All of those taking care of older adult cancer patients are geriatric oncologists. We need to educate ourselves to best manage these complex and vulnerable patients. Our elders deserve nothing less.
—Stuart M. Lichtman, MD, FACP, FASCO
The 15th Annual Conference of the International Society of Geriatric Oncology (SIOG) took place in Prague, Czech Republic, over 3 days (November 12–14, 2015). At the heart of the meeting were presentations on supportive care, comprehensive geriatric assessment and treatment—so that we fully understand the complex problems faced by an elderly patient—and the multidisciplinary cooperation required to address the needs of this population.
With a theme of Geriatric Oncology & Supportive Care: A Global Approach to Advance the Science, there were more than 90 oral presentations spread across 25 scientific sessions and 115 posters. SIOG 2015 was attended by 410 delegates—15% more than at last year’s annual meeting in Lisbon—who came from 40 countries. The plenary session focused on surgery, geriatrics, medical oncology, radiotherapy, and supportive care, and the meeting was opened by the Society President, Etienne Brain, MD, of the Department of Medical Oncology, Institut Curie–Hôpital René Huguenin, Saint-Cloud, France.
Growing Burden of Cancer
Due to the aging population in the United States, 70% of the 2.3 million cancers that arise in 2030 will be in people aged 65 years and older. But the growing burden of cancer in aging populations is also a pressing problem in low- and middle-income nations and has led to urgent calls to action.
By 2020, 70% of cancers will occur in developing nations. Gouri Shankar Bhattacharyya, MD, PhD, DNB, MRCP, of the Fortis Hospital, Kolkata, India, expanded on this issue. Global attention has been focused on maternal and child health, with little attention paid to the elderly and palliative care. This problem is compounded by the fact that cancer is still a stigma, by fatalism, by belief in traditional medicine and, for doctors, by lack of reimbursement.
For the entire population of India (1.2 billion), there are 165 qualified and trained specialists in palliative care. However, even given sociocultural and financial constraints, much could be done relatively easily. This is exemplified in India and Africa by the legal restrictions on the medical use of opiates. One goal of SIOG is to help educate physicians in these countries about caring for older patients and to raise awareness about the appropriate use of opiates.
The surgical session was presented by Michael T. Jaklitsch, MD, of the Dana-Farber/Harvard Cancer Center, Boston. Supportive and perioperative care is making it possible for more elderly patients to undergo surgery with good outcomes. The 30-day operative mortality following open techniques in the elderly has been reduced to 3%. The mortality problem has largely been solved, but morbidity has not.
According to Dr. Jaklitsch, there is now far more assessment of elderly patients, both before surgery (eg, using the Frailty Index and comprehensive care plans) and after surgery. Both “prehabilitation” and rehabilitation are needed. Physical exercise programs in prehab decrease the risk of pulmonary complications and atelectasis; physical exercise post surgery maintains quality of life. Delirium in the postoperative period is a particular problem. This disorder is present in 35% to 80% of surgical patients in intensive care and relates to complications, long-term cognitive dysfunction, and mortality.
An important recent development should further improve prospects for the elderly cancer patient undergoing surgery: In July 2015, the American College of Surgeons received a 4-year grant to develop and implement a Geriatric Surgery Verification and Quality Improvement Program.
Geriatrics was presented by Holly M. Holmes, MD, of The University of Texas Health Science Center, Houston. The presentation focused on new data regarding optimum blood pressure management in the elderly, which is a controversial area. The recent SPRINT trial showed that targeting a systolic blood pressure of 120 mm Hg or less reduced mortality.1 About 28% of patients enrolled were aged 75 or older, but those with diabetes were excluded. Even so, the fact that the hazard ratio of 0.67 demonstrated significant benefit in the elderly subgroup will probably encourage more aggressive treatment of blood pressure, with additional drugs being prescribed.
Complications related to polypharmacy are a concern. The PARTAGE study of nursing home residents aged over 80 years found higher 2-year all-cause mortality in people with a systolic blood pressure < 130 mm Hg on combination antihypertensive medication, compared with controls.2 Hence, a target of 120 or 130 mm Hg may be appropriate for robust elderly patients but harmful for the “old old” and frail, especially since there is some evidence of better cognition at higher blood pressures.
Dr. Holmes also discussed dementia, where there has been little by way of recent advance. In addition, she addressed the role of new vaccines for pneumonia and herpes zoster.
Ravindran Kanesvaran, MD, of the National Cancer Centre, Singapore, discussed medical oncology. Developments likely to have a positive impact on the treatment of cancer in the elderly were presented using three recent SIOG position papers as examples.
Chemotherapy with single oral agents (principally capecitabine and vinorelbine) may be somewhat less active than intravenous formulations, but it is better tolerated. For example, vinorelbine is associated with a low rate of febrile neutropenia seen with intravenous agents. The same is true for metronomic chemotherapy.3
Dr. Kanesvaran also addressed improvements in the treatment of diffuse large B-cell lymphoma and the development of new treatment guidelines.4 As in younger patients, studies have shown overall and progression-free survival benefits from R-CHOP (rituximab [Rituxan] plus cyclophosphamide, doxorubicin, vincristine, and prednisone) in elderly patients. But we now have alternative regimens, for example, for patients with cardiovascular morbidity or for those who request less toxic treatment.
In colorectal cancer, new data have shown that the addition of oral capecitabine to FOLFIRI (leucovorin, fluorouracil [5-FU], and irinotecan) does not bring further benefit.5 The ELDA trial—conducted in older breast cancer patients—showed that weekly docetaxel is not more effective than CMF (cyclophosphamide, methotrexate, and 5-FU) and is more toxic.
The novel checkpoint inhibitors have made a significant impact in melanoma. They are less toxic and more effective compared with chemotherapy, which may give them a greater role in older patients. About 15% to 40% of patients enrolled in checkpoint inhibitor trials have been elderly. This has prompted debate on whether we should still be promoting elderly-specific trials or at least the “geriatricizing” of all-comer trials, or whether the advent of better-tolerated agents will naturally lead to an increase in the proportion of elderly patients in pivotal studies.
The radiotherapy session was presented by Lorenzo Livi, MD, of the Careggi Hospital, Florence, Italy. New technology allows better identification of targeted volume, avoiding organs at risk and maintaining quality of life, and use of a reduced number of radiation fractions. For example, with short-course radiotherapy for glioblastoma multiforme, 5 fractions resulted in overall and progression-free survival rates similar to rates associated with 15 fractions.6
Dr. Livi also noted that stereotactic body radiation therapy improved overall survival relative to no radiotherapy in patients aged 70 or over with early-stage but medically inoperable non–small cell lung cancer.7 And in breast cancer, he said, it may be possible to reduce the use of whole-breast irradiation in some elderly women (aged 65 and older) who undergo breast-conserving surgery and adjuvant endocrine treatment and are at low risk of local recurrence. Such a strategy produced a low rate of ipsilateral breast cancer at 5 years in the PRIME II study.8
Christopher B. Steer, MBBS, FRACP, of Border Medical Oncology, Wodonga, Victoria, Australia, presented supportive care issues. According to Dr. Steer, the goal of supportive care is to ease the cancer journey during diagnosis, treatment, and either end-of-life care or survivorship. Adequate assessment yields appropriate treatment, he noted. Cancer-related disability is not an acute event but results from an accumulation of events over time. Hence, assessments need to be repeated.
Recent examples of the need for a range of support include a study showing that in the year after cancer diagnosis, elderly patients had increasing levels of depression and cognitive impairment.9 A study based on a single-institution registry found that the risk of functional deficit increases with age, comorbidities, and a lower level of education.10 Among the 65% of patients with a potentially modifiable functional deficit, only 9% were referred for occupational or physical therapy within 12 months.
Polypharmacy is another significant problem for older patients. One responsibility of those in supportive care is to ensure that patients are not taking unnecessary and potentially harmful drugs. A comprehensive medication assessment that aims to include all prescription drugs, together with all complementary and alternative medicine products used, is an important part of a geriatric assessment.
Among 234 elderly cancer patients (mean age, 79) assessed at the Jefferson School of Pharmacy in Philadelphia, the mean number of medications was 9.2; 38% were on more than 10 medications, and 40% were judged to be taking potentially inappropriate medication.11 Overall, 77% were on cholesterol-lowering drugs. The relevance of statins in elderly patients with cancer, unless they are being taken for secondary prevention, should be questioned.
The newly updated Beers criteria for potentially inappropriate medication use in older adults provide a guide to drugs that should be avoided in the elderly based on their association with adverse outcomes including confusion, falls, and mortality.12 The STOPP criteria are an alternative.13 Reducing polypharmacy reduces complications including adverse drug events and may lead to improvements in costs and possibly quality of life.14 “De-prescribing” should be attempted but needs to be thoughtful, evidence-based, and negotiated with other clinicians, caregivers, and patients themselves.
A session on drug-drug interactions in the elderly cancer patient was chaired by Stuart M. Lichtman, MD, FACP, FASCO, Memorial Sloan Kettering Cancer Center, New York, and Romano Danesi, MD, University of Pisa, Italy. Drugs taken for cancer can interact with each other, with agents taken as part of supportive care, with drugs taken for comorbid conditions—which are particularly common in the elderly—and with herbal supplements and complementary medicines.
We tend to focus on the narrow therapeutic window of cytotoxics, but the metabolism of tyrosine kinase inhibitors by the cytochrome P450 3A4 enzyme (CYP3A4) makes some of these agents particularly prone to interference with or from other agents sharing this pathway. There is also the potential for adverse pharmacokinetic interactions with new hormonal agents used in advanced prostate cancer.
Wide Range of Topics
The meeting covered a wide range of topics including multiple solid tumors, hematologic malignancies, issues in supportive and palliative care, geriatric oncology training, nutrition, and nursing. Sessions on multidisciplinary care emphasized the complex nature of caring for the older patient. SIOG has placed great importance on the development of guidelines through multiple task forces. This is an important component of the educational mission. SIOG Young Investigators and SIOG Nursing and Allied Health Professionals make valuable contributions to the meeting and the Society as a whole.
The Society presented a number of annual awards, including the Paul Calabresi Award (Hans Wildiers, MD, of University Hospitals Leuven, Belgium); the National Representative of the Year (Kwok-Leung Cheung, MD, University of Nottingham); the BJ Kennedy Award for Best Poster (Shabbir Alibhai, MSc, MD, FRCPC, University of Toronto); the Nursing & Allied Health Investigator Award (Doris L. van Abbema, RN, MSc, Maastricht University Medical Centre, Netherlands); and the Young Investigator Award was given to Cindy Kenis, BSN, PhD candidate, of the University Hospitals Leuven, Belgium).
The next meeting of SIOG will take place November 17–19, 2016, in Milan. More detailed information about the annual meeting and other society activities are available online at www.siog.org. We encourage everyone to join SIOG, contribute to our journal (Journal of Geriatric Oncology), and participate in our events.
Those caring for older adult cancer patients are all geriatric oncologists. We need to educate ourselves to best manage these complex and vulnerable patients. Our elders deserve nothing less. ■
Acknowledgment: The author thanks Robert Stepney for his help in the preparation of the manuscript.
1. SPRINT Research Group: A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 373:2103-2116, 2015.
2. Benetos A, Rossignol P, Cherubini A, et al: Polypharmacy in the aging patient. JAMA 314:170-180, 2015.
3. Biganzoli L, Lichtman S, Michel JP, et al: Oral single-agent chemotherapy in older patients with solid tumours: A position paper from the International Society of Geriatric Oncology (SIOG). Eur J Cancer 51:2491-2500, 2015.
4. Morrison VA, Hamlin P, Soubeyran P, et al: Approach to therapy of diffuse large B-cell lymphoma in the elderly: SIOG expert position commentary. Ann Oncol 26:1058-1068, 2015.
5. Papamichael D, Audisio RA, Glimelius B, et al: Treatment of colorectal cancer in older patients: SIOG consensus recommendations 2013. Ann Oncol 26:463-476, 2015.
6. Roa W, Kepka L, Kumar N, et al: International atomic energy agency randomized phase III study of radiation therapy in elderly and/or frail patients with newly diagnosed glioblastoma multiforme. J Clin Oncol 33:4145-4150, 2015.
7. Nanda RH, Liu Y, Gillespie TW, et al: Stereotactic body radiation therapy versus no treatment for early stage non-small cell lung cancer in medically inoperable elderly patients. Cancer 121:4222-4230, 2015.
8. Kunkler IH, Williams LJ, Jack WJ, et al: Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II). Lancet Oncol 16:266-273, 2015.
9. Deckx L, van Abbema DL, van den Akker M, et al: A cohort study on the evolution of psychosocial problems in older patients with breast or colorectal cancer. BMC Geriatr 15:79, 2015.
10. Pergolotti M, Deal AM, Lavery J, et al: The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer. J Geriatr Oncol 6:194-201, 2015.
11. Nightingale G, Hajjar E, Swartz K, et al: Evaluation of a pharmacist-led medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer. J Clin Oncol 33:1453-1459, 2015.
12. Fick DM, Semla TP, Beizer J, et al: American Geriatrics Society 2015 Updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 63:2227-2246, 2015.
13. O’Mahony D, O’Sullivan D, Byrne S, et al: STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing 44:213-218, 2015.
14. LeBlanc TW, McNeil MJ, Kamal AH, et al: Polypharmacy in patients with advanced cancer and the role of medication discontinuation. Lancet Oncol 16:e333-e341, 2015.
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 the International Society of Geriatric Oncology (www.siog.org).