Managing the Elderly Patient

Abstract

Glioblastoma multiforme (GBM) is a devastating disease at any age. However, GBM has traditionally been associated with particularly poor outcomes in elderly patients, with reported median survival time of just a few months typical in many case series. The reasons for this are not entirely clear, but it has been suggested that the elderly are generally frailer and less able to cope with the toxicity associated with standard treatment approaches to GBM, notably surgery and radiotherapy. This may explain why single-modality therapy or best supportive care only becomes increasingly common with advancing age. More recently, however, there has been speculation that GBM may be a biologically more aggressive disease in the elderly and perhaps inherently more resistant to radiation. This has yet to be confirmed but has provoked interest in understanding precisely why age has such a negative effect on survival at a time when a significant increase in numbers of elderly GBM patients is predicted due to an aging population. Interestingly, since the introduction of the Stupp protocol, which promotes the use of chemoradiotherapy post surgical resection, several reports have emerged indicating that elderly patients can tolerate aggressive multimodality therapy with impressive median survival times of over a year in some cases. However, it is important to point out that patient selection is likely to be critical and the results in these series cannot be extrapolated to the general elderly population. Unsurprisingly, the gold standard treatment of GBM in the elderly has yet to be determined. As such, a number of clinical trials have been developed to specifically answer this question in patients over the age of 70, a group that has previously been excluded from pivotal trials in GBM. It is hoped that these studies will pinpoint clinical and/or molecular prognostic factors that will guide treatment of the individual elderly patient with the optimal ­combination of therapy.