Every oncologist is a geriatric oncologist
Caring for older individuals with cancer is a significant part of routine clinical practice for oncologists. The reason why is simple to explain: cancer is mostly a disease of older individuals: approximately one in two patients with cancer is more than 65 years old and unfortunately, 7 out of 10 patients with cancer who decease, are also older than 65 years. Therefore, every oncologist is a geriatric oncologist.
The Anticancer Fund is well aware of this. Through My Cancer Navigator, our personal service for cancer patients, we also get questions from older adults who have been diagnosed with cancer. Nicolò Battisti, medical oncologist and President-Elect of the International Society of Geriatric Oncology (SIOG), is one of the medical consultants of My Cancer Navigator. He shares his experience and his concerns in this blog.
The ongoing global increase of average life expectancy and the fact that the older adult population is currently the fastest growing segment of the population in low-, middle- and high-income countries alike suggests that the incidence of cancer in older adults is expected to increase. In other words, even more elderly will be confronted with cancer in the future.
Nonetheless, older adults are being underrepresented in the clinical trials investigating the treatment and also in the management of cancer, when therapy choices are made (1). The current standard of care is mainly based on evidence that was generated in a relatively young population. Older patients are frequently excluded due to strict trial inclusion and exclusion criteria, logistic barriers that make recruitment and trial procedures challenging for this specific age group and concerns and misconceptions of clinicians. Unfortunately, this makes the available evidence that has to guide the management of cancer, less applicable in this cohort of patients.
A heterogeneous population
Moreover, older adults are a heterogeneous population. The treatment and management of cancer in this age group is complicated due to a number of challenges that are more prevalent or unique to this specific group of individuals. First, there is a gradual decline in organ function and reserve, which may affect the pharmacokinetics of drugs, meaning the drug doesn’t always have the same impact on the organism of the patient.
Secondly, the higher burden of comorbidities may affect their life expectancy, mitigate anticancer treatment benefits and increase the risk of complications. Polypharmacy, or the use of multiple medicines, is a common issue in this age group which make older adults particularly prone to the risk of drug interactions.
Functional impairment, or limitations due to illness, is also prevalent in this group of adults, and may increase the risk of adverse events independently of other factors.
Older individuals may lack social support and have a higher prevalence of psychological problems, especially depression. In the context of a more limited life expectancy, quality of life may be more important compared with “quantity of life”, which suggests that a thorough understanding of patient preferences and shared decision-making (2) of physicians with patients are critical in this age group.
How to make a good decision?
All these factors make the management of cancer in older adults particularly complicated. Since oncologists cannot assume that in the real world, trial findings are necessarily applicable to older patients with cancer, they have to rely on other ways to fill the gaps of knowledge. Comprehensive geriatric assessment (CGA) can fill these gaps and is mandatory to guide decision-making in this population. CGA is a diagnostic and therapeutic process involving the evaluation of domains that are important for the well-being of older individuals, like comorbidities, functional status, cognitive status, nutritional status, social activity and support, concurrent medications and mood. These validated tools allow personalised interventions aimed at maximising their health.
This is important before elderly embark on anticancer therapy, but also subsequently when they require any change in their cancer management. Three randomised clinical trials presented at the 2020 American Society of Clinical Oncology Annual Meeting documented lower rates of severe toxicities and unplanned hospitalisations, better quality of life and increased uptake of advanced directives in older patients with cancer receiving systemic anticancer therapy and undergoing CGA, compared with those managed with routine care.
Personalised and holistic approach
The complexity makes the field of geriatric oncology particularly rewarding as it offers oncologists a unique opportunity to aim for a truly personalised, patient-centred approach. This should not only involve driving novel anticancer treatment decisions based on new biomarkers, but also a more holistic approach which should take into consideration all the aspects that are crucial to the well-being of older individuals in order to recommend the most appropriate treatment plan in the context of their preferences.
For all these reasons, I strongly believe that caring for older individuals with cancer is an extremely rewarding experience for clinicians, including doctors, nurses and allied healthcare professionals. Managing cancer in this specific population gives us a unique opportunity to integrate considerations on the tumour and its biology alongside considerations on their overall health, in order to formulate an integrated and holistic treatment plan. This way, we can maximise their well-being and have a meaningful positive impact on their lives despite the cancer and its therapy.
(1) What is cancer management? Once cancer is diagnosed, the patient requires medical treatment and specialised care. Different therapies – surgery, radiotherapy and chemotherapy – are given alone or in combination. The corner stone of cancer management is an evidence-based multimodality therapy that has been evaluated by well-designed trials.
(2) In shared-decision making, the patient is informed of his or her treatment options and the risks and benefits of them. Being fully aware, the patient relates his or her preferences and values and these are taken into account in the treatment decisions.