Outcomes in patients aged ≥80 years with Hepatopancreaticobiliary (HPB) malignancies

Introduction: The elderly are underrepresented in oncological clinical trials, and thus data is limited on treatment practices. The incidence of HPB malignancies is higher in the elderly and data on outcomes, particularly in those aged ≥80 years, is lacking. Objectives: This study aimed to assess patient outcomes in those ≥80 years with a HPB malignancy seen at a tertiary referral centre, The Christie NHS Foundation Trust, over a 5 year period. Methods: Patient demographics were collected retrospectively and sequentially using on-line case note review. Survival was calculated using the Kaplan-Meier method and prognostic factors using log rank analysis. Results: Of 1423 patients with a HPB malignancy seen between January 2012 and January 2017, 142 (10%) were ≥80 years. In <80 and ≥80 year old cohorts: 52%/55% were male, 78%/75% Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2, 34%/18% had no co-morbidities, primary site of malignancy: pancreas 56%/58%, hepatocellular carcinoma (HCC): 6%/7%, and biliary tract cancer (BTC): 38%/35%, ampulla of vater: 6%/8%, respectively. Management in those patients <80 and ≥80 years included best supportive care (BSC): 13%/49%, any systemic anti-cancer therapy (SACT): 62%/28%, declined treatment: 0%/13%, surveillance: 5%/4%, other: 20%/6%. Of patients aged ≥80 years who received SACT, 87% received single-agent and 13% double-agent regimens. Only 27% of older patients completed all planned SACT, 18% stopped treatment due to patient decision, 15% due to deteriorating PS, 15% due to toxicity, 13% of patients died and 12% had disease progression. Median overall survival (OS) in patients <80 years was better in comparison to patients ≥80 years in HCC (17.7 vs 8.8 months), pancreatic (8.4 vs 6.3 months) and BTC (14.4 vs 9.0 months), with the exception of ampulla of vater (31.9 vs 36.9 months). Patients <80 (N=649) years receiving palliative SACT had similar median OS to those ≥80 years (N=37) (10.1 months [95% CI 7.6-12.6] vs 9.6 months, [95% CI 8.6-10.8]. In those aged <80 and those ≥80 years, palliative SACT gave an OS advantage over BSC: (9.6 months [8.6 to 10.8] vs 6.7 months [95% CI 4.7 to 8.1] for patients <80 years and 10.1 months [95% CI 7.6-12.6] vs 6.4 months [95% CI 4.6-7.4] for patients ≥80 years) respectively. On log-rank analysis, ECOG PS in both age groups (P<0.001), Adult Co-morbidity Evaluation-27 (ACE-27) score (P=0.03) in those < 80 years, and stage in those ≥80 years was prognostic for OS (P<0.001). Conclusions: Baseline factors were similar in both age cohorts but more co-morbidities were present in patients ≥80 years. Patients <80 years were more likely to receive SACT. Patients aged ≥80 years receiving palliative SACT had an equivalent benefit in OS to younger patients; however, they were more likely to decline treatment and few completed planned SACT. Therefore, SACT may be appropriate treatment for patients’ ≥80 years following careful baseline patient assessment with appropriate tools.