Whether it be to identify a seemingly frail older patient with metastatic colon cancer who would tolerate and benefit from standard treatment, or to prevent a frail older lung cancer patient from experiencing severe side effects due to adjuvant chemotherapy, oncologists are having to make difficult decisions with increasing frequency.
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.2,3
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.8 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.
How can fellowship programs be structured to provide greater exposure to and knowledge of geriatric oncology? Didactics aside, programs can subscribe fellows to ASCO’s Education Essentials for Oncology Fellows, which includes general modules on geriatric oncology and disease-specific modules.11 Some medical centers have a geriatric oncology clinic where fellows can do a rotation. Unfortunately, this is not yet commonplace. A required rotation in geriatrics could be beneficial, particularly for the purpose of allowing fellows to practice doing a CGA.
Interdisciplinary collaboration between geriatrics and oncology, in tumor board for example, can foster more discussion and participation between the specialties. Because geriatricians have recognized the shortage of practitioners in the field, they have collaborated with physicians in other specialties and developed strategies to educate trainees and inspire them to specialize in geriatrics. The Chief Resident Immersion Training (CRIT) in the Care of Older Adults program, developed at Boston University/Boston Medical Center, has been successful in promoting collaboration among disciplines in the management of medically complex older patients. In fact, an opportunity to participate in CRIT as an internal medicine resident helped develop my interest in geriatrics. This program, which focuses on case-based learning of geriatric principles and leadership, has been conducted in more than a dozen institutions nationwide.12
In order to foster the creation of new leaders in the field, in 2006 the ASCO Hartford Foundation provided funding for the development of 10 geriatric oncology training programs.13 Being a fellow at one of these programs provided me with a unique training experience. Aside from addressing the clinical requirements for board eligibility in medical oncology, approximately 1 year of the fellowship program is dedicated to core clinical geriatrics training; this includes rotations in the geriatrics inpatient service, nursing home care, rehabilitation medicine, the Alzheimer’s unit, palliative care, and an outpatient continuity clinic. In addition, fellows gain experience in performing outpatient comprehensive geriatric assessments of older adults who have been referred to the clinic for evaluation.
The integration of didactic, research, and clinical experiences in both geriatrics and oncology can lead to board eligibility in both specialties after 3 years. Some fellows have participated in an additional year of training in order to become board eligible for hematology. The most distinctive feature of my training at Boston University/Boston Medical Center is that I have the opportunity to practice in different models of care and to treat a remarkably diverse patient population. At Boston Medical Center, we care for a large, underserved, and international migrant population. Additionally, we care for veterans at the Boston Veterans Affairs Healthcare System. We also care for patients in a unique way at a Program of All-inclusive Care of the Elderly (PACE) site. (PACE is a capitated payment model focused on multidisciplinary team-based care.)
Whether it be to identify a seemingly frail older patient with metastatic colon cancer who would tolerate and benefit from standard treatment, or to prevent a frail older lung cancer patient from experiencing severe side effects due to adjuvant chemotherapy, oncologists are having to make difficult decisions with increasing frequency. Integrating geriatric oncology principles into fellowship training is one of the many efforts under way that can improve the field of geriatric oncology so as to improve patients’ quality of life, increase survival, and decrease treatment toxicity in our older cancer patients. As a saying in oncology goes, “If you are not a pediatric oncologist, you are a geriatric oncologist.”