Managing elderly soft tissue sarcoma patients-should age drive treatment?

As the mean age of the US population increases because of the maturation of the ‘‘Baby Boomer’’ generation, several important demographic sequellae emerge. The overall incidence of new cancer cases is increasing, there is a concomitant generally increased incidence of cancer cases within specific disease sites, and there is an associated increased incidence of disease site-specific lesions within older age groups as a percentage of those burdened by certain malignancies. In light of these trends, it is both appropriate and timely that we consider how cancer care is given to older populations within the confines of specific disease entities. Within this context, age-denominated patterns of care in some diseases such as soft tissue sarcoma offer particular challenges because of its relative rarity, the comparative paucity of sarcoma-focused high-volume treatment centers that are associated with a higher quality of sarcoma care, and the reality that this is a disease that has a bimodal distribution that preponderantly afflicts both the young as well as a generally older adult population compared with most other solid tumor processes. In light of these considerations, it is appropriate to consider whether or not we are overtreating or undertreating soft tissue sarcoma patients; manifestly, if treatments offered are inappropriate as a function of age, should we consider altering our patterns of care for this and other rare diseases that occur more frequently in older populations? The Annals of Surgical Oncology has provided a bona fide service to soft tissue sarcoma practitioners by publishing 2 seminal studies in 2009 and 2010 that materially contribute to this debate. Lahat and colleagues at The University of Texas MD Anderson Cancer Center analyzed a large cluster of soft tissue sarcoma patients (n = 325) who underwent R0/R1 resection at that institution over a recent 10-year interval. In the current issue the Annals published an additional report; this one authored by AlRefaie and collaborators from the University of Minnesota, who based their study on a carefully considered analysis of Surveillance Epidemiology and End Results (SEER) registries of extremity soft tissue sarcoma patients (n = 2,586) treated between 1991 and 2006. While not exactly comparable, within the constraints of an individual institutional experience versus a population-based study it is intriguing to consider both the similarities and differences of these analyses because they are informative and pertinent to the questions posed above. The MD Anderson series patient median age of 72 years was in keeping with the reality that approximately 55% of these patients had significant comorbidities, resulting in a preoperative ASA score of 3 or greater. The site of the soft tissue sarcoma was most commonly extremity, with highgrade undifferentiated pleomorphic sarcoma (formerly known as malignant fibrous histiocytoma) greater than 5 cm maximum diameter as the most common presentation. Postoperative mortality (30 day) was less than 1%, whereas approximately 30% of patients experienced at least 1 complication. Patients 75 years or older received chemotherapy less often and had a shorter median diseasespecific survival rate (70 vs. 113 months; P = .05); use of radiotherapy did not differ as a function of age. In a multivariable Cox proportional hazards model for soft tissue sarcoma-specific survival, age greater than or equal to 75 years, larger tumor size, and high tumor grade were the only factors significantly related to sarcoma-specific survival of the more than 20 patient, tumor, and treatmentSociety of Surgical Oncology 2010