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Approach to the older patient with cancer
BMC Medicine volume 11, Article number: 218 (2013)
The incidence of cancer increases with advanced age. And as the world populationages, clinicians will be faced with a growing number of older patients withcancer. The challenge that clinicians face involves carefully choosing the typeof therapeutic care plan that is most appropriate given a person’s levelof physical reserve, medical comorbidities, and psychosocial resources.Inclusion of assessment tools in clinical practice such as a comprehensivegeriatric assessment can assist clinicians in identifying patients who willbenefit from aggressive cancer care or palliative measures. The role ofpalliative care, especially in the frail older patient, is critical in improvingquality of life. Improvement in best care practices in older patients withcancer requires their inclusion in clinical trials.
The incidence of cancer increases dramatically with age. Current statistics show thatabout 50% of cancers diagnosed in the United States occur in people over the age of65 and this is expected to rise to 70% by 2030. The incidence of cancer is reportedto be 12 to 36 times higher in patients 65 years or older compared with those aged25 to 44 years, and 2 to 3 times higher in individuals 45 to 64 years of age.Mortality is also higher in older patients, accounting for nearly 70% of cancerdeaths per year . The challenge for cancer specialists is to determine the optimumtreatment for elderly patients, a heterogeneous population in terms of comorbidity,disability, physical reserve, and other geriatric conditions. Best treatmentpractices for older patients with cancer are lacking, in part due to sub-optimal orexcessively toxic treatments and under-representation in clinical trials, resultingin poorer outcomes compared with younger patients. Issues that impact oncologic andsupportive care management unique to the geriatric population will be highlighted inthis article.
Aging is defined as a progressive loss of a person’s entropy and fractalorganization that limits the functional reserve of multiple organ systems and theability to withstand stress. Such changes bring about reduced life expectancy,increased susceptibility to disease and loss of personal independence. The processof aging varies from person to person. Some patients undergo successful aging, whererobust physical and cognitive abilities are maintained throughout life . There are those described as having frailty, which is characterized byweakness and decreased functional reserve [3, 4]. Physiologic age does not correspond to a person’s chronologic ageand is more clinically useful in medical decision-making. Determination ofphysiologic age is largely based on a comprehensive geriatric assessment (CGA). Thismulti-dimensional method incorporates functional status, comorbidities, cognition,nutrition, medications, and social support structures. It assists clinicians tobetter estimate life expectancy and functional reserve, which are relevant intreatment-related decisions. The use of the CGA also allows for identification offrailty and other unrecognized conditions that can influence management.
The older patient diagnosed with cancer can present with various other problems,making evaluation of treatment options for cancer more complex. Besidesconsideration of cancer-related factors, assessment of other aspects of apatient’s health status including social, functional, cognitive, economic andspiritual domains, is crucial in developing a treatment plan that is tailored toindividual needs. Since the mid-1990s, oncologists and geriatricians have sought tointegrate the use of CGA in the oncologic setting, hoping to assist clinicians informulating optimal therapeutic plans. Components of the CGA have been shown to notonly affect life expectancy and function but also tolerance to treatment and symptomburden. Box 1 lists questions that can affect therapeutic choices and measuretreatment efficacy and guide in planning care for the elderly .
Box 1 Questions to ask in deciding therapeutic care plan for the elderlycancer patient 
Is the patient going to die of cancer or with cancer?
Is the patient going to live long enough to suffer the consequences ofcancer?
Is the patient able to tolerate the treatment?
What are the long term consequences of cancer treatment in theelderly?
Will any treatment improve the quality of life?
What are the patient’s goals of care?
Is the social network of the patient adequate to support him/herduring the treatment?
Frailty is a concept that is becoming increasingly used to describe patients withreduced reserve in multiple organ systems resulting in increased risk of disabilityor death with minor stresses. Functionally, these patients are characterized ashaving a wasting syndrome; low energy, gait speed and grip strength; many chronicmedical comorbidities; complex psychosocial problems; significant risk ofdependency; and other adverse health outcomes [7–9]. Cancer and its treatment are substantial stressors that diminishphysiological reserves, so the concept of frailty is particularly pertinent forolder patients with cancer. On the basis of the frailty phenotype, optimalmanagement strategies for treatment and inclusion in clinical trials may be achievedthrough patient stratification. Table 1 showsFried’s criteria for frailty . Fit geriatric patients are good candidates for almost the same type ofcancer treatment as younger patients and have similar survival outcomes. Patientswho are frail would benefit from more palliative approaches to treatment , with the assumption that their functional reserve is so poor that theywill not be able to tolerate even minimal stress that may arise from therapeuticregimens. Those who fall in between are more problematic and would requireindividualization of treatment approach.
Frailty has rarely been measured in patients with cancer. Some evidence shows thatfrailty is present in younger patients with cancer, and can even be observed incancer survivors. This indicates that familiarity and understanding of the conceptof frailty is essential from the time of consideration of treatment to cure andsubsequent follow-ups. Most older adults with cancer will fall into the pre-frailand frail category, therefore it is important that supportive care measures be madeavailable to them. This requires access to palliative care services to managesymptoms that may arise from the burden of disease as well as the adverse effects ofcancer treatment. The interdisciplinary team that is central to the practice ofpalliative care is most useful in the geriatric patient. These patients will benefitfrom specialized care encompassing multiple domains for improved quality of life.Quantifying frailty can help reduce futile and burdensome interventions that are notexpected to improve symptoms or those that may worsen function and quality of life.Frailty assessment is therefore essential for the timely delivery of holisticpalliative care in geriatric patients with progressive and terminal disease .
With the aging of the population and the known association between cancer and olderage, inclusion of older geriatric patients in clinical trials has been advocated byseveral experts. The under-representation of this at-risk population has beenhighlighted by several authors . It has been proposed that exclusion in studies is related to reducedfunction, presence of comorbidities, concomitant medications, lack of access, andpoor social support. Proposals to improve participation of older adults includeclinical trials specifically designed for older adults with multiple comorbidities,trials with dosing regimens tailored for older patients, standardized use ofgeriatric tools, and alternative end points or outcomes [12–14]. Data from 2001 to 2010 showed that 24 drugs were approved by the US Foodand Drug Administration for cancer treatment and only 33% of patients that wereregistered in those trials were 65 years or older . This is a dismal representation given that 59% of patients with cancerduring the same time period were of this age group . The problem with non-inclusion is that evidence-based treatmentrecommendations are not always applicable to the older patient, particularly thosewho are vulnerable and frail. In addition, those included in the trials are notrepresentative of the majority of older adults with cancer. Designing protocolstailored to include older patients should be specially designed to avoidunder-representation. The CGA can be used as a tool that can classify patients fitto receive certain specific treatments other than using age and clinical judgment asthe sole basis for treatment decisions. Such clinical trials would be helpful inguiding appropriate patient selection, risk stratification, and toxicityevaluation.
The incidence of cancer rises with increasing age. Specialists who care for cancerpatients face the difficulty in identifying optimum treatment options for elderlypatients. The concept of frailty and the use of the CGA help guide treatmentdecisions, enabling clinicians to better identify the presence of comorbidities andgeriatric syndromes, and the level of physical reserve or disability. Incorporatingsupportive care measures early in these patients, particularly those who fall intothe pre-frail and frail categories of the frailty index, is crucial to successfulmanagement. Future cancer and palliative care research should be more inclusive ofthis population. Specially designed protocols for older adults are necessary toprovide more appropriate evidence-based approaches to cancer treatment ingeriatrics.
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The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/11/218/prepub
The authors would like to acknowledge Ms Brittany Chenevert for her role inpolishing the manuscript.
MC does not have any competing interests. EB is supported in part by NationalInstitutes of Health grants (RO1NR010162-01A1, RO1CA122292-01, RO1CA124481-01) andin part by the MD Anderson Cancer Center support grant #CA 016672.
Both authors were involved in the conceptualization of the manuscript, its writingand subsequent editing. Both authors read and approved the final manuscript.
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de la Cruz, M., Bruera, E. Approach to the older patient with cancer. BMC Med 11, 218 (2013). https://doi.org/10.1186/1741-7015-11-218
- Advance cancer
- Geriatric patient
- Palliative care
- Supportive care
- Symptom management