10.14639/0392-100X-N0618
Objective. Over the years, evidence-based data and technical improvements have consolidated the central role of radiation therapy (RT) in head and neck cancer (HNC) treatment, even in the elderly. This survey aimed to describe the management of the elderly HNC patients among Italian Radiation Oncology Departments (RODs) and provide possible suggestions for improvement. Methods. An online survey based on 43 questions was sent to RODs via email. For each RODs, a radiation oncologist with expertise in HNC was invited to answer questions addressing his/her demographic data, ROD multidisciplinary unit (MU) organisation and ROD management policy in elderly HNC patients. Results. In total, 68 RODs answered, representing centres located in 16 Italian regions. MU was considered the core of HNC patient management in almost all the entire country. However, in many RODs, there was minimal access to a routinely comprehensive geriatric assessment at diagnosis. Most treatments were reported by respondents as curative (89% on average) and the preferred treatment technique was intensity modulated radiation therapy (IMRT). A considerable variation between RODs was found for RT target volumes. There was a relation between the specialist’s years of experience and type of concomitant systemic therapy prescribed. Conclusions. Substantial differences in elderly HNC management have been found, especially concerning patient clinical evaluation and target volume delineation. This survey shows the necessity to design a prospective national trial to provide a uniform treatment strategy and define an effective patient-centred approach.
application/xml
1827-675X
618
6
en
Fabiola Paiar
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
combined treatment
Results of a survey on elderly head and neck cancer patients on behalf of the Italian Association of Radiotherapy and Clinical Oncology (AIRO)
Text.Serial.Journal
https://www.actaitalica.it/
40
Head and neck
2021-01-21
2020-01-19
2021-01-21
2021-01-21
1
Fabiola Paiar
2020
10.14639/0392-100X-N0618
Department of Radiation Oncology, University Hospital of Pisa, Italy
1827-675X
6
combined treatment
Results of a survey on elderly head and neck cancer patients on behalf of the Italian Association of Radiotherapy and Clinical Oncology (AIRO)
https://www.actaitalica.it/article/download/618/491
40
ACTA OTORHINOLARYNGOLOGICA ITALICA 2020;40:405-409; doi: 10.14639/0392-100X-N0618




Head and neck


Results of a survey on elderly head and neck cancer
patients on behalf of the Italian Association
of Radiotherapy and Clinical Oncology (AIRO)
Risultati di una survey su pazienti anziani con tumore testa collo – a nome
dell’Associazione Italiana di Radioterapia e Oncologia Clinica (AIRO)
Liliana Belgioia1,2, Francesca De Felice3, Almalina Bacigalupo2, Daniela Alterio4, Angela Argenone5, Elisa D’Angelo6,
Isacco Desideri7, Pier Francesco Franco8, Anna Merlotti9, Daniela Musio3, Ester Orlandi10, Stefano Ursino11, Fabiola Paiar11
1
  Health Science Department (DISSAL), University of Genoa, Italy; 2 Radiation Oncology Department, Policlinico San Martino Hospital,
Genoa, Italy; 3 Department of Radiotherapy, Policlinico Umberto I, “Sapienza” University of Rome , Italy; 4 Division of Radiation Oncology,
IEO, European Institute of Oncology IRCCS, Milan, Italy; 5 Radiation Oncology Unit, A.O.R.N. San Pio Benevento, Italy; 6 Radiation
Oncology Unit, University Hospital of Modena, Italy; 7 Azienda Ospedaliera Universitaria Careggi, Radiotherapy Unit, Oncology
Department, University of Florence, Italy; 8 Department of Oncology, Radiation Oncology, School of Medicine, University of Turin, Italy;
9
  Department of Radiation Oncology, S. Croce and Carle Teaching Hospital, Cuneo, Italy; 10 Radiotherapy 2 Unit, Fondazione IRCCS
Istituto Nazionale dei Tumori, Milan, Italy; 11 Department of Radiation Oncology, University Hospital of Pisa, Italy


SUMMARY
Objective. Over the years, evidence-based data and technical improvements have consolidated
the central role of radiation therapy (RT) in head and neck cancer (HNC) treatment, even in the
                                                                                                  Received: January 19, 2020
elderly. This survey aimed to describe the management of the elderly HNC patients among Italian
                                                                                                  Accepted: August 29, 2020
Radiation Oncology Departments (RODs) and provide possible suggestions for improvement.
Methods. An online survey based on 43 questions was sent to RODs via email. For each
                                                                                                  Correspondence
RODs, a radiation oncologist with expertise in HNC was invited to answer questions ad-            Liliana Belgioia
dressing his/her demographic data, ROD multidisciplinary unit (MU) organisation and               Health Science Department (DISSAL), University
ROD management policy in elderly HNC patients.                                                    of Genoa, via Pastore 1, 16132 Genova, Italy
Results. In total, 68 RODs answered, representing centres located in 16 Italian regions. MU       Tel. +39 010 5558050
was considered the core of HNC patient management in almost all the entire country. However,      E-mail: liliana.belgioia@unige.it
in many RODs, there was minimal access to a routinely comprehensive geriatric assessment at
diagnosis. Most treatments were reported by respondents as curative (89% on average) and the      Funding
preferred treatment technique was intensity modulated radiation therapy (IMRT). A consider-       None.
able variation between RODs was found for RT target volumes. There was a relation between
the specialist’s years of experience and type of concomitant systemic therapy prescribed.         Conflict of interest
                                                                                                  The Authors declare no conflict of interest.
Conclusions. Substantial differences in elderly HNC management have been found, es-
pecially concerning patient clinical evaluation and target volume delineation. This survey
shows the necessity to design a prospective national trial to provide a uniform treatment           How to cite this article: Belgioia L, De Felice
strategy and define an effective patient-centred approach.                                          F, Bacigalupo A, et al. Results of a survey on
                                                                                                    elderly head and neck cancer patients on be-
KEY WORDS: elderly patients, head and neck cancer, radiotherapy, combined treatment                 half of the Italian Association of Radiotherapy
                                                                                                    and Clinical Oncology (AIRO). Acta Otorhi-
                                                                                                    nolaryngol Ital 2020;40:405-409. https://doi.
RIASSUNTO                                                                                           org/10.14639/0392-100X-N0618
Obiettivo. Il ruolo della radioterapia nel trattamento dei tumori testa collo è ormai con-
solidato anche per i pazienti anziani. Lo scopo di questa survey è quello di descrivere la        © Società Italiana di Otorinolaringoiatria
gestione del paziente anziano con tumore testa collo tra i centri di radioterapia italiani e      e Chirurgia Cervico-Facciale
fornire possibili suggerimenti di miglioramento.
Metodi. Una survey online basata su 43 domande è stata inviata ai vari centri via mail. Per                      OPEN ACCESS
ciascun centro un radioterapista oncologo (RO) esperto nel trattamento di questi tumori è stato   This is an open access article distributed in accordance with
invitato a rispondere a domande riguardanti i suoi dati demografici, l’organizzazione del team    the CC-BY-NC-ND (Creative Commons Attribution-Non-
multidisciplinare (TM) del centro e la gestione del paziente anziano con tumore testa collo.      Commercial-NoDerivatives 4.0 International) license. The
                                                                                                  article can be used by giving appropriate credit and mentio-
Risultati. In totale hanno risposto 68 RO, rappresentanti centri situati in 16 regioni italia-
                                                                                                  ning the license, but only for non-commercial purposes and
ne. Il TM è stato considerato il nucleo della gestione dei pazienti con tumore testa collo in     only in the original version. For further information: https://
quasi tutto il paese. In molti centri c’era un accesso ridotto a una routinaria valutazione       creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                          405
L. Belgioia et al.




geriatrica multidimensionale. La maggior parte dei trattamenti (89%) aveva intento curativo e la radioterapia a intensità modulata (IMRT) era
la tecnica di trattamento di scelta. È stata rilevata una notevole variazione tra i vari centri circa la scelta dei volumi target e una correlazione
tra gli anni di esperienza dello specialista e il tipo di terapia sistemica concomitante prescritta.
Conclusioni. Sono state riscontrate differenze sostanziali nella gestione del paziente anziano con tumore testa collo, in particolare per quanto
riguarda la valutazione clinica del paziente e la delineazione del volume target. Questa survey mostra la necessità di progettare una sperimen-
tazione nazionale prospettica per omogeneizzare la strategia di trattamento e definire un approccio efficace incentrato sul paziente.
PAROLE CHIAVE: pazienti anziani, tumore della testa collo, radioterapia, trattamenti combinati



Introduction                                                                Survey Monkey platform (www.SurveyMonkey.com). The
                                                                            survey was open from February to April 2018.
Head and neck cancer (HNC) is the sixth most frequent ma-
                                                                            Italian RODs were invited to participate via e-mail with an
lignancy worldwide 1. Despite an increase in the incidence
                                                                            introduction letter using the AIRO mailing list and to delegate
of human papilloma virus (HPV)-related cancer in younger
                                                                            survey compilation to a radiation oncologist with expertise
patients, HNC can still be considered pertinent to an elderly
population 1,2. Current data estimate that more than 60% of all             in HNC. Each radiation oncologist was allowed to answer
new HNC diagnoses occur in patients aged over 65 years 2.                   the survey only once. Data were referred to the HNC patient
Whether a standard treatment approach, especially in locally                population treated during the year 2017 in each department.
advanced cases, is applicable to an elderly population rep-
resents a crucial issue. It has been reported that patient age              Survey description
affects the benefits of chemotherapy in this setting 3,4. The up-           A panel of experts of the AIRO Head and Neck working
date of the meta-analysis of chemotherapy in head and neck                  group designed a 43 item-based self-produced question-
cancer (MACH-NC) showed that the benefit of concomitant                     naire. The 43 items were defined over a multi-step process
chemotherapy was lower in older patients, and, similarly,                   and subsequently validated by the AIRO Head and Neck
there was a decreasing effect of bio-radiotherapy (RT) with                 working group. The items were grouped in four sections,
age in a subgroup analysis of the Bonner’s study 3,4. Neverthe-             including i) ROD and equipment general information,
less, these studies were not sufficiently powered for this sub-             ii) multidisciplinary team characteristics, iii) management
group analysis and, generally, elderly patients were grossly                of elderly (defined as over 70 years) HNC patients treated
underrepresented in clinical trials, accounting for < 5% of en-             with curative intent, iv) management of elderly HNC pa-
rolled cases. The worse clinical outcomes observed in elderly               tients treated with palliative intent. Geriatric assessment
patients are mainly due to patient-related factors, such as                 (screening tools) and treatment data (total dose, dose per
general conditions, cognitive status and comorbidity. Conse-                fraction, target volume, technique, regimens of concomi-
quently, these patients are at a higher risk to develop toxicity            tant systemic therapy) were collected.
leading to the delivery of suboptimal treatments 5. In recent               Statistical analysis. All values – numbers, percentages and
years, geriatric evaluation and categorisation have gained im-              estimates – presented in the results are derived from sur-
portance in order to define the most appropriate management.                vey data that are prone to sampling limitations. The values
Several screening tools – geriatric 8 (G8), mini-cog, adult                 met the criteria for statistical reliability. Values that did not
comorbidity evaluation-27 (ACE-27), Charlson comorbidity                    meet reliability criteria were suppressed. Descriptive anal-
index (CCI), vulnerable elders survey (VES-13) – have been                  ysis focused on percentages, since they take into account
developed to stratify elderly patients into those who would                 any changes in the size of the total cohort and facilitate the
tolerate standard therapy and those who would be at an in-                  comparison of values across variables.
creased risk of suffering severe toxicity 5. However, defini-
                                                                            To identify relatively homogeneous groups based on select-
tive data on impact of these tools for selected frail patients in
                                                                            ed characteristics such as years of experience in HNC field,
clinical practice are still scarce.
                                                                            number of HNC treatment per year in ROD, type of chemo-
The purpose of the present national survey was to analyse
                                                                            therapy and RT treatment volumes, we used the k-means
the patterns of care across Italian Radiation Oncology De-
                                                                            clustering method via principal components analysis using
partments (RODs) to identify trends that may provide in-
sights into the management of HNC among the elderly.                        the Hartigan and Wong method 6. Multidimensional data
                                                                            are represented on two axes and the cluster centroids (vec-
                                                                            tor of mean values of each variable) can be defined. Sta-
Materials and methods                                                       tistical analysis was carried out using R-Studio 0.98.1091
An anonymous survey was conducted online using the free                     software.



406
                                                     Results of a survey on the management and treatment of elderly head and neck cancer patients




Results                                                              cally applied the comprehensive geriatric assessment (CGA).
                                                                     In 14 (20.6%) RODs, elderly patients scheduled to receive RT
                                                                     with or without concomitant chemotherapy were offered pro-
Centre distribution                                                  phylactic percutaneous endoscopic gastrostomy (PEG) tube.
The survey was sent to all Italian RODs (n = 195) and 68
answers were received (response rate = 34.8%). Globally,             Radiation therapy treatment
RODs were recorded in 16 regions, distributed as 32 public           In 2017, among the analysed centres, 1404 elderly HNC
structures (48%), 19 University departments (28%), 16 pri-           patients received RT with curative (n = 1255) or palliative
vate centres providing health care through the national health-      (n = 149) intent. In the curative RT setting, 268 patients
care system (23%) and 1 private centre. The highest number           were treated with concurrent platinum-based chemoradio-
of RODs was located in the northern regions (n = 40), fol-           therapy (CRT), 108 patients with RT plus cetuximab, 377
lowed by central (n = 19) and southern regions (n = 9).              patients with definitive RT, 98 patients received induction
                                                                     chemotherapy before RT, 31 patients interstitial brachy-
Participant characteristics                                          therapy and 373 patients underwent surgery followed by
For each ROD, a radiation oncologist answered the survey.            adjuvant RT (n = 318) or CRT (n = 55). Adjuvant CRT was
In total, 46 radiation oncologists were aged 30-50 (67.6%)           mainly programmed in case of adverse risk features, in-
and 22 (32.4%) were over 50 years old. None was less than            cluding positive margins and extranodal extension.
30 years old. Thirty-nine were females (57.4%) and 29                In case of curative RT, more than 85% of elderly patients
were male (42.6%). Forty-seven (69.2%) had been work-                were treated using intensity-modulated RT (IMRT) tech-
ing as a specialist for more than 10 years. All responders           nique at a planned dose of 66-70 Gy delivered in conven-
declared daily clinical practice in HNC field and the vast           tional fractionation (2-2.2 Gy/fraction). Less than 10%
majority (n = 64; 94.1%) believed that selected fit elderly          of patients received accelerated RT. In total, 30/68 (44%)
patients could receive standard treatment.                           RODs delineated standard treatment volumes, based on
                                                                     TNM stage and HNC sub-site and 38/68 (56%) RODs pro-
HNC patient population characteristics                               posed target volume reduction.
The global number of HNC patients treated per year per               In the reduced volume group, 9/38 (23.7%) RODs deline-
RODs varied from fewer than 10 (n = 2; 2.9%) to more than            ated only the macroscopic disease sites and 29/38 (76.3%)
100 (n = 7; 10.3%); about half of RODs (n = 31; 45.6%)               defined as target the macroscopic disease sites (including
ranged between 10 to 50 HNC patients. In 2017, the aver-             the possible nodal involvement) plus the first uninvolved
age number of RT treatment courses in elderly HNC pa-                lymphatic drainage echelon.
tients was 22, with a large variation from fewer than 5 treat-       In case of concurrent treatment, RT with cetuximab was
ments per year in 5 RODs to ≥ 50 in 4 RODs.                          considered the first option in only 3 RODs; the remainder
                                                                     (n = 65; 95.6%) proposed cetuximab only if patients were
Multidisciplinary unit characteristic                                considered medically unfit for concomitant platinum-based
In total, 58 RODs discussed HNC cases in a multidiscipli-            chemotherapy.
nary unit (MU) and most (n = 46; 79.3%) at regular weekly            During treatment, 28 RODs (48.3%) declared a higher hos-
intervals. Other than maxillofacial/head and neck surgeon,           pitalisation request than in the case of non-elderly patients.
medical oncologist, radiation oncologist, radiologist and his-
topathologist, the other main highly specialised figures in-         Cluster analysis
cluded in the MU were nutritionist (n = 28; 48.3%), pain spe-        Four variables – year of experience in HNC field, number
cialist (n = 20; 34.5%), speech and language therapist (n = 12;      of HNC treatment per year in ROD, type of chemotherapy
20.7%) and head and neck dedicated nurse (n = 24; 41.4%).            and RT treatment volumes – were used in the clustering
Only 4 (6.9%) MUs had a geriatrician within the team.                analysis. These variables were graphically depicted using
                                                                     two axes which represented 76.71% of the total variability
Evaluation of the elderly patient                                    (Fig. 1). Using these two components, we found three clus-
In clinical practice, 36 RODs (52.9%) used different index           ters of RTUs. Details are presented in Figure 1. Cluster 1
score, mainly including Charlson’s comorbidity index, ACE-           was defined by 13 RODs, including Abruzzi (n = 1), Calabria
27 score or G-8 tool, to actively screen elderly patients for        (n = 1), Latium (n = 2), Liguria (n = 1), Lombardy (n = 3),
disorders. Before treatment decision, 11 (16.2%) RODs rou-           Piedmont (n = 1), Trentino Alto Adige (n = 1), Tuscany
tinely performed evaluation of function and quality of life in       (n = 1) and Veneto (n = 2). Cluster 2 was formed by 45 ROD
elderly HNC patients, but only 7 (10.3%) RODs systemati-             distributed as Abruzzi (n = 2), Campania (n = 3), Emilia Ro-



                                                                                                                                           407
L. Belgioia et al.




                                                                    peutic plan escalation 7; according to the survey results the
                                                                    majority of RODs (85%) discussed HNC cases in a MU.
                                                                    Secondly, few data exist on the presence of a geriatrician
                                                                    as an effective MU member; our survey recorded that only
                                                                    6.9% of RODs regularly included a geriatrician in the MU
                                                                    team members. We have mainly ascribed this result to the
                                                                    lack of a standardised method to evaluate HNC elderly
                                                                    patients and the difficulty to integrate a complete geriatric
                                                                    evaluation in the daily clinical practice. Only a minority
                                                                    of RODs (10%) performed a CGA in all elderly patients.
                                                                    Considering that many patients are susceptible to a curative
                                                                    treatment, an adequate geriatric evaluation at diagnosis is
Figure 1. Cluster plot found through k-means clustering analysis.
                                                                    extremely relevant to guide therapeutic approach. The main
                                                                    risk is to under-treat or over-treat elderly patients due to
magna (n = 3), Friuli Venezia Giulia (n = 1), Latium (n = 4),       their chronological age or their degree of frailty.
Liguria (n = 3), Lombardy (n = 12), Marches (n = 1), Molise         To date, the role of CGA is debated; the international soci-
(n = 1), Piedmont (n = 5), Puglia (n = 2), Sardinia (n = 1),        ety of geriatric oncology (SIOG) recommended its system-
Tuscany (n = 5) and Veneto (n = 2). The remaining 10 RODs           atic use in the pre-treatment assessment of elderly people
defined cluster 3 (n = 1 Emilia Romagna, Piedmont, Veneto,          with cancer 8, but it is still not validated in HNC manage-
Campania; n = 2 Puglia; n = 4 Lombardy).                            ment 9. Actually, two randomised clinical trials 10,11 have
Cluster 1 showed high young (in term of year of experience)         been designed to validate CGA in HNC patients, the pre-
HNC specialists and the highest cetuximab use. Cluster 2            liminary results of one of these showed that CGA changed
prescribed platinum-based CHT and presented the highest             the planned treatment in 8% of patients 12; nevertheless, no
specialist experience. Cluster 3 showed centroid values for         data has demonstrated that CGA ameliorates the results
specialist experience and chemotherapy prescription.                in HN cancer patients. It must also be considered that the
                                                                    main reported issue on systematic adoption of CGA is that
                                                                    take too much time to be performed routinely 8, so often
Discussion                                                          pre-screening evaluation using specific tools such as G8 or
This survey firstly addresses at the national level the rel-        VES-13, was performed in order to identify those patients
evant issue of the RODs choices for the treatment of el-            who require further geriatric assessment 13. Both G8 and
derly patients with locally advanced HNC. In most RODs,             VES-13 are validated tools in HNC patients 13 and several
a MU discussion is held for HNC cases. The majority of              literature data clearly indicated that the G8 better correlates
elderly patients (56%) received RT with curative doses              with geriatric assessment at baseline compared to the VES-
but with reduced volumes (in these cases, about 24% and             13 (sensitivity 85.7% versus 57.1%, respectively) 14. There-
76% of RODs delineated only the macroscopic disease                 fore, the G8 should be considered the main screening tool
sites or macroscopic disease sites plus the first uninvolved        to distinguish between fit from vulnerable HNC patients.
lymphatic drainage echelon, respectively). The majority             Lastly, the choice of the concomitant systemic therapy, the
of patients received intensity modulated radiotherapy. In-          definition of target volumes and the fractionation schedules
terestingly, cluster analysis showed that more experienced          remain the major concerns. The meta-analysis of radiothera-
specialists prescribed cisplatin-based chemotherapy more            py in carcinomas of head and neck (MARCH) collaborative
often than young HNC specialists did. Possible explana-             group showed a decreasing effect of altered fractionated in
tions could include the lower experience with radiation             older patients 15. No firm conclusions can be stated mainly
sensitisers and the presumed gentler toxicity profile of ce-        because the intrinsic questionable results generalisability in
tuximab compared to cisplatin-based toxicity and seque-             a meta-analysis and the lack of objective and reproducible
lae, including renal dysfunction and hearing loss. Robust           criteria to evaluate elderly patient in the included studies.
evidence for HNC management in elderly patients is still            In our analysis, despite the high percentage of curative treat-
lacking, but several considerations can be made.                    ments (89%), a heterogeneous scenario was depicted, with
Firstly, both expertise and multidisciplinarity should be em-       different options chosen, including concurrent platinum-based
phasised. It is reported that MU meetings change the diag-          chemoradiotherapy, RT plus cetuximab or definitive RT alone.
nostic and/or therapeutic approach up to 60% of the cases,          Another key question concerns RT details, such as the distribu-
due to staging refinement and more frequent use of thera-           tion of radiation dose over time and target volume delineation.



408
                                                                  Results of a survey on the management and treatment of elderly head and neck cancer patients




Radiation volume de-escalation could be an effective strat-                       4
                                                                                       Bonner JA, Harari PM, Giralt J, et al. Radiotherapy plus cetuximab
egy to reduce toxicity and facilitate treatment compliance.                            for locoregionally advanced head and neck cancer: 5-year survival
                                                                                       data from a phase 3 randomised trial, and relation between cetuxi-
High-quality RT and adequate patient selection should be                               mab-induced rash and survival. Lancet Oncol 2010;11:21-8. https://
promoted to guarantee reliable treatment outcome. In the                               doi.org/10.1016/S1470-2045(09)70311-0
literature, different experiences reduced RT volume avoid-                        5
                                                                                       National Comprehensive Cancer Network (NCCN). Guidelines Head
ing elective nodal volume irradiation in elderly and frail pa-                         and Neck Cancers, Version 1.2019. available at http://www.nccn.org
tients with good rate of local control 16-19. However, this is
                                                                                  6
                                                                                       Hartigan JA, Wong MA. Algorithm AS. 136: a K-Means clustering
                                                                                       algorithm. J R Stat Soc Ser C (Appl Stat) 1979;28:100-8.
not the standard and it should be considered with caution in                      7
                                                                                       Bossi P, Alfieri S. The benefit of a multidisciplinary approach to the patient
treatment with radical intent. Moreover, we underline that                             treated with (chemo) radiation for head and neck cancer. Curr Treat Op-
these data should be interpreted with caution for several is-                          tions Oncol 2016;17:53. https://doi.org/10.1007/s11864-016-0431-3
sues such as, inhomogeneous study population, irradiation                         8
                                                                                       Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for mul-
techniques or incomplete follow up 16-19.                                              tidimensional health problems warranting a geriatric assessment in
                                                                                       older cancer patients: an update on SIOG recommendations. Ann On-
This survey had several limitations. First of all, the data do                         col 2015;26:288-300. https://doi.org/10.1093/annonc/mdu210
not represent the collection of individual patient data from a                    9
                                                                                       Maggiore R, Zumsteg ZS, BrintzenhofeSzoc K, et al.; CARG-HNC
database but the answers from a respondent per each centre                             Study Group. The older adult with locoregionally advanced head
with inevitable introduction of bias due to uncertainty in data                        and neck squamous cell carcinoma: knowledge gaps and future di-
                                                                                       rection in assessment and treatment. Int J Radiat Oncol Biol Phys
collection. The main inhomogeneities highlight in this survey
                                                                                       2017;98:868-83. https:// doi.org/10.1016/j.ijrobp.2017.02.022.
correspond to points in which literature data does not reveal a                   10
                                                                                       Brugel L, Laurent M, Caillet P, et al. Impact of comprehensive geri-
clear standard of care. Second, we underline that only about a                         atric assessment on survival, function, and nutritional status in el-
third of Italian RODs answered the survey (68 of 196 centres).                         derly patients with head and neck cancer: protocol for a multicentre
However, considering that one of the missions of the AIRO is                           randomised controlled trial (EGeSOR). BMC Cancer 2014;14:427.
                                                                                       https://doi.org/10.1186/1471-2407-14-427
to promote research, it is our hope that the obtained data will                   11
                                                                                       ClinicalTrials.gov,https://clinicaltrials.gov/ct2/show/NCT03614936?
be a strong incentive and form the basis for the AIRO Head                             term=NCT03614936&rank=1. Accessed 04 October 2019.
and Neck working group to design a prospective clinical trial                     12
                                                                                       Mertens C, Le Caer H, Ortholan C, et al. The ELAN-ONCOVAL
especially to identify optimal target volumes and clarify if, a                        (ELderly heAd and Neck cancer-Oncology eValuation) study: evalu-
subgroup of elderly patients, might benefit from combined                              ation of the feasibility of a suited geriatric assessment for use by on-
                                                                                       cologists to classify patients as fit or unfit. Ann Oncol 2017;28(suppl.
treatment.                                                                             5):v372-v94. https://doi.org/10.1093/annonc/mdx374
                                                                                  13
                                                                                       Soubeyran P, Bellera C, Goyard J, et al. Screening for vulnerability
Conclusions                                                                            in older cancer patients: the ONCODAGE Prospective Multicenter
                                                                                       Cohort Study. PLoS One 2014;9:e115060. https://doi.org/10.1371/
This survey documented a significant heterogeneity in the                              journal.pone.0115060
management of elderly patients with HNC. Adequate pa-                             14
                                                                                       Pottel L, Boterberg T, Pottel H, et al. Determination of an adequate
                                                                                       screening tool for identification of vulnerable elderly head and neck
tient evaluation is mandatory and significant expertise is                             cancer patients treated with radio(chemo) therapy. J Geriatr Oncol
required to propose a patient-centred treatment. Prospec-                              2012;3:24-32. https://doi.org/10.1016/j.jgo.2011.11.006
tive studies are needed for this setting of patients.                             15
                                                                                       Bourhis J, Overgaard J, Audry H, et al.; Meta-Analysis of Radio-
                                                                                       therapy in Carcinomas of Head and neck (MARCH) Collaborative
                                                                                       Group. Hyperfractionated or accelerated radiotherapy in head and
Acknowledgements                                                                       neck cancer: a meta-analysis. Lancet 2006;368:843-54. https://doi.
                                                                                       org/10.1016/SO140-6736(06)69121-6
The content of the paper has been approved by the Scien-                          16
                                                                                       Bernier J, Bataini JP. Regional outcome in oropharyngeal and pharyn-
tific Committee of Italian Association of Radiotherapy and                             golaryngeal cancer treated with high dose per fraction radiotherapy.
Clinical Oncology (AIRO).                                                              Analysis of neck disease response in 1646 cases. Radiother Oncol
                                                                                       1986;6:87-103. https://doi.org/10.1016/s0167-8140(86)80015-9
                                                                                  17
                                                                                       Boysen M, Lovdal O, Soberg R, et al. Elective radiotherapy of the
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