Shin Yin Lee, MD
“I am a veteran and a fighter—I will do anything so that the cancer doesn’t come back,” my patient said to me as I sat with him and his daughter in clinic to discuss his treatment options.
The resected tumor was a locally advanced squamous cell carcinoma of the lung with high-risk features, indicating a high likelihood of disease recurrence. Most guidelines would recommend adjuvant chemotherapy; in fact, his daughter did her own research on the Internet and came to the same conclusion.
As I shifted my focus from the tumor back to my patient, the benefits of treating him with chemotherapy became less clear. Although he was recovering well from surgery, he was a frail male octogenarian with multiple medical problems who required assistance with some of his activities of daily living and all of his instrumental activities of daily living.
I asked myself, “Are the expected benefits from adjuvant chemotherapy going to outweigh the risks in a patient with limited life expectancy and decreased tolerance of stress? Is a good Eastern Cooperative Oncology Group (ECOG) performance status enough to pronounce him fit for chemotherapy?”
This type of scenario is becoming increasingly more common in the United States. A demographic shift known as the “silver tsunami” makes it likely that the number of older patients with cancer will increase.1
Age itself is a known risk factor for developing cancer: it has been reported that a majority of cancer diagnoses and deaths occur in patients older than 65 years.2
By 2030, it is predicted that 70% of cancer diagnoses will be made in adults in this age group.3
When making treatment decisions for older cancer patients, the challenge is in selecting the appropriate therapy for the appropriate patient. Age alone should not be used to preclude a patient from receiving the best available treatment. For this reason, the field of geriatric oncology was born.
The specific needs of older cancer patients are different from those of younger adults. Older patients are more likely to have significant comorbidities, disabilities, and geriatric syndromes. Physiological changes also occur with age, such as decreased creatinine clearance, impaired gas exchange, and decreased cardiac output.2
Unfortunately, there is a lack of high-quality evidence to help guide clinicians in selecting treatment, as the majority of cancer treatment clinical trials have excluded older patients.4
Most oncologists use scoring systems such as the ECOG and Karnofsky score to determine performance status.5 Compared with these scoring systems, the Comprehensive Geriatric Assessment (CGA) is more sensitive in detecting functional impairments in older adults and can help with clinical risk stratification and individualized treatment planning. The CGA evaluates key domains that are predictive of morbidity and mortality risk in older adults. These domains include functional status, comorbid medical conditions, cognition, psychological state, current medications, social support, and nutritional status.6
The American Society of Clinical Oncology (ASCO) is recognizing the increasing importance of geriatric oncology and is playing a large role in promoting this field. There have been many presentations and educational sessions surrounding the field of geriatrics during recent ASCO annual meetings. Additionally, more funding has been provided to promote research and career development. Geriatric oncology is now being recognized in major journals such as the Journal of Clinical Oncology
A cooperative group, the Cancer and Aging Research Group, has made many important contributions to the field, including the development of a tool to help gauge the likelihood of chemotherapy toxicity in older adults.7
Outside of the United States, the International Society of Geriatric Oncology has established task forces to help in making treatment recommendations. The society now has a peer-reviewed journal called the Journal of Geriatric Oncology
The National Comprehensive Cancer Network also has specific guidelines that pertain to older patients with cancer.9
Most hematology and oncology fellowship program directors agree that geriatric oncology should be incorporated into fellowship curriculums. However, only one-third of hematology and oncology programs formally cover topics related to geriatric oncology as part of their curriculum.10
Therefore, it is clear that although an understanding of the needs of geriatric patients is vital to successfully treating cancer in adults, many hematology and oncology trainees will complete fellowship without any formal exposure to geriatrics.