Caring for the Frail, Older Patient With Cancer: Four Practical Approaches


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Cancer may be a disease of aging, but data suggest that older patients with cancer are undertreated, especially with respect to chemotherapy. One analysis showed that approximately 40% of patients in their 70s—and 60% of patients in their 80s—do not receive adjuvant therapy after surgery for colon cancer.1 According to Aminah Jatoi, MD, a medical oncologist at the Mayo Clinic, in Rochester, Minnesota, although older patients may suffer greater toxicity when they are treated, they can still enjoy good quality of life with chemotherapy.

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“Health-care providers should be cautious when treating older patients with any type of antineoplastic therapy, as adverse events are somewhat worse in this population. But it’s important not to give up on these patients,” said Dr. Jatoi. “There’s a balance that can be reached with cancer therapy to enable many older patients to live longer and to maintain a good quality of life.”

At the 2017 Palliative and Supportive Care in Oncology Symposium, Dr. Jatoi presented four practical approaches that may make therapeutic decisions easier for older cancer patients: consider clinical trial enrollment, use prognostic tools, employ geriatric assessment, and consider initial chemotherapy dose reductions.2

Clinical Trial Enrollment

As Dr. Jatoi reported, less than 5% of patients with cancer in the United States are enrolled on a clinical trial, but this -“abysmal percentage” is even lower for older patients, who may be the predominant group within a certain cancer type but are the minority when it comes to accrual for cancer clinical trials. And yet, she added, it is through enrollment and following patients over time that researchers discover how best to treat all patients but specifically older patients with cancer.

Practical Considerations in Cancer Care for Older Patients

  • Clinical trial enrollment, prognostic tools for adjuvant chemotherapy, geriatric assessment tools, and initial dose reductions for chemotherapy may make therapeutic decisions easier for older cancer patients.
  • Geriatric assessment may help in the decision-making process of whether a patient can tolerate chemotherapy or not.

Dr. Jatoi and colleagues conducted a study looking at trials specifically designed to accommodate older patients (either with dose reductions or with another pharmacologic rationale for dosing) and compared those with trials that included older patients not designed specifically for them. They found that patients in elderly-specific trials had much better toxicity profiles.3 These patients suffered lower rates of severe adverse events with no statistically significant differences in survival.

“These data suggest we should try to enroll older patients in trials, particularly trials designed for older cancer patients, in an effort to learn how best to optimize cancer therapy in older populations,” concluded Dr. Jatoi.

Prognostic Tools

According to Dr. Jatoi, in the setting of adjuvant chemotherapy, where the decision to proceed with treatment affords patients a better chance of achieving cure, prognostic tools can help clinicians and patients make better treatment decisions. An analysis of large cooperative group studies by Kimmel et al looked at patients with breast cancer who were receiving adjuvant chemotherapy.4 Using an electronic prognostic tool relevant to older individuals’ general health, researchers assessed how long these patients could live if cancer were removed from the equation and then compared that number with actual rates of mortality. Surprisingly, commented Dr. Jatoi, cancer patients actually performed better in terms of mortality in these scenarios if cancer were removed from the equation.

“This type of tool can be invaluable when talking with older patients and deciding on whether to pursue adjuvant chemotherapy,” she explained. “Oncologists could factor in a patient’s morbidities and provide possible timetables with and without chemotherapy…. A prognostic tool makes those conversations so much easier.”

Geriatric Assessment

According to Dr. Jatoi, given the limitations of Karnofsky and Eastern Cooperative Oncology Group (ECOG) Scores, which are “inadequate in older patients,” additional tools must be used to predict how a patient might tolerate cancer treatment. By applying multiple variables within a geriatric assessment—a multidimensional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances—Arti -Hurria, MD, and colleagues at the City of Hope and within the Cancer and Aging Research Group (see article beginning on page 25) have devised a risk-stratification schema to predict how patients will tolerate chemotherapy (www.mycarg.org/chemo_toxicity_calculator).5

The geriatric assessment can help us understand that certain patients might not be good candidates for chemotherapy.
— Aminah Jatoi, MD

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“The geriatric assessment only takes 22 minutes to complete. It’s feasible, detects frailty issues, and helps predict toxicity,” said Dr. Jatoi, who emphasized that sometimes the tool helps clinicians decide not to give chemotherapy. “Specific numerical scores derived from this tool can tell us if a patient has a high likelihood of suffering grade 3 or worse toxicity with -chemotherapy.”

In a prospective study of elderly patients with advanced non–small cell lung cancer, a comprehensive geriatric assessment was compared with treatment allocation based on performance status and age.6 Although treatment allocation on the basis of geriatric assessment did not improve treatment failure–free or overall survival, it did reduce treatment toxicity, revealed Dr. Jatoi.

“The geriatric assessment can help us understand that certain patients might not be good candidates for chemotherapy,” Dr. -Jatoi added. “Sometimes such information is of value when talking with older cancer patients, as decisions are made about whether or not to pursue chemotherapy.”

Initial Chemotherapy Dose Reduction

Finally, as Dr. Jatoi reported, initial chemotherapy dose reductions should be considered in older patients. In the -FOCUS2 trial, which looked at chemotherapy options in elderly and frail patients with metastatic colorectal cancer, 459 patients were randomly assigned to one of four study arms.7 Although the primary endpoint of progression-free survival was not met, when oxaliplatin was given with an initial dose reduction of approximately 20%, older patients were able to tolerate the treatment better.

“The bottom line is we can’t just rely on performance score when deciding on cancer therapy for older patients. We need more data to make better clinical decisions,” said Dr. Jatoi. “Sometimes that means referral to a geriatrician to gain collaboratively a sense of how well a given patient might tolerate chemotherapy. At the end of our assessment, we may decide in conjunction with the patient not to treat with chemotherapy. We need to take the extra time with these patients.” ■

DISCLOSURE: Dr. Jatoi has received research funding from Boston Biologics, Entera Health, the Andersen Foundation, the Minnesota Ovarian Cancer Alliance, and the National Cancer Institute.

REFERENCES

1. Muss HB, Bynum DL: Adjuvant chemotherapy in older patients with stage III colon cancer: An underused lifesaving treatment. J Clin Oncol 30:2576-2578, 2012.

2. Jatoi A: An approach to care for the vulnerable, frail patients as they navigate cancer care. 2017 Palliative and Supportive Care in Oncology Symposium. General Session 2. Presented October 27, 2017.

3. Jatoi A, Hillman S, Stella P, et al: Should elderly non-small-cell lung cancer patients be offered elderly-specific trials? Results of a pooled analysis from the North Central Cancer Treatment Group. J Clin Oncol 23:9113-9119, 2005.

4. Wang LE, Shaw PA, Mathelier HM, et al: Evaluating risk-prediction models using data from electronic health records. Ann Appl Stat 10:286-304, 2016.

5. Hurria A, Togawa K, Mohile SG, et al: Predicting chemotherapy toxicity in older adults with cancer: A prospective multicenter study. J Clin Oncol 29:3457-3465, 2011.

6. Corre R, Greillier L, Le Caër H, et al: Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non-small-cell lung cancer: The phase III randomized ESOGIA-GFPC-GECP 08-02 study. J Clin Oncol 34:1476-1483, 2016.

7. Seymour MT, Thompson LC, Wasan HS, et al: Chemotherapy options in elderly and frail patients with metastatic colorectal cancer (MRC FOCUS2): An open-label, randomised factorial trial. Lancet 377:1749-1759, 2011.


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