Geriatric Oncology: A Multidisciplinary Approach in a Global Environment
Stuart M. Lichtman, MD, FACP, FASCO
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 at Weill Cornell Medical College, New York. He is also President of SIOG. For more information about geriatric oncology, visit www.siog.org and the ASCO Geriatric Oncology website (www.asco.org/practice-guidelines/cancer-care-initiatives/geriatric-oncology/geriatric-oncology-resources).
Meeting the unique needs of older patients with cancer is not just an issue of developed countries eg, the United States and Japan, where the Silver Tsunami has already arrived—20% of the U.S. population is older than age 65 and 27% of the Japanese population is older than age 65. But addressing the special needs of the older population challenges the medical establishments in developing countries, too. The middle- and lower-income nations are in transition epidemiologically, economically, and in terms of health priorities and disparities.
Approaching geriatric oncology from a multidisciplinary perspective in a global environment was the theme of the Society of Geriatric Oncology’s (SIOG) annual meeting in Milan. In a testament to its international and multidisciplinary scope, there were 457 delegates from 42 countries, with faculty from 24 countries. The scientific program explored newer aspects of patient-centric geriatric oncology with emphasis on how the management needs of this population could and should be performed by assessment of overall health status and physiology. It is these factors unique to every individual that influence the prognosis, efficacy, and tolerability of treatment and need to be considered when assessing the older patient.
There are currently validated predictive models, which are a better supplement to clinical judgment at predicting toxicity in patients’ treatment with chemotherapy. We know that geriatric assessment does not have to be time-consuming, and much of this assessment can be self-administered with the help of technology. The need now is to move into the next phase: that of controlled trials that confirm the clinical benefits of management guided by geriatric assessment—whether it be increased efficacy or effectivity, reduced toxicity, or all. Such trials are underway, but many more are needed.
Ponnandai Somasundar, MD, Associate Professor of Surgery, Boston University School of Medicine, discussed the usefulness (and use) of preoperative assessment and prehabilitation. Two years ago, the American College of Surgeons recognized the importance of perioperative management of geriatric patients in the National Surgical Quality Improvement Program (NSQIP). Now, importance of preoperative assessment is also being recognized.
Adult oncologists need to become geriatric oncologists to adequately evaluate and care for their patients, whether for curative or palliative therapy.— Gouri Shankar Bhattacharyya, MD, and Stuart M. Lichtman, MD, FACP, FASCO
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Geriatric assessment adds to the information provided by the Eastern Cooperative Oncology Group (ECOG) performance status: It predicted complications in elderly patients after elective surgery for colorectal cancer in a prospective observational cohort.1 In South Korea, a multidimensional frailty score predicted postoperative mortality and hospital stay.2 But for outcomes to improve with preoperative assessment, we need preoperative interventions.
At Dr. Somasundar’s hospital (Roger Williams Medical Center, Providence, Rhode Island, which is affiliated with Boston University School of Medicine), a nurse navigator conducts a geriatric assessment in all new patients 65 years and older, leading to intervention by a multidisciplinary team and further geriatric assessments at 30, 90, and 100 days. The team includes geriatricians, palliative care and nurse specialists, dieticians, rehabilitation specialists, members of social services, and also a pharmacist for medication review. A relatively recent SIOG survey of surgeons’ attitudes about management of older patients found that more than 90% of respondents offered surgery regardless of patient age, but only 48% considered it mandatory to conduct a preoperative frailty assessment, and only 36% collaborated with geriatricians.3
Focus on the Patient, Not the Disease
Professor Stefania Maggi, President of the European Union of Geriatric Medicine Society, addressed the topic of focusing attention on the patient and not the disease. The specialty of geriatrics aims to deal with acute and chronic problems as well as rehabilitation in the community, in long-term care and hospital settings. It encompasses the patient, his or her family, and the wider social environment. It involves geriatric assessment, team work, targeted interventions adapted to a patient’s needs, and integration of services.
Geriatric assessment does not have to be time-consuming. We can learn a lot of useful information in 20 minutes.— Gouri Shankar Bhattacharyya, MD, and Stuart M. Lichtman, MD, FACP, FASCO
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As a specialty group, SIOG favors a deficit-driven approach to frailty, which views an individual patient’s condition as an accumulation of medical, functional, and social deficits—rather than the concept of frailty as driven by age-related biology. The corollary of this is the concept of resilience and reversibility, as discussed in more detail by Robinson and colleagues.4 They emphasized the impact on health and longevity of a strong social network, willing caregivers, financial stability, a positive attitude, and dependable relationships. Frailty in certain patients may be reversible. Some older people in a frail state—given appropriate interventions—can become “prefrail,” certain prefrail patients can be made robust. The Padova group developed a multidimensional prognostic index (Onco-MPI) to predict mortality in cancer patients aged 70 or older.5 This index includes patient function and cognition, comorbidities, as well as tumor characteristics.
However, there is “a gap between knowing and doing,” according to Gladman and colleagues,” 6 which represents the rationale for a randomized controlled trial in the Netherlands.7 The -intervention group was followed up by a nurse for a year after discharge. Reduced mortality at 1 and 6 months suggests that such transitional care might improve outcomes during the vulnerable period after hospital discharge. There was no effect on functional outcome or cognition.
With Regard to immunotherapy, Dr. Loïc Mourey, an oncologist from Toulouse, France, updated some clinical trials being conducted in older patients with cancer. To begin, encouraging phase III data are available on patients with lung, renal, prostate, and bladder cancers; melanoma; and colon cancer with microsatellite instability. Benefits of treatment appear to extend to older patients who do not experience worse toxicity than their younger counterparts.
Two important studies were conducted by Eggermont and colleagues8 and Balar and colleagues.9 In the Eggermont study, prolonged survival was reported in patients with stage III melanoma who were treated with adjuvant ipilimumab (Yervoy) therapy.8
In the KEYNOTE-052 trial by Balar and colleagues,9 18% of patients were 65 years or older. Included in this study were 350 first-line bladder cancer patients with metastatic or locally advanced disease who were unfit to receive cisplatin for one or more of the following reasons: creatinine clearance < 60 mL/min, an ECOG performance status of 2, grade 2 or higher peripheral neuropathy or hearing loss, New York Heart Association class III heart failure. The patients were given intravenous pembrolizumab (Keytruda) at 200 mg; the overall response rate was 24% in the first 100 patients, who had a median age of 75 years. The median time to disease progression had not been reached. A total of 83% of patients have had a response lasting more than 6 months. However, new treatments mean new toxicities, and so we have to be vigilant in monitoring for side effects with immunotherapy.
Dr. Laura Lozza, of the Istituto Nazionale dei Tumori of Milan, discussed radiotherapy in older patients with cancer. Almost 60% of patients with cancer receive radiotherapy at some stage during their disease course, whether delivered with curative or palliative intent. Because of its limited systemic toxicity, radiotherapy can be an excellent option for many older patients and a possible alternative to surgery for some.
Age per se does not decrease a person’s tolerance to radiotherapy delivered to the most common tumor sites, but it is important to conduct a geriatric assessment, evaluate individual patient characteristics, and have a clear understanding of treatment objectives. It is also helpful to distinguish between factors that may make radiotherapy technically more difficult to deliver in elderly patients (eg, pacemakers, prostheses, impaired cognition that complicates compliance, and limited physical mobility and flexibility) as well as factors that may exacerbate radiotherapy toxicities (eg, existing diarrhea, nausea, and vomiting). In these circumstances, radiotherapy may be adapted in terms of total dose, fractionation schedule, and volume treated, and patients should also be positioned in greater comfort for radiotherapy.
It should be noted that if the aim is curative, the total dose generally should be delivered. However, limited, highly conformal target volumes may enhance tolerability in older patients. This approach can be guided by positron-emission tomography/computed tomography imaging and techniques that identify areas of high tumor metabolic activity. Also, there are alternatives to standard-fractionation schedules (eg, delivering several fractions daily, split-course regimens, hypofractionation) to help older patients with logistical problems in traveling to the hospital.
Other relevant developments in terms of radiotherapy include the following:
- Stereotactic radiotherapy using tools that give an accuracy of millimeters, as explored in an analysis of Surveillance, Epidemiology, and End Results (SEER) data by Dalwadi and colleagues on the treatment of elderly patients with stage I non–small cell lung cancer.10 With widespread adoption of stereotactic body radiotherapy in the community setting, an increasing number of elderly patients are having definitive radiotherapy as an alternative to surgery.
- Radiosurgery for extracranial targets
- Proton therapy
- Intraoperative radiotherapy used alone or as a boost (eg, for breast cancer)
- As an alternative to external-beam radiotherapy, brachytherapy safely delivers high doses to a target region over a short time while irradiating little healthy tissue, since the absorbed dose falls rapidly with the distance from the source.
- Combining radiotherapy with immunotherapy, to take advantage of the abscopal effect—in which localized treatment of one metastasis causes shrinkage not only of the treated tumor but also of tumors in untreated sites
- Concurrent chemotherapy for elderly patients with head and neck cancer undergoing definitive radiation therapy was explored by Amini and colleagues.11 Among more than 4,000 patients with stage III/IV disease, patients older than age 70 were randomized to receive radiotherapy alone or chemoradiotherapy. The 5-year overall survival with radiotherapy alone was doubled with chemoradiotherapy (30% vs 15%), although there was no survival benefit in patients older than age 80.
- In 562 patients aged 65 or older with glioblastoma, a Canadian-led randomized controlled trial showed that adding temozolomide to short-course radiotherapy followed by maintenance chemotherapy reduced the risk of death by 33%.12 Median overall survival was 9.3 vs 7.6 months favoring the addition of concomitant and adjuvant temozolomide to hypofractionated radiotherapy.
Geriatric Oncology Worldwide
In Western Europe, mainly France, Italy, Norway, and the Netherlands, coordinated geriatric oncology and geriatric programs have been established, although an audit shows that they are accessible to only a limited number of patients.13 Japan’s Cancer Control Act aims to further research to improve cancer care and reduce cancer incidence.14 In Latin America, frailty assessments have been developed and incorporated into treatment strategies for older patients, and use of a simplified geriatric evaluation tool has allowed resource stratification. In other parts of the world, however, geriatric oncology is just becoming recognized and developed.
Faculty and others at the SIOG meeting emphasized a need to incorporate geriatric principles into all aspects of oncology care. Thus, adult oncologists need to become geriatric oncologists to adequately evaluate and care for their patients, whether for curative or palliative therapy. The SIOG provides an excellent educational forum for the presentation of data and exchange of ideas. The Society’s Journal of Geriatric Oncology is another educational resource, as are the published guidelines and e-learning on the SIOG website (www.siog.org). The Society also sponsors a training course for young investigators to learn the fundamentals of geriatric oncology research (http://www.siog.org/content/siog-2017-advanced-course-treviso-italy). SIOG’s 2017 annual meeting will be held November 9–11 in Warsaw. We encourage you to attend.
Acknowledgment: Robert Stepney assisted in the preparation of this article. ■
Dr. Bhattacharyya is Attending Consultant, Department of Medical Oncology, Fortis Hospital, Kolkata, West Bengal, India. Dr. Lichtman is Attending Physician at Memorial Sloan Kettering Cancer Center, Commack, New York, and Professor of Medicine at Weill Cornell Medical College, New York.
DISCLOSURE: Drs. Bhattacharyya and Lichtman reported no conflicts of interest.
11. Amini A, et al: Does age matter? Survival outcomes with the addition of concurrent chemotherapy for elderly head and neck cancer patients undergoing definitive radiation using the National Cancer Data Base. 2016 Multidisciplinary Head and Neck Cancer Symposium. Poster 100.
12. Perry JR, et al: A randomized phase III study of temozolomide and short-course radiation vs. short-course radiation alone in the treatment of newly diagnosed glioblastoma in elderly patients. 2016 ASCO Annual Meeting. Abstract LBA2.