The development of geriatric oncology has been slow but progressive. Thanks to the effort of investigators throughout the world, embattled but undeterred by the objection of a cautious establishment, geriatric oncology has provided a blueprint for the treatment of cancer in the population of patients most commonly affected by the disease: older adults.Here we outline the most important steps that have led to lasting achievements in this field of oncology.
They include the assessment of physiologic age in terms of life expectancy and functional resilience; the elimination of obstacles in the participation of older adults in clinical trials; the alternative forms of clinical research, such as rapid-learning databases; and a multidisciplinary approach to the complexity of aging.
Although we may appear to exalt the role of pioneers in the field, this history is also a tribute to the thousands of protagonists worldwide, without whom these accomplishments would not have been possible. In writing this history, we hope to inspire a new generation of investigators to explore and heed the emerging needs of an always changing population. Major medical achievements, such as the prolongation of life expectancy and the elimination of many infectious diseases, have caused a rise in new medical problems, including cancer. Advancing age is a high-risk factor for cancer, with more than two-thirds of all new cancers diagnosed in adults aged 60 and older. As the number of adults living to older ages increases, so, too, will the number of new cancer diagnoses.1
History Lessons for Young Clinical Investigators
In these years of instantaneous communication, the influences of medical publications on clinical practices have been shrinking. Still, books and journals fulfill important roles in oncology management, including the delivery of historical information that may inspire novel areas of clinical research. Here we highlight important messages on the history of geriatric oncology—a history of successes despite embattled beginnings and widespread skepticism—that are relevant to today’s young clinical investigators.
The first is a message of confidence that promising innovations will lead to clinical success despite the objections of an always diffident establishment. Clinical trials have been the mainstay of oncology since its beginning. Patients were highly selected according to restrictive recruitment criteria and the majority of patients with cancer were excluded.2-5 Geriatric oncology showed that clinical trials may be adapted to the diversity of older patients and that alternative approaches to clinical research, for example, through the use of rapid-learning clinical research database systems,6 may provide equally reliable and more universal information.
The second message is intended to move the focus of clinical research from the disease to the patient. To do so, it may be necessary to involve geriatricians to work side by side with clinical oncologists to assess patients’ physiologic age, resilience, and their geriatric syndromes to capture a more holistic view of the patient. To this end, one cannot underestimate the importance of integrating the skills of nurses, dietitians, social workers, and other health-care professionals into the medical team.
The third message is directed at young trainees eager to identify research and practice niches. To accomplish that goal, they will need to pay particular attention to the rapidly evolving demographic of older patients. When we first started talking about the importance of studying cancer in the elderly, we heard a common objection: “Why do you want to study cancer in the elderly if you don’t have treatments for cancer?” Today, the proper answer would be, “Because if we ignore research and treatment in older patients, we ignore the majority of cancers diagnosed.” The roots of geriatric oncology are the same as those for gerontology and geriatrics since these disciplines have the same objective: the study and management of functional aging.
Understanding the Differences Between Chronologic and Functional Age
In ancient times, a progressive loss of resilience was believed to be the unescapable consequence of aging and the harbinger of impending death. The Latin playwright Publius Terentius Afer wrote Senectus Ipsa Est Morbus (“Old age is in itself sickness”), and ancient Greek poets called old age “dreadful” and “hateful.
Only at the beginning of the 20th century was it realized that aging was a complex situation resulting from a combination of different physical, emotional, social, and cultural domains and deserved the attention of researchers. The word “gerontology,” which literally means “the study of the old man,” was introduced by Ilya Iliych Mechnicov, in 1903, to signify that aging involved the interaction of these different domains, and that the study of aging should focus on these areas.The word “geriatrics,” also called “medical gerontology,” means medical care of the older patient.
It goes without saying that one may find a lot of similarities between gerontology and geriatrics, as the study of disease in older adults in relation to their social, psychological, and cognitive function. It may be impossible to provide adequate care to older patients without compensating for their loss in daily living function, for their declining cognitive capacity, and for the economic restrictions that may come with aging. For these reasons, we often say “aging centers” or “aging institutions” rather than “gerontology institutions” or “geriatric institutions” when referring to research and clinical organizations devoted to the study of the aging process.
Reviewing the Critical Time Points in the Progress in Aging and Cancer
The dramatic increase in the average life expectancy around the world has been the main thrust for the development of aging studies. For example, in the United States, the average life expectancyincreased from 47 years in 1900 to 78 years in 2010.7 In other countries, such as Japan, the increase in life expectancy has been even more dramatic, from less than 40 years in 1900 to 82 years in 2010.8 The consequence of this increase in life expectancy has been twofold: an increase in the number of older individuals and the appearance of a new population almost unknown until the past century, those older than age 85, the so-called oldest old, which is also a segment of the population that is experiencing the most rapid growth.9
All of the disciplines focusing on aging met at the same crossroad in the early 20th century, when “old” was defined as anyone 65 and older, mostly due to the establishment of the Social Security Administration in 1935 and people became eligible to collect Social Security benefits when they turned 65. In 1935, the average American life expectancy was 61, and the prevalence of illness and disability was much higher than it is today, and chronic diseases, such as hypertension and diabetes, were poorly controlled, and infectious diseases such as tuberculosis were more commonly causes of mortality than cancer.
Today, it is understood that chronologic age is just a landmark, and for older people, that landmark should be positioned between ages 70 and 80. To clarify this principle, by setting the landmark at 75 we mean that the majority of people who are considered functionally old are found beyond this landmark. By no means is it meant to indicate that everybody 75 and older is “functionally” old. It simply helps determine when a functional evaluation to estimate the physiologic age of a person, for example, resilience and life expectancy, is warranted.
The history of geriatric oncology may be divided into three time periods. The prehistory encompasses approximately 15 years during which age was considered just a prognostic and predictive variable. Since the outcome was universally worse for older people, most clinical trials excluded patients older than 65 or 70, or they reduced doses of chemotherapy for older individuals.2-5
The second period involves the first steps to collect reliable information on the risks and benefits of cancer treatment in older adults. Epidemiologists and clinicians became aware that the majority of cancers affected individuals 65 and older.8 Hence, one could not claim to treat cancer and ignore cancer in older people. The beginning of this realization can be traced to a combined conference by the National Institute on Aging and the National Cancer Institute in the early 1980s and promoted by Rosemary Yancik, PhD, a medical sociologist, with the publication of the conference proceedings by Dr. Yancik and cancer researcher Paul Carbone, MD,. in 1983.10
During this time, a worldwide call went out to study cancer in the older patient. An international group of investigators was established and met periodically to report and discuss the new advances in the field of geriatrics. Eventually, this informal organization became the International Society of Geriatric Oncology.
The discipline of geriatric oncology is the result of the establishment of these important agencies:
The third period, which brings us to the present, involved the practical realization of the principles developed during the second period and led to the worldwide installation of cooperative multi-institutional research in cancer and aging. The origin of this period may be traced to the founding of the International Society of Geriatric Oncology (SIOG) in New York in 2000. [Editor’s Note: Three of the authors of this article, Drs. Monfardini, Balducci, and Aapro, are cofounders of SIOG.] This society gathered all the experts in the field, provided a forum for clinical and biological investigators, organized training for young geriatricians and oncologists, and issued a number of treatment and research guidelines in cooperation with other medical societies. During this time, the Comprehensive Geriatric Assessment toolkit, a multidisciplinary diagnostic and treatment process that identifies the medical, psychosocial, and functional capabilities of older adults, was developed and has become the standard approach to measure physiologic age. As a result, a number of biologic markers of aging have been investigated.
Altogether the history of geriatric oncology encompasses at least 55 years that have seen unprecedented progress in the understanding of both cancer and aging.
In this issue of The ASCO Post we begin our history of geriatric oncology. In the related article, we explore the first chapter, looking at the pre-history and past-history of geriatric oncology.
The references for this introduction can be found in the related article below.
Disclosure: The authors reported no conflicts of interest.
Dr. Monfardini is Director of the Geriatric Oncology Program at Instituto Palazzolo, Fondazione Don Gnocchi, in Milan, Italy. Dr. Balducci is Professor of Oncology and Medicine at the University of South Florida College of Medicine and Chief of the Division of Geriatric Oncology, Senior Adult Oncology Program at H. Lee Moffitt Cancer Center & Research Institute. Dr. Overcash is Professor of Clinical Nursing and Co-Director of the Academy for Teaching Innovation, Excellence and Scholarship. Dr. Aapro is Member of the Board, Genolier Cancer Center in Genolier, Switzerland, and of the International Society of Geriatric Oncology (SIOG) until September 2020.
In this first installment of our history of geriatric oncology, we outline what we consider the most relevant steps in the prehistory and past history of geriatric oncology. In a future issue of The ASCO Post, we will explore the contemporary history of the field.
The Prehistory of Geriatric...