Head and Neck Cancer in the Elderly: A Retrospective Study over 10 Years (1999 - 2008)

The percentage of elderly people with head and neck cancer is rising due to an overall increase in life expectancy. Age has been shown to be an independent predictor of perioperative outcome, morbidity, and mortality risk. The main risk factors for head and neck cancer can be smoking and alcohol consumption, and these factors are also often associated with cardiovascular and pulmonary comorbidities, leading to a challenge concerning treatment decisions in this patient group.

In the literature, no exact age seems to be associated with the word "elderly." In any case, surgical indications should not be based on age, but rather on risk assessment. Socinski et al. defined an "old patient" as one whose health status has begun to interfere with oncological decision-making guidelines [1]. Therefore, some authors recommend using the ASA score as a tool for risk assessment [2–4].

Postoperative delirium is a common complication, with the overall incidence estimated at 10% in elderly patients following major elective non-cardiac surgery [7]. It usually presents around 24 hours postoperatively, resolving in most patients within 48 hours, but episodes can last for months [8]. With delirium the course usually fluctuates and revolves over some days, up to a week, but with dementia symptoms are progressive. Hallucinations and delusions are also often absent in dementia, unlike in delirium. Concerning therapy, Dexmedetomidine is recommended for long-term sedation in the intensive care unit (ICU) as it leads to a decreased incidence of ICU delirium [9, 10], while low-dose Haloperidol or Donazepil does not reduce the incidence [11–13].

In general, preoperative risk assessment is predictive for the development of postoperative morbidity [14–16]. Serletti et al. [2] regarded surgical time longer than 10 hours as a predictive factor for development of postoperative surgical complications. Further factors are large fluid shifts and significant blood loss. Another important factor in reconstructive failure seems to be the presence of peripheral vascular disease.

Concerning chemotherapy, Shayne et al. reported that in patients ≥ 70 years who were receiving full-dose chemotherapy, increasing age alone did not increase the risk of hematologic toxicity [17].

The aim of the present study is to identify the concerns and needs of elderly patients suffering from head and neck cancer. From these patterns special considerations for this group can be deduced.

Out of 376 patients treated from 1999 through 2008 that were suffering from head and neck cancer, 99 (26.3%) were older than 70 years. This group was evaluated retrospectively concerning smoking/alcohol abuse, ASA status, kind of malignant neoplasm, location of malignancy, treatment, and outcome.

Muir et al. estimated that as many as 24% of head and neck cancers are found in patients older than 70 years [18], and this was supported by our study. A higher female proportion, as in the present study, was also confirmed by Sarini et al. [19].

Furthermore, in the present study the rate of patients with alcohol abuse or smoking risk factors was found to be lower than that in younger patient groups. This finding follows the logic that malignant tumors occur earlier under the influence of risk factors, but are also likely to occur without them as time passes by. Malignancy may interfere with accumulation of mutations, decreased efficiency in DNA repair, and reduced immune surveillance.

Concerning the higher portion of maxillary carcinomas in elderly patients, similar results can be shown in other studies [20, 21]. These findings are also important with regard to therapy planning because performing elective neck dissections for maxillary carcinoma is still controversial. It is also striking that, particularly in maxillary carcinoma, the proportion of females is higher than that of males [21].

Four patients had a verrucous form; this type of well-differentiated squamous cell carcinoma is well known in elderly patients [22].

In deciding which treatment strategy would be suitable for an individual elderly patient, a comprehensive geriatric assessment seems to be the essential step, because age by itself is an unreliable parameter for decision making. In the present study, only 3 patients had an ASA status of 1, and the predominant therapy was primary closure.

Due to changed renal function (reduced glomerular filtration rate, decreased renal blood flow) and changed hepatic metabolism (reduced hepatic blood flow and reduced activity of the microsomal oxidizing system), drug distribution is also changed in elderly patients. Moreover, increased myocardial stiffness, increased aortic impedance, increased left atrium size, and increased vascular stiffness, in addition to decreased β-adrenoceptor responsiveness, must be considered before a surgical treatment is planned for elderly patients (Table 1).

Though our population is becoming older and, therefore, the risk of developing cancer is also increasing, little research evaluating age-related toxicities has been conducted, and age-related guidelines for chemotherapy administration are often missing. The therapy decision should be based on the patient's wishes, ASA score, and combined quality of life and function, instead of being based on the patient's age and years of life expectancy.

Even if the concept of "elderly" has no clearly defined parameters, these patients do have a different pattern of head and neck tumors with regard to risk factors, tumor entities, and treatment options. The group of patients older than 70 years with head and neck cancer is characterized by a higher proportion of female patients, a higher number of maxillary carcinomas, and a higher prevalence of previous cancers.

Therefore the elderly patient does require an exact evaluation of his biological situation and an especially individual treatment concept.

The authors declare that they have no competing interests.