CA in Elderly Patients

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Critical Reviews in Oncology/Hematology 53 (2005) 71–80

Treatment of head and neck cancer in elderly patients:state of the art and guidelines

Daniele Bernardia,∗, Luigi Barzand, Giovanni Franchinb, Roberta Cinellia,Luca Balestreric, Umberto Tirellia, Emanuela Vacchera

a Division of Medical Oncology A, National Cancer Institute, Aviano (PN), Italyb Division of Radiotherapy, National Cancer Institute, Aviano (PN), Italyc Department of Radiology, National Ca ncer Institute, Aviano (PN), Italy

d ENT Division, Ospedale S. Maria Degli Angeli, Pordenone, Italy

Accepted 5 August 2004

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

2. Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

2.1. Standard radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

2.2. Unconventional fractionation radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

3. Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

4. Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

5. Combined modality treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

6. General conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Biographies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Abstract

Although the majority of head and neck cancers occur between the fifth and sixth decade, their onset in patients older than 60 years is not

a rare event.

A peculiar characteristic of almost all case series is the lower prevalence of radical treatments among elderly as compared to younger

patients, in particular surgery and combined treatment of surgery plus radiation therapy or chemotherapy and radiation therapy.Radiotherapy is a feasibletreatment in elderly patients, also in very advanced agegroupsand, in the era of organ preservation, chemotherapy

combined with RT has a paramount importance. Therapeutical planning must be based not only on tumor characteristics, but also on the

physiological, rather than the chronological agethe patient. The main clinical problem is, therefore, the selection of patients to be administered

anticancer treatment. In patients aged 70 or older, complete geriatric assessment and a multidisciplinary approach are the crucial points.

© 2004 Elsevier Ireland Ltd. All rights reserved.

Keywords: Head and neck; Cancer; Elderly; Review

∗ Corresponding author. Tel.: +39 0434659284; fax: +39 0434659531.

E-mail address: [email protected] (D. Bernardi).

1040-8428/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.critrevonc.2004.08.001


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72 D. Bernardi et al. / Critical Reviews in Oncology/Hematology 53 (2005) 71–80

1. Introduction

In western countries cancer-related morbidity and mortal-

ity increase progressively with age. About 60% of all tumors

arise in patients older than 65 years and 70% of all deaths

due to cancer occur in this age [1–4]. The majority of head

and neck (H–N) cancers occur between the fifth and sixthdecade. Nevertheless, the onset of tumors in patients older

than 60 years is not a rare event. In a retrospective study con-

ducted by the Italian Geriatric Radiation Oncology Group

(GROG), H–N cancers were present in 12% (1112/9422)

of patients older than 70 years with different tumors, re-

ferred to 37 radiation therapy centers located in the whole

Italian territory [5]. In mono-institutional case series, mostly

European, elderly patients with an age between 70 and 75

years represent 6–32% of all patient with H–N cancers. The

most frequent histologic type is squamous cell carcinoma and

the most frequent sites of disease are larynx and oral cavity

and, less frequently, oropharynx and hypopharynx. The dis-

tribution of stages is more or less superimposable to that of

the younger patients, with the exception of some case series

where a prevalence of stage N0 is present in elderly patients

(Table 1). A peculiar characteristic of almost all case series

is the lower prevalence of radical treatments among elderly

patients as compared to younger patients (30–74% versus

67–91%, P ≤ 0.001), in particular surgery and combined

treatment of surgery plus radiation therapy or chemotherapy

and radiation therapy. Overall survival is significantly lower

in elderly patients, with an actuarial rate at 5 years of 17–31%

versus 30–44% (P ≤ 0.001) in younger patients in the same

caseseries [5–11]. However, thesedifferences tendto become

smaller and, sometimes to disappear, in the case series wherecancer-specific survival is analyzed and/or the groups of pa-

Table 1

Clinical characteristics of H–N cancers in elderly patients

OLMI [7] (%) Hirano [8] (%) Sarini [9] (%) Seer [10] (%) Vaccher [11] (%)

Total 365/1114 (32%) 751/2508 (30%) 273/4610 (6%) 9386/? 181/2143 (8%)

Age (years) ≥70 ≥70 ≥75 ≥65

Year of diagnosis 1960–1992 1971–1995 1974–1983 1985–1993 1975–1998

Site of disease

Oral cavity 32 12 40 39 23

Oropharynx 28 17 29 20 17

Larynx 40 22 25 42 49

Hypopharynx – 25 9 – 10TNM stage

−T1 − T2 62 40 61

T3 − T4 38 60 39

−N0 81a 60 72

N1 – 13

N2 − N3 19 – 14

−M1 – 1 1 2

UICCb stage

I 31 52

III 69 48

Main case series from literature.a N0 + N1.b UICC = Union Internationale Contre le Cancer.

tients are homogeneous in terms of radicality of treatment

[11,12]. When considering cancer-specific overall survival,

the difference between the two groups was at borderline sta-

tistical level, being at 5-year 55% versus 59%, respectively,

P = 0.008). Cancer-specific overall survival was similar be-

tween the two groups for oral cavity and oropharynx cancer

(at 5-year 37% versus 50%, P = 0.4 and 44% versus 44%, P= 0.5, respectively), whereas elderly patients with larynx and

hypopharynx cancer had a significantly worse 5-year cancer-

specific overall survival than the younger counterpart (71%

versus 78%, P = 0.02 and 30% versus 42%, P = 0.05, respec-

tively).

In the case–control study by the surveillance, epidemi-

ology and result data base (SEER) of Baltimore, on 2508

cases of carcinoma of the larynx, tongue and tonsil in pa-

tients older than 50 years, cancer-specific survival of patients

older than 70 years has been shown to be superimposable to

that of patients of 50–69 years, with the exception of stage

I and IV glottic carcinoma and stage III tonsil carcinoma,

whose cancer-specific prognosis has been demonstrated tobe worse and better in elderly patients, respectively (Table 2)

[12]. Noteworthy is the fact that both groups were homoge-

neous according to sex, year of diagnosis, tumor character-

istics (all of them M0) and type of treatment. According to

the same group, the overall medical morbidity and mortality

rates were 5.65 and 2.98%, respectively. The presence of a

major medical complication increased the odds of death by

5.65 (P < 0.001). Post-operative pneumonia was the most

common medical complication (3.26%) and was associated

with a mortality rate of 10.94% (odds ratio for mortality, 4.4).

Acute myocardial infarction and stroke were rare (combined

incidence, 1.86%) and were not statistically associated withincreased mortality. Procedures that involved the esophagus


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D. Bernardi et al. / Critical Reviews in Oncology/Hematology 53 (2005) 7 1–80 73

Table 2

Cancer-specific survival (CSS) in cancer of the larynx, tongue, tonsil in 2508

patients ≥70 years compared with 2508 patients


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Table 4

EORTC radiationtrials in H–Ncancers (1589 patients): evaluationad impact

of age on acute toxicity

Acute toxicity Age

200 cGy)

and hyperfractionated RT (more than one fraction per day),

often used in combination, represent a promising method to

improve the treatment outcome in patients with H–N carci-

noma. Elderly patients, in general, are excluded from pro-tocols with unconventional fractionated RT, due to the fear

of an increased toxicity, sometimes relevant also in younger

patients. A Swiss group recently published the first study

with an unconventional RT regimen (accelerated concomi-

tant boost RT schedule), in a group of 39 patients older than

70 years with carcinoma of the hypopharynx–larynx (49%)

and of the oral cavity–oropharynx (46%), compared with 81

patients


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Table 5

Severe toxicity and outcome of 120 patients with H–N cancers treated with

accelerated radiotherapy, stratified by age

Patients

≥70 years (n = 39) (%)


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in the airways, is feasible in cooperative elderly patients. In

his series of 69 patients older than 65 years (median age 71

years), with a carcinoma of the glottic and supraglottic lar-

ynx (stage I–II 61%), mortality was shown to be absent and

the rate of surgical complications (13%) and medical com-

plications (10%) during the operative procedure and in the

immediate post-operative period was similar to that reportedin younger patients. Twenty-two percent of patients showed

an inhalation pneumonitis in the first 6 months of follow-up

and 1% died after 3 years, due to pulmonary complications.

Nutritional rehabilitation after this surgical procedure must

therefore be continued for a long period of time [25].

Age does not affect the outcome of reconstructive surgery

withfree flaps,whose engraftment occurs overall in 95–100%

of elderly patients [26–31]. Nevertheless, patients older than

70 years, with important comorbidities, show a rate of lo-

cal complications, such as ischemic necrosis, significantly

higher as compared to younger patients without comorbidi-

ties (12% versus 8% in the case series of Pompei) [30].

Patients older than 80 years examined by Blackwell, 92 %with ASA 3–4 class, have a rate of medical intra- and post-

surgical complications higher than that of younger patients

(62% versus 15%, P = 0.02),after reconstructive surgery with

free flaps. Considering the same ASA class, the incidence of

complications is still higher in patients older than 80 years

and is correlated with the duration of the surgical procedure

[31].

The advances in anesthesiology techniques, in peri-

operative monitoringand in post-operative support allow now

to face with lower risks surgical procedures in older patients

as well. In general, in tumors of the oral cavity, surgical pro-

cedures including wide reconstructions (skin–bone–mucosa)and revascularized flaps are more difficult to be performed.

In the carcinoma of the oropharynx, wide resections of base

of tongue or of the lateral wall more easily can lead to chronic

inhalation and therefore should not be performed. In the car-

cinoma of the larynx and hypopharynx, conservation surgical

procedures must be weighted in relation to the entity of the

predictable resection, the patient’s respiratory function and

his/her possibility to cooperate in a post-operative rehabili-

tation program.

Chronological age should not be considered a limit for

neck dissection. Appropriate surgery treatment should be of-

fered to elderly patients with N0

disease but at high risk of

relapse/distant metastases. The deterioration of the general

conditions, that inevitably occurs as time goes by, and the

diagnostic delay following the impossibility of an adequate

follow-up, can often render non-feasible the salvage surgery

in elderly patients [6]. In this setting, despite advances in con-

servative laryngeal surgery and radiotherapy, total laryngec-

tomy remains a valuable and reliable treatment for advancer

pharyngo-laryngeal cancers in elderly patients

The classification of the operative risk according to the

ASA score does not seem to have a predictive value in el-

derly patients. An integration of a comprehensive geriatric

assessment (CGA) is needed.

Transoral laser surgery hasachieved a key position in min-

imally invasive treatmentconcepts in theears, nose andthroat

area, especially for the treatmentof malignancies of the upper

aerodigestive tract. The CO2 laser is the approach most com-

monly used. In the hands of experienced surgeons it remains

a valuable option for elderly patients since it is a minimally

invasive, functional and rapidly performed treatment [32].

4. Chemotherapy

Elderly patients are often excluded from chemotherapy

clinical trials, because they are considered subjects at high

risk for toxicity from cytotoxic drugs [1]. A theoretical back-

ground exists for an increase in toxicity, but clinical stud-

ies, aimed at evaluating the relationship between toxicity

from chemotherapy and age, are very few [33]. Standard

chemotherapy for H–N carcinomas is the Al-Sarraf regi-

men, a sequential combination of cisplatin and infusional

5-fluorouracil (5-FU) that, in thetreatment of locoregional re-

currences and/or distant metastases achieves a response rate

of 40–50% (CR 5–10%) and in neoadjuvant setting (CT–RT)

for organ preservation of 70–88% (CR 40–60%) [34]. The

reduced functional reserve of elderly patients can potentially

alter the pharmacokinetic of cytotoxic drugs and reduce the

capacity of healthy tissues to recuperate. Moreover, polyphar-

macy, typical of the older age can be responsible for phar-

macokinetic and pharmacodynamic interactions between the

differenttypesof drugs. Table 7 reportsdata on toxicity of cis-

platin and 5-FU in elderly patients with miscellaneous solid

tumors [2–4,33,35]. Cisplatin is associated with an increase

in peripheral neuropathy, anemia, and nephropathy. Gen-erally, sensory-motor peripheral neuropathy initially arises

with paresthesia, loss of deep tendinous reflex and tactile

sensitivity and then with muscular weakness that sometimes

severely affects patient’s autonomy [33,35]. In vitro studies

have demonstrated that elderly patients have a reduced capac-

ity to repair cisplatin-induced DNA damages. The inter-chain

bindings that are present on the monocytes of young subjects

treated with cisplatin, are almost completely eliminated af-

Table 7

Acute toxicity related to cisplatin and 5-fluorouracil in elderly patients

Toxicity Cause

Cisplatin

Peripheral neuropathy Reduced capacity of DNA-damage

reparation

Anemia Pharmacokinetic alterations

Multiorgan functional reduction

Nefrotoxicity Reduced glomerular filtration rate

5-Fluorouracil

Cardiotoxicity Cardiomiopathy

Mucositis Pharmacokinetic alterations

Reduced intracellular concentration of

dihydropirimidine carboxylase

Leukopenia Reduced bone marrow reserve


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ter 24–48 h from the exposure to the drug. In the monocytes

from elderly patients,the capacity to repairafter 48 h is signif-

icantly lower and has a higher degree of inter-individual vari-

ability as compared to younger patients [36]. Treatment with

5-FU, mostly administered in continuous infusion at high

dose, determines in elderly patients a potential increase in

cardiotoxicity, mucositis and leukopenia. Cardiotoxicity hasits main cause in the frequent co-existence of a cardiomyopa-

thy and/or alterations in electrolytes that occur during treat-

ment. Mucositis is in general more severe than in younger

patients and requires significantly longer time to recuperate.

One the main risk factors is the physiologic decline in aging

of the intracellular concentration of the dehydropirimidine

decarboxylase, the main enzyme involved in the catabolism

of the drug. Leukopenia is mostly determined by a reduc-

tion in the bone marrow functional reserve and its severity is

strictly related to the age of the patient [33,35,37].

Schneider reported on 71 patients aged 70 or older treated

with cisplatin and 5-FU, with an age-adjusted dose regimen.

Patients aged 70–79 years were treated with standard-dosageof cisplatin 100 mg/m2 /day 1 and 5-FU 1000 mg/m2 /day con-

tinuous infusion for 5 days, while those aged 80–84 years

with a reduction of the dosage by 20% and those older than

85 years with a reduction of the dosage of 30%. The objective

response rate was 79% (CR 52%) among the 54 patients aged

70–79 years and only 31% (CR 6%) among the 17 patients

aged 80 or older. In the group of patient older than 80 years,

patients responsive to chemotherapy were in better general

conditions as compared to the non-responsive patients. My-

ocardial ischemia, the only form of cardiotoxicity that was

examined in this study, was very low and superimposable in

the two age groups, witha rateof 2%in the firstgroupand3%in the second [38]. Chemotherapy seems to be feasible also in

patients aged 80 years or older, but a reduction in the dosage

dependent only on the chronological age can seriously affect

the efficacy of the treatment.

The Eastern Cooperative Oncology Group(ECOG) has re-

cently analyzed data from two randomizedstudies employing

intensive cisplatin-based regimen for the treatment of patients

with recurrent/metastatic H–N carcinoma, to evaluate the

outcome of elderly patients. Fifty-three patients aged 70–80

years had comparable response rates (28% versus 33%) and

survival outcomes (1-year survival 26% versus 33%) com-

pared with 346 younger patients. However, severe nephro-

toxicity, thrombocytopenia and diarrhea were more common

in the elderly than in the younger patients, occurring in 8%

versus 2% (P = 0.04), 26% versus 12% (P = 0.009) and 17%

versus 3% (P = 0.0002), respectively [39]. Strategies to ame-

liorate toxicity should be pursued in the elderly.

In the era of organ preservation, chemotherapy combined

with RT has a paramount importance in the treatment of H–N

tumors [34]. Elderly patients, an emerging problem for pub-

lic health in the industrialized countries, cannot be excluded

a priori from programs of organ preservation. Patients aged

70–79 years who are independent on the functional point of

view and do not show severe comorbidities must be treated

in the same exact manner as younger patients, but during the

treatment, supportive treatment must be increased. In partic-

ular the administration of bone marrow growth factors, such

as G-CSF and erythropoietin (rhEpo) must be always eval-

uated. Data concerning the use of rhEpo in the prevention

of chemotherapy-related anemia in early or advanced H–N

cancer are not extensive [40–43]. The role of recombinantrhEpo in preventing or correcting chemotherapy-related ane-

mia in elderly patients with H–N cancer has been recently

focused by Gebbia et al. [43]. In this study, recombinant

rhEpo is able to prevent anemia, to reduce transfusion re-

quirements and improve quality of life parameters in patients

treated with carboplatin and 5-FU as compared to untreated

controls.

The use of amifostine in the prevention of mucositis from

CT is still controversial and should be eventually considered

only when RT is administered [44]. On the other hand, topical

use of GM-CSF, administered as oral gargles, might accel-

erate the resolution of mucositis, even if an improvement of

the quality of life has never been clearly demonstrated.In all patients particular attention should be paid to main-

tain an adequate nutritional status, since malnutrition can

affect both efficacy of chemotherapy and patients survival

[2–4,33,35]. In fact, nutrition is often deficient in elderly pa-

tients in general, due to several reasons, such as depression,

poor dentition, functional impairment, cognitive impairment,

lack of appetite due to chronic comorbid disease, and lack of

caregiver. Elderly patients with cancer may also face addi-

tional problems brought on by chemotherapy, such as nau-

sea, vomiting, diarrhea, and painful oral ulcerations. Correct-

ing malnutrition and establishing a suitable dietary plan are

simple measures that can substantially improve the patient’sclinical outcome and quality of life.

The main concern with respect to emotional conditions

in these patients is depression, which is common in both

geriatric and oncology populations, and is therefore espe-

cially common in elderly patients with cancer. Depression

and cognitive disorders can be mistaken for each other and

either type of condition could adversely affect the patient’s

functional status and the outcome of cancer treatment.

Patients older than 80 years, patients not functionally in-

dependent and/or with severe associated comorbidities, must

be treated in the setting of new treatment protocols, in which

the choice of the regimen employed and the dose of the

drugs must be adjusted according to a comprehensive geri-

atric evaluation (CGA)-based score. CGA is an instrument

aimed at evaluating the overall status of the patient and its

efficacy has been documented by several randomized study

[2–4,33,35,45]. We recently described the preliminary results

of an ongoing trial using CGA to tailor the treatment of pa-

tients affected by aggressive non-Hodgkin’s lymphoma; to

date, 23 patients have been treated with reasonable efficacy

and toxicity [46]. Noteworthy is the fact that in none of the

studies concerning treatment in H–N cancers that have been

published so far in the literature, a CGA has been used in the

evaluation of the clinical status of the elderly patient.


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5. Combined modality treatment

To address locoregional control and systemic tumor dis-

semination, combined modality therapies have been evalu-

ated. To date, induction chemotherapy has failed to improve

survivalrates conclusively. However it has beenusedsuccess-

fully with subsequent radiotherapy in studies aimed at organpreservation. Similarly, adjuvant chemotherapy has not been

clearly demonstrated to be effective [47].

A number of important factors should be considered in

deciding the best therapy for the patient when chemoradio-

therapy is used in a combined modality plan for the cura-

tive treatment of locally advanced H–N cancer. It is essential

to identify appropriate patients for combination therapy. Pa-

tients with underlying comorbidities, age-related frailty, or

underlying severe psychosocial problems are not good candi-

dates for highly intensive treatment plans. Many physicians,

however, are pressured to overestimate patient tolerance to

qualify a patient for the best treatment. These patients may

be better served by less complicated or less potentially toxic

treatmentplans. Thebiology of thepatient’s disease also must

be considered in selecting or planning a combined modality

approach. Patients with rapidly growing tumors or with ad-

vanced nodal presentation are less likely to be cured with

surgery or radiation therapy alone and are most likely to ben-

efitfrom theaddition of chemotherapy. Thelocation andlocal

extension of the primary tumor is also an important factor in

selecting therapy. Small lesions in the larynx, base of tongue

and hypopharynx may benefit from an organ preservation ap-

proach, while similarlysizedlesions in theanteriororal cavity

might be better treated with direct surgical and radiotherapy

approaches. The goals of chemotherapy in a treatment planmust be considered in determining the best therapy: appropri-

ate goals in the curative treatment of locally advanced H–N

cancer include organ preservation, improved survival, opti-

mization of quality of life and reduction in metastases [34].

A recent study by Airoldi et al. [48] assessed treatment

toxicity, patient compliance, and clinical results in 40 pa-

tients >70 years who were treated with concomitant adjuvant

chemoradiotherapy. The results of this study confirm previ-

ously established beliefs that adjuvant chemioradiotherapy

can be successfully applied in older patients who are fit to

receive such treatment. The role of the combination therapy

in the post-operative setting can only be validated by phase

III trials. A comparison of the results of the study by Airoldi

with those of the group 70 years or older treated with radio-

therapy alone suggests that superior results can be obtained

with chemoradiotherapy compared with radiotherapy alone

in this age group.

6. General conclusions

In H–N cancers in elderly patients, as well as in all other

tumors, therapeutical planning must be based not only on

tumor characteristics, but also on the physiological, rather

than the chronological age the patient. The main clinical

problem is, therefore, the selection of patients to be admin-

istered anticancer treatment. In patients aged 70 or older,

CGA and a multidisciplinary approach are the crucial points

for an adequate therapeutical planning. A determinant fac-

tor in the prognosis of the patient with H–N tumors of any

age is the multidisciplinary management of the disease. Sur-geons, radiation-therapy specialists, medical oncologists and

geriatricians must actively cooperate in a multidisciplinary

setting.

Reviewers

Dr. Ashok R. Shaha, MD, FACS, Memorial Sloan-

Kettering Cancer Center, Head and Neck Service, 1275 York

Ave, New York, NY 10021, USA.

Prof. François Eschwege, Département de Radiothérapie,

Institut Gustave Roussy, 39, rue Camille Desmoulins, F-

94805 Villejuif, France.Prof. Jean-Claude Horiot, Directeur, Centre de Lutte con-

tre le Cancer G.F. Leclerc, 1, rue Marion, BP 77980, F-21079

Dijon, France.

Dr. Philippe Pasche, Privat Docent & MER, Médecin Ad-

joint, Service d’ORL et de Chirurgie Cervico-faciale, Centre

Hospitalier Universitaire Vaudois (CHUV), Av. du Bugnon,

CH-1011 Lausanne, Switzerland.

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Biographies

Daniele Bernardi M.D. was born in 1961 and gradu-

ated at the University of Padova in 1988, where he ob-

tained the Specialty Degree in Medical Oncology in 1994.

He is a Member of the American Society of Clinical Oncol-

ogy (ASCO) and the Italian Society of Medical Oncology

(AIOM); he is presently a Staff Physician at the National

Cancer Institute of Aviano, Italy. He has performed sev-

eral observerships in highly esteemed institutions abroad,

including the Karolinska Institute of Stockholm, Sweden,


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the Stanford University of Palo Alto, CA, USA and the H.

Lee Moffitt Cancer Center of Tampa, FL, USA. His cur-

rent research interests include tumors in the elderly, genito-

urinary tumors and HIV-related malignancies, areas where

he has authored numerous published articles.

Luigi Barzan is the chairman of the Division of Otolaryn-gology, General Hospital of Pordenone and consultant at the

Centro di Rifermento Oncologico of Aviano, Italy. His ac-

tivity is focused on head and neck oncologic surgery. He

has published over 130 papers in Italian and international

journals, participates in many mono- and multi-institutional

research projects and protocols of therapy and is an active

member of scientific societies.

Giovanni Franchin is a full time hospital assistant at the

Division of Radiotherapy of the Centro di Riferimento On-

cologico of Aviano, Italy. His areas of interest are therapy

of solid tumors, Head & Neck cancer, Lung cancer, Thyroid

cancer, Innovative Radiotherapy Modalities (Conformal Ra-diation Therapy and IMRT). He is a member of the ESTRO

organization.

Roberta Cinelli is a specialist in Infectious Diseases and

works at the Division of Medical Oncology A of the Centro

di Riferimento Oncologico of Aviano, Italy. She is involved

in several mono- and multi-institutional research projects

and protocols of therapy. She is author and co-author of over

20 publications in international journals.

Luca Balestreri is full time hospital assistant at the Divi-

sion of Radiology of the Centro di Riferimento Oncologico

of Aviano, Italy. His areas of interest are: Magnetic Res-

onance Imaging, Computerized Tomography and Interven-

tistic Radiology, particularly regarding early diagnosis and

staging in oncologic setting.

Umberto Tirelli is the director of the Department of Med-

ical Oncology and the head of the Division of Medical

Oncology A at the Centro di Riferimento Oncologico of

Aviano, Italy. His activity is focused on tumors, in par-

ticularly tumors in the elderly, malignant lymphomas and

new antineoplastic drugs; on infectious diseases (neoplas-

tic complications, sexual transmission, discrimination); and

recently on CFS. He has published over 540 papers in the

most important international and national journals. He also

participates in many mono- and multi-institutional research

projects and is an active member of international scientific

societies.

Emanuela Vaccher works as a Senior Assistant at the Di-

vision of Medical Oncology A at the Centro di Riferimento

Oncologico of Aviano, Italy, She is an active member of the

Head-Neck cancer CRO Committee and the Chief of the

“Terapia medica dei tumori del capocollo” Unit. She coor-

dinates the activity of the Scientific Secretariat for the Ital-

ian Cooperative Group on Tumors and AIDS (GICAT). She

authored over 250 publications and more than 280 commu-

nications.

CA in Elderly Patients

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