Should radiotherapy be standard therapy for brain tumors in the elderly? Cons.

Elderly patients with malignant gliomas present unique treatment challenges. Data are limited on the efficacy of various treatment modalities for high-grade gliomas in the elderly patient population, particularly for patients over 70 years of age, and the most appropriate treatment strategies remain a matter of debate. These patients generally have a poor clinical course and lower tolerance to therapy compared with younger patients. Standard radiotherapy (RT) may provide a survival benefit for patients with a good Karnofsky performance status (>/=70); however, RT is associated with significant neurologic toxicity in elderly patients. Some argue that the apparent modest clinical benefits of RT do not outweigh the risks and inconvenience of the standard schedule. Clearly, more effective and better-tolerated treatments are needed. Chemotherapy agents with good safety profiles, such as oral temozolomide (Temodar [US], Temodal [international]; Schering-Plough Corporation, Kenilworth, NJ), are being considered as alternatives to RT. When used as single-agent therapy, temozolomide induced objective responses and improved neurologic status in elderly patients with newly diagnosed, unresected glioblastoma. For patients with good performance status, treatment options should be discussed and the risks and potential benefits of RT carefully considered. Furthermore, prospective randomized studies should be performed to define the best therapeutic option for efficacy, toxicity, convenience, and quality of life.