الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Summary and Conclusions
As HNC is a heterogeneous disease and given the treatment modalities (surgery, chemotherapy, radiation therapy and targeted therapy), patient selection is essential, especially in the geriatric population. The most ideal approach would have to take into account the clinical presentation, the primary tumour site, risk factors, human papillomavirus (HPV) tumour positivity and biological markers.
Assuming a thorough presurgical evaluation of co-morbidities has been completed, surgical treatment options should not be excluded in elderly patients treated with curative intent as part of the multidisciplinary care of HNC. Surgery can also be considered when planning RT. If surgically accessible, radical procedures can also be considered, even for relapsed disease.
The majority of retrospective studies support appropriate surgical management of resectable HNC in elderly people. Careful pre-operative staging and evaluation of associated medical illnesses, as well as skillfull peri- and post-operative management, are essential for reducing operative morbidity and mortality in the elderly. Successful outcomes depend on appropriate surgical management, treatment of concurrent
Summary & Conclusions
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illnesses, and minimization of post-operative complications.The choice of definitive local therapy must take into account: The likely functional outcome of treatment, the resectability of the tumor, the comprehensive geriatric assessment and the patient‟s wishes (Teymoortash et al., 2009).
On the other hand, many studies showed that standard treatment with curative intent can be safely performed in elderly patients with a good performance status and without severe comorbidities. Huang et al. reported no differences in respect to Unplanned RT interruptions, premature termination of the RT regimen or treatment-related deaths between younger (aged <75 years) and older (aged ≥75 years) patients on definitive RT (Huang et al., 2011). Analyzing the data of 1307 patients included in the EORTC trials with RT, Pignon et al. found that the age profiles of patients with and without toxicity were similar, and neither locoregional control nor survival were affected by age (Pignon et al., 1996) . A similar observation regarding treatment-related complications was described in several surgical series and for systemic therapy.As reported by Peters et al., age was not recognized as an independent prognosticator for treatment-related complications in a group of 428 patients (aged ≥75 years, 32%) with laryngeal cancer after curative RT or surgery, (Peters et al., 2011) as was the case in
the study by Milet et al. involving 261 patients (aged ≥70 years, 11%) with different primaries treated with upfront surgery (Milet et al., 2010).
Anyhow, elderly patients are underrepresented in nonage- related clinical trials, and there is no sufficient data from high-quality phase III studies to guide the treatment decision-making process for these patients.
A comprehensive oncogeriatric initial assessment of their functional status and psychological profile is crucial for the selection of the most appropriate therapy or treatment combinations for the individual patient. Age alone should not be used as a criterion to limit therapy. However, only elderly patients in a good general condition following the initial assessment should be considered candidates for curative interventions. Bearing in mind that treatment could be harmful, adequate supportive care must be provided in order to improve patients‟ compliance (Sanabria et al., 2013).
Combined modality treatment is considered the standard curative therapeutic approach for stage III and IV HNSCC, as well as in the adjuvant setting. Such intensive treatment can be of benefit in well selected and fit older patients. A retrospective analysis has demonstrated that multimodality therapies, either curative surgery with postoperative RT or neoadjuvant three
drug chemotherapy followed by RT, can achieve long disease-free survival with an acceptable toxicity profile in selected older patients with advanced HNSCC (3-year survival rate of 27–30%) (Bernier, 2009).
Phase II and III studies of cancer therapies in HNSCC older adults are desperately needed, as the usual study endpoints of efficacy and toxicity do not fully address the risks and benefits of therapy for an older patient. Such studies must investigate treatment regimens with different grades of aggressiveness and optimize these. In the very old and frail, minimal treatments must be compared with observation in terms of their effects on survival, cancer control and quality of life.
After correction of physiological and biological risk factors, a large proportion of geriatric patients can and should be offered the same cancer treatment as that offered to younger patients. If advances in the treatment of HNC are incorporated into the management of older patients, this should result in better cure rates with improved treatment tolerability for these patients (Fakhry et al., 2008).