A major problem facing oncologists today is how best to treat elderly patients; according to some recent studies,1,2 the number of “baby boomers” being diagnosed with cancer is skyrocketing, thus driving more attention to improve the care of elderly patients. Each day in the United States, 10,000 baby boomers reach age 65 years, and the incidence of cancer in this population is estimated to increase 67% between 2010 and 2030.1 In addition, it is well established that the risk for cancer rises with age and results in more deaths in adults over age 65 compared with younger patient populations with cancer.
“Care of the older cancer patient is a complex mix of attending to the treatment of the cancer while being aware of the age-related issues that can impact care such as comorbidities, geriatric syndromes, and age-related physiological changes,” said Harvey Jay Cohen, MD, a professor of medicine and the director of the Center for the Study of Aging at Duke University Medical Center in Durham, NC.
Dr. Cohen is the coauthor of a recent editorial published in The Journal of the American Medical Association on the challenges facing cancer care for an aging population.1 He and his colleagues wrote that the workforce shortage, the financial stressors across the health care system, and family networks are all contributing to a crisis in cancer care for older adults. To help address this need, they suggest passing new laws that raise the age of patients who can be included in clinical trials. In recent years, laws and policies for pediatric patients have changed and those types of changes may be needed for geriatric patients as well. “Only very healthy individuals typically participate in clinical trials, which once again does not truly represent the population seen in oncologists’ offices, as they often have multiple medical comorbidities,” said Mateusz Opyrchal, MD, PhD, assistant professor of oncology at Roswell Park Cancer Institute in Buffalo, NY.
Dr. Cohen said that the shift in demographics also brings to the forefront the problem of overdiagnosis. Along the same lines, Dr. Opyrchal said oncologists are more likely to offer treatments that are potentially toxic only to those patients who are expected to benefit from them. Many studies suggest that patients over age 65 years benefit from chemotherapy treatments; yet, little data exist on the safety of these treatments in the geriatric population. “As has been shown, the elderly tend to value quality of life over length of life. Therefore, it is imperative that more research is done to study the efficacy and toxicity of treatments in older populations to allow oncologists to be able to offer the most appropriate treatments to their patients,” Dr. Opyrchal told ChemotherapyAdvisor.com.
New Trends in Clinical Trials
Geriatric oncology specialist Tanya Wildes, MD, an assistant professor of medicine at Washington University School of Medicine in St. Louis, MO, said there is a growing awareness among oncologists that there is a need to revamp clinical trials. Researchers in the United Kingdom recently conducted a cancer study using cytotoxic drugs that were started at below-standard doses, which is common in clinical practice but not in clinical trials.3 This study also employed a comprehensive geriatric health assessment to identify factors that might aid future selection of patients or treatment regimens. In addition, the trial used a composite measure of overall treatment utility that incorporated objective and subjective measures of benefit and harm.
“It is a unique way to conduct a trial,” said Dr. Wildes in an interview with ChemotherapyAdvisor.com. “So, I think there is a change that is occurring, but it is just in its infancy. One of the big problems is that people don’t have the ability to approach trials with a geriatrician.”
More cancer studies are including patient-reported outcomes and, in general, there is a movement towards letting the patient decide what works. Dr. Wildes was very pleased to see that a study presented in December at the American Society of Hematology (ASH) Annual Meeting specifically looked at comorbidities among older patients (median age, 73 years) with chronic lymphocytic leukemia (CLL).4 This large randomized trial investigated first-line chemo-immunotherapy in patients with CLL in a much older patient population. The primary endpoint was investigator-assessed progression-free survival and the key secondary endpoints were response rates, minimal residual disease, and overall survival.
Times Are Changing
Melding the fields of geriatrics and oncology is now required to meet the complexity of care required for older adults—this merge does seem to be occurring and at a faster pace. The International Society of Geriatric Oncology (SIOG) is reporting that it has grown dramatically over just the past 12 months, with an increase in membership of 17%, abstract submissions increased to 36%; also a 50% increase in the number of national representatives providing feedback on activities in their respective countries during 2013. In addition, there was a doubling in the number of individuals who joined the SIOG scientific committee in 2013, and the SIOG’s official publication, the Journal of Geriatric Oncology, is now being indexed by PubMed.
“SIOG has been at the forefront of trying to get oncologists to adopt some of the standard geriatric measures to decide on cancer treatment. That is, people over 65, over 75, and over 85 are more different from one another in terms of fitness for rigorous treatment than people in middle age, the people who are generally recruited for clinical trials,” said geriatrician Miriam Rodin, MD, PhD, an associate professor of medicine at Saint Louis University School of Medicine in St. Louis, MO.
According to Dr. Rodin, applying clinical trial data to a geriatric oncology patient is complicated. Dr. Rodin noted that geriatricians make fine distinctions among the fit, the frail, and the in-between (so-called pre-frail or vulnerable) among the elderly. “The ‘in-betweeners’ are the ones that take some special care,” Dr. Rodin told ChemotherapyAdvisor.com. “Some very elderly people do well with standard cancer treatment and some apparently okay people crash and burn after only one or two treatments.”
Dr. Rodin also noted that significant numbers of geriatric patients with treatable cancers are told they are too old and don’t get treated “or get half-hearted ineffective treatment.” Conversely, she said other geriatric patients are treated too aggressively and therapies end up causing more harm than good. However, Dr. Rodin indicated there is now new reason for optimism because these clinical issues are coming to the forefront, creating a new level of awareness for oncologists who treat elderly patients.
- Hurria, A, Naylor, M, Cohen HJ, et al. Improving the quality of cancer care in an aging population: recommendations from an IOM report. JAMA. 2013;6;310(17):1795-1796.6
- Smith BD, Smith GL, Hurria A, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009; 27(17):2758-2765.
- Seymour MT, Thompson LC, Wasan HS, et al. Chemotherapy options in elderly and frail patients with metastatic colorectal cancer (MRC FOCUS2): an open-label, randomised factorial trial. Lancet. 2011;377(9779):1749-1759.59
- Goede V, Fischer K, Busch R, et al. Head-to-head comparison of obinutuzumab (GA101) plus chlorambucil (Clb) versus rituximab plus Clb in patients with chronic lymphocytic leukemia (CLL) and co-existing medical conditions (comorbidities): final stage 2 results of the CLL11 trial. Presented at the 2013 American Society of Hematology Meeting; December 7-10, 2013; New Orleans, LA.