Assessment and treatment of elderly patients with cancer

doi:10.1016/j.suronc.2009.11.008

Surgical Oncology

Volume 19, Issue 3, September 2010, Pages 117-123

https://doi.org/10.1016/j.suronc.2009.11.008 Get rights and content

Abstract

In the US, the total projected cancer incidence will increase by 45% yearly from 2010 to 2030. The majority of these neoplasms will affect the elderly. The National Institute on Aging has characterised the aging of our society as a “silver tsunami”. Thus, the management of cancer in the older aged person represents a priority for health care delivery in the immediate future.

Aging, age-related changes, frailty, prolongation of active life expectancy, prevention of Adverse Drugs Reactions (ADRs), Comprehensive Geriatric Assessment (CGA), and individualised treatment in the future will become the most widely used concepts in the management of cancer patients.

Introduction

Cancer is a disease of aging. In the US, the number of adults aged 65 years or older increased from 25 million in 1980 to 35 million in 2000, and is further expected to increase to 72 million by 2030 [1], [2]. Assuming that age and sex of the population and the organ specific cancer incidence remain relatively constant over time, the total projected cancer incidence will increase by 45%, from 1.6 million to 2.3 million yearly from 2010 to 2030. The majority of these neoplasms will affect the elderly [2]. The aging of the population will add stress to already limited health care resources, in large part due to the increased incidence of cancer.

Thus, the management of cancer in the older aged person represents a priority for health care delivery in the immediate future. Elderly people with cancer are less likely to be offered cancer treatments that have the potential to improve survival because of concerns regarding their ability to tolerate treatment [3], [4]. They have been under represented in cancer clinical trials and consequently the information related to benefits and risks of any cancer treatment in the elderly is often inadequate [5], [6], [7]. The National Institute on Aging has characterised the aging of our society as a “silver tsunami for which we are unprepared” [8].

The management of cancer in the older aged person involves a number of age-related questions: Is the patient going to die of cancer or with cancer? Is the patient going to live long enough to suffer the consequences of cancer? Is the patient able to tolerate the treatment? Is the social network of the patient adequate to support him or her during the treatment? What are the long-term consequences of cancer treatment in the elderly? Will any treatment improve quality of life?

The present article addresses these questions, after reviewing the physiology of aging.

Section snippets

Aging and successful aging

Aging is the process of becoming older; we don't know how, when and why, we don't have a model or a phenotype. Aging is a process, a complex mosaic that is determined from the interaction of a variety of environmental and genetic variables. Irrespective of causes and mechanisms, aging is associated with the loss of functional reserve of multiple organ systems, increased prevalence of chronic diseases and enhanced susceptibility to stress. These changes conspire to reduce the life expectancy and

Comprehensive geriatric assessment (CGA)

The comprehensive geriatric assessment is a multidimensional assessment tool that examines different age-related domains including comorbidity, function, physical performance, cognition, nutrition, emotional status, polypharmacy, social support, and living environment.

The CGA provides a more accurate estimation of the patient's active life expectancy and functional reserve than a standard clinical evaluation. In addition, the CGA unearths unsuspected conditions that may compromise treatment

Frailty

Frailty is a physiologic state that may lead to disability following minimal stress. Disability represents the loss of a function necessary for independence. The term frailty purports high vulnerability to negative health-related outcomes, such as physical disability, hospitalisation and mortality. The prevalence of frailty is usually estimated to be around 10–25% in subjects aged 65 years and older [57]. The term frail may be related to a wide range of phenotypes. In geriatrics, frailty is

Treatment

The main treatment goal, in an old cancer patient, is the prolongation of active life expectancy, in addition to survival. Important goals include symptom management and the prevention of adverse drugs reactions (ADRs). The prevention of ADRs is in part possible by a careful review of drugs. Patients taking two drugs face a 13% risk of ADRs, rising to 38% when taking four drugs and to 80% if seven or more drugs are given simultaneously. If medication-related problems were ranked as a disease by

Conclusion

The assessment of aging is a multidisciplinary endeavour, aimed to define individual physiologic age that is poorly reflected in chronology. We recommend that all individuals aged 70 years and older undergo some form of geriatric assessment.

Aging itself does not increase surgical risk, rather an increased prevalence of chronic disease and the deterioration of organs' functions, generally associated with aging, may increase the risk of surgical complications.

A careful review of drugs, a diligent

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ReviewAssessment and treatment of elderly patients with cancer

Abstract

Introduction

Section snippets

Aging and successful aging

Comprehensive geriatric assessment (CGA)

Frailty

Treatment

Conclusion

Gynecol Oncol

Crit Rev Oncol Hematol

Eur J Cancer

Am J Clin Nutr

Am J Clin Nutr

J Clin Epidemiol

Soc Sci Med

Crit Rev Oncol Hematol

J Chronic Dis

Crit Rev Oncol Hematol

Clin Geriatr Med

Ann Epidemiol

Lancet

Crit Rev Oncol Hematol

Census

National population projections

Underrepresentation of patients 65 years of age or older in cancer-treatment trials

N Engl J Med

Older female cancer patients: importance, causes, and consequences of undertreatment

J Clin Oncol

Racial disparities in cancer therapy: did the gap narrow between 1992 and 2002?

Cancer

Leading on behalf of an aging society

J Am Geriatr Soc

Human aging: usual and successful

Science

Psychological perspectives on successful ageing: the model of selective optimization with compensation

Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the international society of geriatric oncology (SIOG)

Crit Rev Oncol Hematol

Geriatric assessment methods for clinical decision-making

J Am Geriatr Soc

Geriatric assessment: methods for clinical decision making

JAMA

Geriatric rehabilitation unit: a 3-year outcome evaluation

J Gerontol

Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence

J Am Geriatr Soc

Disability in older adults: evidence regarding significance, etiology, and risk

J Am Geriatr Soc

The predictive validity for mortality of the index of mobility-related limitation–results from the EPESE study

Age Ageing

Comorbidity and physical function: results from the aging and longevity study in the Sirente geographic area (ilSIRENTE study)

Gerontology

Disability as a public health outcome in the aging population

Annu Rev Public Health

The aging of America. Impact on health care costs

JAMA

Review
Assessment and treatment of elderly patients with cancer