With the aging of the population, virtually all of the subspecialties of oncology will soon be concerned primarily with the care of older patients. While there is not one precise definition of the age of “geriatric” patients, it is clear that the aging of our society has necessitated a focus on the older segment of the population.
It has long been recognized that the most significant risk factor for the development of cancer is aging. Together with the epidemiologic shift, this has resulted in a striking increase in the number of older patients with cancer, which, in turn, has markedly increased the burden of cancer on our nation.1 Cancer compromises the life expectancy as well as the active life expectancy of older individuals. Moreover, the disease and its treatment are among the prime causes of disability in older individuals.
Early Efforts in a New Field
The traditional way in which cancer is studied—ie, clinical trials focusing on younger, healthier patients—has left us with a void in the data needed to manage older patients in an evidenced-based fashion. These trials often fail to establish the validity of cancer treatment in the elderly, and may also fail to provide information related to the long-term complications of treatment, including decline in function.2
Among the first to recognize this issue was Dr. Rosemary Yancik, who in 1981 organized a symposium sponsored by the National Cancer Institute and the National Institute on Aging. The conference reached a number of conclusions and set a research agenda, as described in the 1983 monograph, “Perspectives on Prevention and Treatment of Cancer in the Elderly.”3
In his 1988 ASCO Presidential Address, subsequently published in the Journal of Clinical Oncology, Dr. B.J. Kennedy also encouraged the study of aging and cancer.4 He stated, “[O]ur society need not ration how we will treat our disadvantaged members, but should continue to seek those preventive and positive measures that can shorten our later period of morbidity. A very major cancer load will persist well into the 21st century, even if the attempts at prevention are eventually a total success. There is a developing knowledge on aging. Care of the older person needs to be part of medical education and oncology education. Research will help attain a desirable quality of life with aging and a reduced morbidity.”
Drs. Yancik and Kennedy pointed us in the right direction, but their goals have proven to be somewhat elusive.
Important Strides
Since these publications, studies of older patients with cancer have revealed a significant amount of important clinical information. This growing body of knowledge has included the degree and severity of comorbidity and its effect on treatment, the role of polypharmacy, and the various social and financial problems facing older patients with cancer.
The underrepresentation of older patients in clinical trials has been amply documented.5 The adverse outcomes of inadequate dosing and supportive care in both curative and palliative treatments have been demonstrated in numerous treatment settings. Even when clinical trials are available, barriers to participation of older patients have been shown to be primarily due to physician reluctance due to fear of toxicity, limited expectation of benefit, or ageism.
Important strides have been made in the evaluation of older patients through various methodologies of geriatric assessment. The comprehensive geriatric assessment (CGA), developed by geriatricians, is a multidisciplinary evaluation of the older patient encompassing several important clinical domains.6 Researchers in this area have shown that traditional measures of performance in oncology are not adequate in older patients and that geriatric-specific measures (ie, activities of daily living, instrumental activities of daily living) have a much greater predictive value.7 Recent advances in the assessment of geriatric oncology patients were reported with the publication of two important trials.8,9 These newer assessment tools need to be validated in prospective trials, but they appear to be predictive and easy to administer.
Professional Organization Activities
Some oncology professional societies and organizations have shown a major interest in Geriatric Oncology. In 1995, the Cancer and Leukemia Group B (CALGB) organized a Cancer in the Elderly Committee.10 The formation of this committee has led to a number of completed and published studies in barriers to participation, supportive care, and cancer therapeutics. The newly formed Alliance of CALGB, the North Central Cancer Treatment Group (NCCTG), and the American College of Surgeons Oncology Group (ACOSOG) will strengthen this committee. The Gynecologic Oncology Group (GOG) recently formed an Elderly Task Force and has initiated a clinical trial in ovarian cancer (GOG 273).
ASCO sponsored a clinical practice forum in 2000, “Cancer Care in the Older Patient,” as part of its Curriculum Series and has incorporated geriatrics in the ASCO University program. The Annual Meeting has included numerous Education Sessions, Clinical Science Symposia, and oral presentations emphasizing Geriatric Oncology, and has established a Geriatric Oncology track.
The International Society of Geriatric Oncology (SIOG), with headquarters in Switzerland, has implemented a number of task forces to evaluate the current literature in geriatric oncology and to make treatment recommendations. Its annual meeting is a forum for updates and discussions about moving the field forward.
The National Comprehensive Cancer Network (NCCN) has published practice guidelines for Senior Adult Oncology. The Cancer and Aging Research Group have been particularly productive in the development of geriatric assessment. A major milestone is the Journal of Geriatric Oncology, which began publication in 2010.
Further Changes Needed
Despite all of the changes that have taken place in the past few years, there is still much that needs to be done. There needs to be improvement in the assessment of the older patient to allow clinicians to make appropriate treatment decisions. An easily administered, predictable measure is critical. Practical treatment questions include whether adjuvant therapy is appropriate based on potential benefit of treatment vs predicted survival; what is the best palliative regimen; and when is best supportive care appropriate.
Clinical trial participation needs to be encouraged. Clinical trial design, statistical analysis, and trial reporting need to incorporate the specific needs of older patients and provide practical information for the clinician. Endpoints need to be practical in the elderly—for example, maintenance of independence, avoiding functional decline, and time without symptoms. The publication of large trials in which older patients have participated should give age-associated data, a practice that is still lacking.11
An Evolving Society
American society has evolved over the past few decades in terms of how we view aging. An age of 65 years is, for the most part, no longer considered elderly. People are often very active into their 70s and 80s. Chronologic age should not be the sole parameter used in treatment decisions. Physicians caring for older patients need to be educated about these very important issues.
Older patients should be systematically evaluated to the degree necessary to make evidence-based decisions. In addition, studies in the basic sciences, including the biology of aging, need to be explored. As older patients become the majority of the patients we evaluate and treat, they need to become the focus of our endeavors. Our elders deserve nothing less. ■
Disclosure: Dr. Lichtman reported no potential conflicts of interest.
Dr. Lichtman is a Medical Oncologist at Memorial Sloan-Kettering Cancer Center in Commack, New York, and participates in the 65+ Clinical Geriatric Program at the Center. He is Professor of Medicine, Weill Cornell Medical College.
References
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2. Muss HB, Woolf S, Berry D, et al: Adjuvant chemotherapy in older and younger women with lymph node-positive breast cancer. JAMA 293:1073-1081, 2005.
3. Yancik R (ed): Perspectives on Prevention and Treatment of Cancer in the Elderly. New York, Raven Press, 1983.
4. Kennedy BJ: Aging and cancer. J Clin Oncol 6:1903-1911, 1988.
5. Hutchins LF, Unger JM, Crowley JJ, et al: Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 341:2061-2067, 1999.
6. Cohen HJ, Feussner JR, Weinberger M, et al: A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 346:905-912, 2002.
7. Extermann M, Overcash J, Lyman GH, et al: Comorbidity and functional status are independent in older cancer patients. J Clin Oncol 16:1582-1587, 1998.
8. 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.
9. Extermann M, Boler I, Reich RR, et al: Predicting the risk of chemotherapy toxicity in older patients: The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer. November 9, 2011 (early release online).
10. Cohen HJ, Muss HB: The Cancer and Leukemia Group B Cancer in the Elderly Committee: Addressing a major cancer need. Clin Cancer Res 12(11 Pt 2):3606s-3611s, 2006.
11. Lichtman SM: Call for changes in clinical trial reporting of older patients with cancer. J Clin Oncol. February 13, 2012 (early release online).
Adapted, in part, from Lichtman SM, Balducci L, Aapro M: Geriatric oncology: A field coming of age. J Clin Oncol 25:1821-1823, 2007.
