The challenge of treating older patients with pancreaticobiliary malignancies

Pancreatic and biliary tract cancers are aggressive malignancies. They commonly present with metastatic or unresectable disease. Those that do present with resectable cancer have high rates of recurrence. Despite recent advances in surgical technique, chemotherapy, and radiotherapy regimens, they are associated with poor survival outcomes. These cancers represent an exception to the trend of improved overall survival evident in most malignancies in recent decades. Depending on the goal of treatment, active management of pancreatic and biliary cancers involves surgery, chemotherapy, and radiation therapy, either alone or in combination. Both pancreatic and biliary tract cancers have a preponderance in the older population. Older patients are a heterogeneous group; although tolerability of multimodality treatment may be a challenge for some, many fit older patients may be undertreated based on their age alone. The growing field of geriatric oncology has highlighted the importance of a comprehensive assessment of these patients, and not relying on age alone as a discriminating factor for treatment. Management of older patients with pancreaticobiliary cancers is particularly challenging owing to limited prospective data in this population. As such, there is uncertainty with regard to optimal treatment approaches for these patients. In this article, we outline the therapeutic options available to patients with localized or advanced pancreatic and biliary tract cancers, and the evidence for specified treatment options in the elderly. We examine the inclusion and outcomes of elderly patients in relevant clinical trials; the morbidity that may be encountered by elderly patients receiving specified treatments and the tools that may assist the physician in selecting elderly patients for particular treatments.