“The management of older individuals, including older cancer patients, involves a wisdom developed over a lifetime, thanks to time-consuming listening and painstaking collection and interpretation of clinical details.”
—Lodovico Balducci, MD
It is not simple to be a geriatrician in a world of oncologists. When I arrived at the cancer center where I have been working for the past 6 years, I had to significantly fine-tune the principles that had been the backbone of my profession. As a geriatrician in a primary care practice or working as a geriatric hospitalist, I had strived to provide high-quality care for older adults, minimizing unnecessary interventions, avoiding polypharmacy, and always keeping in mind the patient’s independence and quality of life as critical factors of the equation.
Coming into a cancer center, I was confronted with a different principle: These older adults came with one purpose only: to treat and beat their cancer. They did not want to hear about “less is more.” They wanted to live, and in order to do that, their cancer needed to be treated. My role shifted. I was there to help the frail patient walk a difficult path of suffering the fewest possible adverse events while preventing complications related to geriatric syndromes such as delirium, falls, incontinence, or failure to thrive, which would have placed him or her at higher risk not only of death but also of suffering treatment failure, institutionalization, and a very poor quality of remaining life.
Treating Older Patients
With the increase in the aging population and life expectancy, oncologists are aggressively treating patients into their 80s and even 90s, patients who a few decades ago would have received only symptomatic treatment without hesitation. With a paucity of data to make evidence-based decisions in this population, clinicians need to extrapolate from studies done with a much younger cohort. However, treating patients in their 80s is not the same as treating patients in their 50s or 60s.
The clinical behavior of some tumors changes with age. Some become more aggressive due to a prevalence of unfavorable genomic changes or resistance to chemotherapy. Others, like breast cancer, become more indolent due to an increased prevalence of hormone-receptor rich tumors and endocrine senescence.
The aging process itself brings physiologic changes leading to decline in the function of organs. For example, kidney function decreases with age and pulmonary compliance declines, as does bone marrow cellularity and reserve. The remodeling of physiologic reserve or “homeostenosis” is influenced not only by genetic factors but also by environmental factors, dietary habits, and interactions with comorbidity as well as social conditions.
Chronologic age differs from functional age, and this difference—the uniqueness of each patient—needs to be captured and integrated in the decision-making process of cancer treatment. It is essential to identify patients with a longer life expectancy or those who are fitter, potentially more resilient, and therefore more likely to benefit from aggressive treatment vs those who are more vulnerable to adverse outcomes.
Increased Comorbidities
The incidence of pathology increases as we age. The presence of multiple chronic diseases or comorbidities represents a major difference between the younger and the older cancer patient. Frequent comorbidities in the elderly such as cardiovascular disease, hypertension, diabetes, or dementia influence the management of the cancer. Comorbidities may increase the risk of complications, modify cancer behavior, or mask symptoms, with subsequent delays in cancer diagnosis.
On the other hand, cancer treatment may worsen cormorbidities or increase the frequency of drug interactions. Comorbidities influence the patient’s life expectancy independently of the cancer. In the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Older Adult Oncology, version 2.2015, the approach to decision-making in the older adult starts with the question: “Is the patient at moderate or high risk of dying or suffering from cancer considering his or her overall life expectancy?” If the answer is no, symptom management and supportive care are recommended.1
Cognitive Dysfunction
Cancer patients with cognitive dysfunction represent a new challenge for oncologists. After age 65, the risk of developing Alzheimer’s disease doubles about every 5 years. By age 85, nearly half of all people will have some signs of the disease. The increased rate of dementia in the elderly converges with the higher likelihood of developing cancer. Patients with cancer/dementia overlap are often diagnosed later in the disease process, screening is less standardized, and adherence with treatment is often difficult.
The ability of patients to decide on a course of therapy in concert with the oncologist is critically important. Many oncologists are conflicted as to whether true informed consent for treatment can be obtained from older cancer patients when their cognitive abilities are impaired or unclear. It is imperative that health-care providers who care for older adults with cancer be able to assess cognitive function, understand the implications of cognitive impairment when patients need to make decisions, address the potential for treatment-related further cognitive decline, and be able to facilitate shared, patient-centered cancer decision-making.
Geriatric Assessment
Decline in functional status is associated with frailty and worse cancer treatment outcomes. Basic and instrumental activities of daily living and other performance measures such as walking speed and muscle strength tests have been shown to have a greater predictive value on physical function compared to traditional oncology measures of performance. Therefore, comorbidity, disability, and frailty need to be clearly recognized as markers of risk in the elderly.
The comprehensive geriatric assessment is a multidimensional, multidisciplinary patient evaluation that leads to the identification of patient problems in all these domains and the development of a plan for resolving these problems. This tool has been validated in geriatric oncology and was shown to predict morbidity and mortality in older patients with cancer as well as to uncover problems relevant to cancer care that would otherwise go unrecognized. It provides important information about the health status of the older patient prior to cancer treatment and ascertains a patient’s need for psychosocial support, care giving, transportation, and so forth, which may be critical for adequate cancer treatment.
Hurria et al2 and Extermann et al3 used elements of the comprehensive geriatric assessment in addition to other factors for the development of the CARG (Cancer and Aging Research Group) and CRASH (Chemotherapy Risk Assessment Scale for High age patients) scores, respectively, which may predict hematologic and nonhematologic chemotherapy toxicity. The CARG score was shown to be more effective than the Karnofsky performance status for the prediction of grade 3 to 5 hematologic toxicities.
The NCCN and the International Society of Geriatric Oncology (SIOG) have recommended that some form of geriatric assessment be conducted to help cancer specialists determine the best treatment for their older patients. However, comprehensive geriatric assessment is time-consuming and requires close cooperation between oncologists and geriatricians. An important practical aspect of the comprehensive geriatric assessment is the feasibility of incorporating it into an already busy clinical oncology practice.
One approach is the development of screening tools that would sort out who is an “older adult” with intact physiology and psychosocial conditions and who is in need of further multidisciplinary evaluation. Puts et al4 showed that the effectiveness of such an approach—a screening tool for all older patients followed by an in-depth assessment of those deemed to be at risk—is not established yet and needs to be validated in randomized controlled trials. Randomized controlled trials are also needed to clearly demonstrate that a resource-intensive comprehensive geriatric assessment is effective in improving outcomes compared with usual care in the oncology setting.
Closing Thoughts
How are we going to apply geriatric principles to oncology patients? Innovative models of care need to be developed and disseminated in order to transform these principles into an integral part of routine oncology practice. In addition, the development of longitudinal shared-care models that optimize the contribution of each discipline offers a tremendous opportunity for partnerships between oncologists and geriatricians.
As Harvey Jay Cohen, MD, wrote in the Journal of the American Geriatrics Society, “Hopefully, through such a shared approach, the burden of dealing with the complexities of care for the older cancer patient can be eased for the patient as well as family and professional care provider.”5 ■
Disclosure: Dr. Korc-Grodzicki reported no potential conflicts of interest.
References
1. National Comprehensive Cancer Network: NCCN Guidelines Version 2.2015: Senior Adult Oncology. Available at www.nccn.org/professionals/physician_gls/pdf/senior.pdf. Accessed July 31, 2015.
2. 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.
3. Extermann M, Boler I, Reich RR, et al: Predicting the risk of chemotherapy toxicity in older patients. Cancer 118:3377-3386, 2012.
4. Puts MT, Hardt J, Monette J, et al: Use of geriatric assessment for older adults in the oncology setting: A systematic review. J Natl Cancer Inst 104:1133-1163, 2012.
5. Cohen HJ: A model for the shared care of elderly patients with cancer. J Am Geriatr Soc 57(suppl 2):S300-S302, 2009.
Dr. Korc-Grodzicki is Chief of the Geriatrics Service at Memorial Sloan Kettering Cancer Center and Professor of Clinical Medicine at Weill Cornell Medical College, New York.
Geriatrics for the Oncologist is guest edited by Stuart M. Lichtman, MD, FACP, FASCO, and developed in collaboration with the International Society of Geriatric Oncology (SIOG). Dr. Lichtman is an Attending Physician at Memorial Sloan Kettering Cancer Center, Commack, New York, and Professor of Medicine, Weill Cornell Medical College, New York. He is also President Elect of SIOG. Visit www.siog.org for more on geriatric oncology.
