all likely hoods, the nonagenarian cancer patients who were frail and with extremely poor general health did not turn up for diagnosis and treatment, and thus this study does not reflect the actual population scenario and only reflects an institutional scenario. In the NRAI group, in the not received category, patients included were of poor general health and who could not tolerate the treatments, and this might have also naturally lowered the survival in the NRAI group. Another limitation of the present study is that reasons for treatment abandonment in the NRAI group, the reasons for not offering treatment by oncologists, and data on the toxicity of radiation were not available in the dataset of HBCR.


 > Conclusion Top


This analysis gives us some insight into the various types of cancer in the very old patients in our setting. Selected nonagenarian cancer patients from our population with a favorable performance status should receive curative treatments in all possible ways. The improved OS and lower risk of death in nonagenarian cancer patients who received treatment in comparison to the NRAI group should be aware the oncologist of the weighted benefits of curative treatment instead of plain palliation.

Acknowledgment

The authors thank the National Centre for Disease Informatics and Research under the Indian Council of Medical Research for funding the task force project “Hospital-Based Cancer Registry at Dr. Bhubaneswar Borooah Cancer Institute.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Dell'Oglio P, Bishr M, Boehm K, Trudeau V, Larcher A, Tian Z, et al. Survival outcomes in octogenarian and nonagenarian patients treated with first-line androgen deprivation therapy for organ-confined prostate cancer. Eur Urol Focus 2017. pii: S2405-4569(17)30026-3.  Back to cited text no. 1
    
2.
Extermann M, Crane EJ, Boulware D. Cancer in nonagenarians: Profile, treatments and outcomes. Crit Rev Oncol Hematol 2010;75:160-4.  Back to cited text no. 2
    
3.
Li Destri G, Cavallaro M, Trovato MA, Ferlito F, Castaing M, Puleo S. Colorectal cancer treatment and follow-up in the elderly: An inexplicably different approach. Int Surg 2012;97:219-23.  Back to cited text no. 3
    
4.
Ikeda H, Ishikura S, Oguchi M, Niibe H, Yorozu A, Nakano K, et al. Analysis of 57 nonagenarian cancer patients treated by radical radiotherapy: A survey of eight institutions. Jpn J Clin Oncol 1999;29:378-81.  Back to cited text no. 4
    
5.
Indian Council of Medical Research. Consolidated Report of Hospital Based Cancer Registries 2012-14. National Cancer Registry Programme. Bengaluru: Indian Council of Medical Research; 2015.  Back to cited text no. 5
    
6.
Rivoirard R, Chargari C, Kullab S, Trone JC, Langrand-Escure J, Moriceau G, et al. Chemotherapy regimen in nonagenarian cancer patients: A Bi-institutional experience. Chemotherapy 2016;61:65-71.  Back to cited text no. 6
    
7.
Rambaud C, Boulahssass R, Gonfrier S, Sanchez M, Borchiellini D, Durand M, et al. The nonagenarian patients with cancer in the UCOG PACA-EST cohort. Innov Aging 2017;1:269-70.  Back to cited text no. 7
    
8.
Saltzstein SL, Behling CA. 5- and 10-year survival in cancer patients aged 90 and older: A study of 37,318 patients from SEER. J Surg Oncol 2002;81:113-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

 
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