Head and Neck Cancer in the Elderly: Frailty, Shared Decisions, and Avoidance of Low Value Care

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Key points

  • Head and neck cancer is a disease of older adults, with an estimated 61% of patients ages 65 and older by the year 2030.

  • Even with treatment advancements, recurrent/metastatic head and neck squamous cell carcinoma remains a lethal disease with median overall survival of less than 12 months.

  • It is imperative to distinguish fit individuals, who may tolerate multimodality therapy, from frail patients, who may benefit from prehabilitation or palliative and supportive services.

  • Chemotherapy, radiation,

Identifying the Frail Patient

Chronologic age alone is not a consistent predictor of life expectancy, treatment-related toxicity, or perioperative risk.3, 23 Because senescence is a heterogenous process, it is imperative to identify those who are fit, who may tolerate standard-of-care therapy, and those who are frail, who may benefit from prehabilitation or palliative intervention. Frailty is a syndrome—distinct from age, comorbidity, or disability alone—which describes decreased physiologic reserve and resistance to

Current Treatment Paradigms

In primary early-stage disease, patients may be treated with either surgery or RT. Close routine surveillance is necessary to identify potential recurrences or detect second primary tumors. A majority (>90%) of recurrences are observed within 3 years of initial therapy.46, 47 Locoregionally advanced disease requires combined-modality approaches (surgery, RT, and/or chemotherapy) to optimize tumor control. Nonetheless, advanced HNSCC is associated with a high incidence of local recurrence and

Implementation

In the management of HNC, treatment plans may be complex and challenging to comprehend. Shared decision making is a collaborative effort that empowers patients and their providers to make treatment-related decisions together, considering evidence-based best practices in the context of a patient’s goals and values. The Agency for Healthcare Research and Quality SHARE Approach outlines a 5-step model for shared decision making (Table 1).62

Through an invitation to join in the decision-making

Clinical vignette

A 73-year-old man presented to clinic with recurrent HNSCC of the oral cavity, for which he underwent treatment of his disease 9 months prior. His medical history was significant for polypharmacy and numerous comorbidities, including heart disease, chronic obstructive pulmonary disease related to a 50-pack year tobacco history, and dialysis-dependent chronic kidney disease. On examination, he appeared malnourished, corroborating his history of a 70-pound unintentional weight loss. He described

Summary

The clinical vignette illustrates key issues in the management of geriatric HNC patients. Recurrent and metastatic HNSCC is a lethal disease with median overall survival of less than 12 months. Within this vulnerable population, it is imperative to distinguish those who are fit from those who are frail, who may be unable to tolerate standard-of-care therapy. Chemotherapy, radiation, and molecular therapeutics present distinct challenges in the elderly, with limited efficacy in the palliation of

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