What is the role of immunotherapy in an elderly patient with right buccal carcinoma?

Role of Immunotherapy in Elderly Patients with Right Buccal Carcinoma

Immunotherapy with immune checkpoint inhibitors (ICIs) is a viable treatment option for elderly patients with buccal carcinoma, but must be preceded by a comprehensive geriatric assessment (GA) to identify vulnerabilities and guide management decisions. 1

Key Considerations for Treatment Decision-Making

Mandatory Geriatric Assessment

• Perform a formal geriatric assessment before initiating any systemic therapy, including immunotherapy, in patients ≥65 years old. 1
• The GA should evaluate: physical performance, functional status, comorbidities, falls risk, frailty screening (G-8 tool), nutrition, cognition, polypharmacy, and social support 1
• Patients who screen positive for frailty using the G-8 tool experience higher hospitalization rates and shorter survival when receiving immunotherapy 1
• GA-guided management significantly reduces chemotherapy toxicity and improves treatment adherence, with benefits extending to patients receiving immunotherapy 1

Efficacy Profile in Older Adults

• Immunotherapy demonstrates similar overall survival and progression-free survival in older adults compared to younger patients in practice-changing trials 1
• However, older adults (especially ≥75 years) may have higher discontinuation rates due to adverse events 2
• Case reports demonstrate durable complete responses to pembrolizumab in geriatric patients with gingival squamous-cell carcinoma, with ongoing responses at 19 months and minimal side effects 3

Safety Considerations Specific to Elderly Patients

• The incidence of immune-related adverse events (irAEs) is not necessarily higher in older patients, but the profile may differ 4
• Management of irAEs is more challenging in elderly patients due to:
  • Risks associated with corticosteroid use (standard irAE treatment) 4
  • Reduced physiological reserve 4
  • Higher prevalence of comorbidities that may complicate immunosuppressive therapy 1
• Patients ≥90 years discontinue immunotherapy due to adverse events more than twice as often as younger patients 1

Critical Comorbidity Assessment

• Evaluate for conditions that increase risk with immunotherapy or its toxicity management: 2
  • Cardiovascular disease (hypertension, coronary artery disease, arrhythmias)
  • Cerebrovascular disease
  • Autoimmune disorders (not a contraindication but requires individualized assessment) 1
• Review medications that could complicate management of anaphylaxis or other severe reactions, particularly β-blockers 1

Treatment Algorithm for Elderly Patients with Buccal Carcinoma

Step 1: Perform Comprehensive Geriatric Assessment

• Use validated tools: G-8 frailty screening, functional status measures, comorbidity indices 1
• Classify patient as: fit, vulnerable, or frail 1

Step 2: Risk-Benefit Stratification

For Fit Elderly Patients (good functional status, minimal comorbidities):

• Proceed with standard immunotherapy protocols 1, 3
• Monitor closely for irAEs with same vigilance as younger patients 4

For Vulnerable Elderly Patients (some functional limitations, moderate comorbidities):

• Immunotherapy remains appropriate but requires enhanced supportive care 1
• Implement GA-guided interventions: fall prevention, nutritional support, medication optimization, social support 1
• Consider geriatric co-management throughout treatment 1

For Frail Elderly Patients (significant functional impairment, multiple comorbidities):

• Exercise extreme caution; higher risk of hospitalization and shorter survival 1
• Prioritize quality of life over aggressive treatment 3, 5
• Consider palliative intent immunotherapy only if goals of care align with potential toxicity burden 5

Step 3: Special Monitoring for Patients ≥75 Years

• Anticipate higher discontinuation rates (38-43% vs 23-24% in all ages) 2
• Schedule more frequent clinical assessments during first 3 months 1
• Lower threshold for hospitalization or intervention for irAEs 1

Common Pitfalls to Avoid

• Do not assume age alone is a contraindication to immunotherapy - chronologic age is less important than functional status and comorbidity burden 1, 6
• Do not skip the geriatric assessment - standard oncologic evaluation misses vulnerabilities that predict poor outcomes 1
• Do not underestimate corticosteroid risks in elderly patients - standard irAE management with high-dose steroids carries greater risks in this population 4
• Do not fail to have early goals of care discussions - the uncertainty around immunotherapy response rates necessitates honest conversations about expectations 5

Quality of Life Considerations

• GA-guided management improves health-related quality of life, with maximal benefit at 18 weeks of treatment 1
• Integrated oncogeriatric care reduces unplanned hospital admissions by 40% compared to usual care 1
• For patients prioritizing quality of life, palliative intent immunotherapy may allow avoidance of morbid surgery while maintaining disease control 3