Cancer's age wave (ASCO annual meeting)

When assessing cancer screening and treatment needs, the advice is to consider a patient's physiologic condition, rather than age alone.

By Susan J. Landers — Posted July 16, 2007

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Cancer is a disease of aging. More than 50% of all malignancies develop in people 65 and older. Since all indicators point to more people living longer -- one in every five is expected to be in this age category by 2030 -- concerns are being raised over which older patients should be treated and how aggressively.

An element of uncertainty also arises from the fact that these patients generally are excluded from clinical trials that test the safety and efficacy of therapies.

The challenges posed in treating this age group were discussed in several sessions at the American Society of Clinical Oncologists annual meeting in Chicago June 1-5.

An additional concern, this one triggered by the anticipated boom in elderly cancer patients, is that there will not be enough oncologists available to treat them. A work force report released by ASCO last March indicated that the demand for services would likely outpace the number of trained specialists.

An education session at the annual meeting was devoted to solutions to this pending work force shortage. One possibility discussed was the formation of patient care teams consisting of oncologists and primary care physicians, nurses and social workers. Another is a stronger emphasis on treatment by primary care physicians for patients in remission.

"It is essential that we look ahead and see where our future is going, to know how we can best meet the challenge," said Michael Goldstein, MD, an assistant clinical professor of medicine at Harvard Medical School in Boston. The issue affects all who see patients with cancer, he said.

Care for the elderly with cancer is complex, and one expert in geriatric oncology urged that physicians manage cancer patients not according to their chronological age, but consider physiologic age instead. "Every time I hear that adjuvant chemotherapy for breast cancer is ineffective beyond age 70, I am tempted to ask whether anybody has studied adjuvant chemotherapy in women of different hair or eye colors," said Lodovico Balducci, MD, professor of medicine and oncology and program leader of the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida in Tampa.

Dr. Balducci, who has studied older cancer patients for 35 years, received the first B.J. Kennedy Award for Scientific Excellence in Geriatric Oncology at the meeting. He also delivered a lecture on cancer care for the elderly. Stressing that people age differently, Dr. Balducci used the example of his twin aunts.

Despite having the same genetic material, growing up in the same small town in northern Italy and sharing the same occupation -- elementary school teacher -- they were, by age 90, very different. One had severe dementia while the other remained cognitively sharp until her death at age 100.

Geriatric assessments are useful

Dr. Balducci recommended the use of geriatric assessments to help identify older patients who may be candidates for cancer screening and treatment. Such assessments cover a patient's physical and mental health, support network, ability to perform basic tasks of daily life and safety of their physical environment.

In an education session on the management of frail elderly women with breast cancer, Dr. John Michael Dixon, a consulting surgeon at Edinburgh Breast Unit at Western General Hospital in Scotland, agreed that age alone was not the deciding factor when considering treatment for these patients.

He noted that there are alternatives to mastectomy, even for patients in their 70s.

"Older women don't want mastectomies any more than younger women," he said. "The art is in choosing the right treatment for the right patient."

Assessing for frailty among breast cancer patients is important when considering a course of radiation therapy, added Krystyna Kiel, MD, assistant professor of radiation oncology at Northwestern University in Chicago. But the definition of frailty can be a little vague, she allowed. She considers frailty to be "a clinical syndrome manifested by diminished muscle strength, decreased physical activity, inability to walk, frequent falls, poor appetite and impaired cognition and depression."

When assessing cancer treatments for older patients, among the first things to consider is the chance they will succumb to some disease other than breast cancer, she said. Co-morbidities are common among this age group. "Is radiation important for someone with limited survival? Perhaps not," she noted. Plus six to seven weeks of radiation is difficult for even the most able of patients, she said.

In a session on hematologic cancer in the elderly, Harvey Cohen, MD, director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C., asked, "What's different about older patients?"

Patients in their mid-70s and older are a heterogeneous group when it comes to health status, but there is a tendency for them to have multiple and interactive diseases, Dr.Cohen said. They also often underreport symptoms, perhaps attributing aches and pains to aging.

Paul Hamlin, MD, a medical oncologist at Memorial Sloan-Kettering Cancer Center in New York City, added that age is the most important predictor of outcome in non-Hodgkin's lymphoma. But should treatment be limited to those 60 and younger? Maybe not. He suggested that "perhaps 70 is the new 60."

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Demand outpacing supply

By 2020, the demand for oncology services is predicted to increase by 48%.

The supply of oncologists is predicted to fall short by nearly 4,000 physicians -- roughly a third of the 2005 supply.

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Age matters

People 65 and older have a cancer incidence rate 10 times greater than younger people and a mortality rate 16 times higher. Cancer is second only to heart disease among causes of death for people older than 65. Other factors also influence treatment options:

Comorbidities: Older patients are more likely to have additional conditions.

Physiological vs. chronological age: Chronological age should not be the deciding factor.

Activities of daily living: Geriatric assessments can help determine ability to function independently.

Frailty: Muscle weakness, inability to walk, poor appetite and impaired cognition should be weighed.

Sources: American Society of Clinical Oncology, National Cancer Institute, Centers for Disease Control and Prevention

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Treating the whole patient

Treatment for cancer pain calls for an individualized approach for all patients, including the elderly, said Amy Abernathy, MD, a medical oncologist at Duke University Medical School, in Durham, N.C. Dr. Abernathy spoke during an education session at the American Society of Clinical Oncology on pain, depression and fatigue in older cancer patients.

Key factors in addressing pain are to treat aggressively and to keep the focus on enabling the patient to continue to enjoy daily activities, she said.

Dr. Abernathy described patient "Chuck" as someone who wants to fish more than anything else. As a result, she focuses on reducing his cancer-related shoulder and arm pain to allow him to continue to board his boat and toss in his line. Musculoskeletal pain is probably one of the most common causes of pain among the elderly, she said. "As patients become inactive, and as they lose weight, the risk of musculoskeletal pain and the impact on joints is real."

Jimmie Holland, MD, a psychiatrist at Memorial Sloan-Kettering Cancer Center in New York who has worked with cancer patients for decades, noted that elderly patients are likely to express depression, or what can also be called distress, via poor appetite and fatigue. But interventions can work. Even phone calls seem to lower levels of depression in this group, as many believe that no one cares about them, she said. Low doses of antidepressants such as escitalopram oxalate or paroxetine are also effective.

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External links

Information about lectures, presentations and other developments at the 2007 American Society of Clinical Oncology Annual Meeting (link)

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