These [new] tools are shorter and easier to give (and results easier to evaluate) than the Comprehensive Geriatric Assessment.
—Supriya Gupta Mohile, MD, MS
More than 1,400 people from 62 countries attended the 2012 Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) International Symposium on Supportive Care in Cancer, held in New York last June. One of the featured sessions, which was jointly sponsored by the International Society of Geriatric Oncology (siog.org), centered on improving oncology care for older patients with cancer, an increasing concern for oncologists as the rate of older adults with cancer rises.
According to the National Institute on Aging, the number of people aged 65 and over is expected to double between 2000 and 2030, growing to 72 million and representing nearly 20% of the U.S. population. Because the chances of developing cancer increase with age—60% of all cancers and 70% of cancer-related deaths occur in people 65 and older—the incidence of cancer among this population is expected to skyrocket by 67%.
More Treatment Challenges
“Cancer is very common among older patients, and oncologists are increasingly caring for patients who are older than 70. We have to start integrating geriatric oncology more into our practices in order to make better decisions for our patients,” said Supriya Gupta Mohile, MD, MS, Associate Professor of Medicine and Director of the Geriatric Oncology Program at the University of Rochester, New York, and a presenter at the MASCC/ISOO conference.
For myriad reasons, older patients with cancer can be more challenging to treat than their younger counterparts, said Dr. Mohile. For example, the presence of two or more comorbidities, disabilities that require help with performing routine daily activities such as bathing and feeding, and cognitive impairment resulting from dementia, delirium, or depression can all complicate treatment decisions. Determining the most effective—and safe—chemotherapy agents for geriatric patients with cancer and how to assess whether older patients will even reap a benefit from such therapy were the focal concerns at the meeting’s geriatrics session.
More Effective Assessment Tools
Clinical tools such as the Comprehensive Geriatric Assessment (CGA), Karnofsky performance status, and Eastern Cooperative Oncology Group (ECOG) performance status are currently available to help oncologists measure patients’ functional status, comorbid conditions, cognition, and medication use as well as aid in predicting appropriate treatment, disease prognosis, and chemotherapy toxicities. That said, newer, more efficient assessment tools are being developed.
The Chemotherapy Risk Assessment Scale for High-age Patients (CRASH) is specifically designed to score laboratory test values and geriatric assessment parameters besides age, such as functional and nutritional status, comorbidity, cognition, psychological state, and social support, to predict the risk of severe toxicity from chemotherapy in older patients. The CRASH score has been validated in clinical studies as a new tool to predict significant differences in the risk of severe chemotoxicity and as a way to individualize treatment on an objective basis. It is moving into greater clinical use.
The Cancer and Aging Research Group (CARG) incorporates measures within geriatric assessment, which is also meant to identify risk factors for chemotherapy toxicity in older patients with cancer and develop a risk stratification schema for chemotherapy toxicity. The Cancer and Aging Research Group is in the process of validating the CARG chemotoxicity assessment tool.
“Both of these tools are shorter and easier to give (and results easier to evaluate) than the Comprehensive Geriatric Assessment. They will help identify patients who are more at risk from treatment, especially when you have a patient with a very poor prognosis from a difficult cancer and you know that the chemotherapy doesn’t work very well even in younger patients,” said Dr. Mohile, a CARG researcher and coauthor of a study on predicting chemotherapy toxicity in older adults with cancer.2 “These tools can help oncologists decide whether or not to initiate the treatment, which is sometimes worse than the cancer. Some patients may make different decisions if we approach the discussion with more information on toxicity.”
Increasing Clinical Trial Participation
Even with more effective assessment tools to measure how well older patients with cancer will fare during chemotherapy, one of the central roadblocks to better care for aging individuals is their lack of participation in clinical trials. As a result, less is known about the risks and benefits of cancer treatment in this age group, and there are fewer medical guidelines that specifically address the evaluation and treatment of this population.
“There are very few people over the age of 75 enrolled in clinical trials,” said Stuart M. Lichtman, MD, FACP, FASCO, Attending Physician, 65+ Clinical Geriatrics Program at Memorial Sloan-Kettering Cancer Center and Professor of Medicine at Weill Cornell Medical College, New York. “We talk about evidence-based medicine, but there is no evidence-based medicine for treating older people, so everything is an extrapolation to some degree.”
Co-chair of the geriatrics panel session, Dr. Lichtman also presented information at the MASCC/ISOO conference on the effect of renal function in the aging patient with cancer.3 He stressed that serum creatinine blood level alone is insufficient as a means of evaluating renal function. Moreover, obesity, cardiovascular disease, and drugs that affect renal function, such as nonsteroidal anti-inflammatory agents, all need to be considered before choosing a chemotherapy regimen and dosage.
“Chemotherapy dose reduction for renal dysfunction depends mainly on the type of therapy you are giving. If you are giving nephrotoxic chemotherapy, such as cisplatin, you have to provide all the supportive care measures around that therapy, including hydration, to make it safe for elderly patients,” said Dr. Lichtman.
However, Dr. Lichtman cautioned, there is insufficient data to allow oncologists to modify their clinical decisions about many standard chemotherapy drugs prescribed for older patients with renal impairment or to be able to determine how comorbidities affect cancer outcomes. That information will only be learned through clinical studies designed with realistic parameters, so that older patients are not unnecessarily excluded from trials because of renal dysfunction—or other health issues—alone, he said.
To develop strategies to increase enrollment of older patients with cancer into clinical trials, a conference supported under the National Institutes of Health’s Cooperative Agreement (U13) Program will be held November 17–18, 2012, in Chicago. The conference, “Design and Implementation of Therapeutic Clinical Trials for Older and/or Frail Adults With Cancer,” is being developed by the Cancer and Aging Research Group in collaboration with the Geriatrics and Clinical Gerontology branch of the National Institute on Aging and the National Cancer Institute.
The principal investigators of this U13 grant include two leaders in the field of geriatric oncology, Arti Hurria, MD, Associate Professor of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California, and William Dale, MD, PhD, Chief, Section of Geriatrics and Palliative Medicine, The University of Chicago Medicine, and Supriya Gupta Mohile, MD, Asociate Professor of Medicine in Hematology/Oncology, University of Rochester Medical Center.
“This is our second U13 conference and our goals are to discuss research priorities in geriatric oncology and how we can design better therapeutic clinical trials for older patients with cancer,” said Dr. Mohile. “We need evidence-based data to reduce medical costs and to provide better care for our patients. There also needs to be more funding for research and more advocacy for older patients with cancer.”
For more information on the U13 meeting, visit mycarg.org. ■
Disclosure: Drs. Mohile, Hurria, and Dale reported no potential conflicts of interest.
1. Smith BD, Smith GL, Hurria A: Future of cancer incidence in the United States: Burdens upon an aging, changing nation. J Clin Oncol 27:2758-2765, 2009.
2. Hurria A, Togawa K, Mohile SG, et al: Predicting chemotherapy toxicity in older adults with cancer: A prospective multicenter study. J Clin Oncol 25:3457-3465, 2011.
3. Lichtman SS: Renal function: A key element in the aged patient. 2012 MASCC/ISOO Symposium. Abstract 2001028. Presented June 29, 2012.