Zosia Chustecka

October 29, 2012

MANCHESTER, United Kingdom — "Cancer care in the elderly must include a geriatrician," according to Margot Gosney, MD, professor of elderly care medicine at Reading University in the United Kingdom.

"You would not care for a child with cancer without a pediatrician, so why would you care for an older patient without a geriatrician?" she asked here at the 12th International Society of Geriatric Oncology (SIOG) Meeting.

"All elderly patients need assessment, " she told meeting attendees; "there is no such thing as a typical 80-year-old."

Specialist input is the way of the future, she noted, explaining that stroke patients are now directed to a stroke clinic and patients with broken hips are sent to specialized hip clinics.

New legislation in the United Kingdom now protects "older people," so treating cancer in an older patient without first carrying out a geriatric assessment is unethical, she said.

The idea of involving geriatricians in oncology care is still fairly new, and geriatric oncology is an emerging specialty. This is only the twelfth SIOG meeting, but each year it gets bigger.

"We are making significant progress," said Riccardo Audisio, MD, FRCS(Engl), consultant surgical oncologist and honorary professor at the University of Liverpool, United Kingdom, and outgoing president of the SIOG. "The momentum is there and awareness is growing."

The elderly patient is a special patient. Dr. Riccardo Audisio

Why is there is a need for the specialty of geriatric oncology? Cancer is most likely to occur in older people, Dr. Audisio explained, and people are now living longer, so the majority of cancer patients are going to be elderly. "The elderly patient is a special patient; they are different from younger adults," he told Medscape Medical News in an interview.

How old is "older"? That is a changing target, Dr. Audisio noted. The United Nations definition is 65 years; the threshold in the medical literature is usually 70 years, and many clinical trials do not recruit patients older than 70 years, although this is changing. "Now we are maybe looking at 75," he said.

The aging process alters metabolism, cardiovascular factors, and kidney function, and older people are likely to have comorbidities and to use multiple medications. They might also experience incontinence, mobility problems, social isolation, depression/mood fluctuations, and decreased hearing and vision. All of these factors need to be considered when treating an older person with cancer; the cancer cannot be treated in isolation.

Because people age at different rates, chronological age can be misleading. Patients need to be assessed for functional age and biological functioning so the oncologist can determine the most appropriate therapeutic regimen. This is where the expertise comes in. The geriatrician can assess each patient from a health point of view, and work with the oncologist to optimize and tailor the cancer treatment accordingly, Dr. Audisio explained.

A major theme of the SIOG meeting was how best to carry out such a geriatric assessment, and many different research groups reported their approaches.

The gold standard is the Comprehensive Geriatric Assessment (CGA), which is multidimensional interdisciplinary evaluation that assesses medical, functional, cognitive, social, nutritional, and psychological parameters. This can take 5 or 6 hours to complete, and involves a physician, a nurse, a social worker, and then the geriatrician to synthesize all of the data, explained Catherine Terret, MD, PhD, from the geriatric oncology program at the Centre Léon-Bérard in Lyon, France.

"For this, the patient comes to the hospital for a whole day," she told meeting attendees.

"This is a cumbersome tool," said Dr. Audisio. It is just not feasible to assess every elderly patient in this manner, so in "real-life" practice, screening tools are used, he explained. These are quicker, and they identify patients who need further assessment.

Brief Screening Tools

According to Dr. Audisio, the most popular screening tools are the 4-question Vulnerable Elderly System 13, the 15-question Groningen Frailty Index, and the Time to Up and Go (TUG) test, which involves getting up from a chair, walking 5 meters, returning to the chair, and sitting back down.

Dr. Audisio explained that the TUG test is very easy to do yet can be quite illuminating. If a patient cannot complete the test in 20 seconds, there might be problems with walking/balance, blood pressure, shortness of breath, or stiffness/arthritis, and further assessment is needed.

The TUG test is now compulsory in the Netherlands for all older patients. "Geriatricians there do it as a matter of course," he noted.

A number of pilot studies of screening tools are underway in the United Kingdom and have been completed in Belgium, Dr. Audisio said.

Geriatric oncology has really been a European development; in the United States, "the field is still in its infancy," said Richard Rosenbluth, MD, from the division of geriatric oncology at Hackensack University Medical Center in New Jersey, which is one of only a handful of such centers that exist in the United States. Another is the cancer and aging research program in the Department of Medical Oncology at City of Hope, in Duarte, California, headed by Arti Hurria, MD, incoming president of the SIOG.

The need for centers specializing in caring for elderly patients with cancer is rapidly increasing. "As the population ages over the next decade, we can expect that the percentage of older people diagnosed with cancer will grow," Dr. Rosenbluth noted. "We as a society owe it to our seniors to be ready for them."

Dr. Rosenbluth told Medscape Medical News that he has been coming to the SIOG meetings for the past 5 years. He explained that although there has been progress and agreement on the concept of geriatric assessment of older patients with cancer, there is still no consensus on how it should be carried out.

This was also the conclusion of a recent review by Martine Puts, PhD, from the University of Toronto, in Ontario, Canada, and colleagues (J Natl Cancer Inst. 2012:104:1134-1164). They make the point that both the SIOG and the National Comprehensive Cancer Network recommend that "some form of geriatric assessment be conducted to help cancer specialists determine the best treatment for their older patients...[but] neither organization has indicated what constitutes the best form of assessment. "

Interestingly, of the 73 studies that Dr. Puts and colleagues reviewed, 4 examined the impact of geriatric assessment on treatment decisions. Of those, 2 showed that such an assessment altered 40% to 50% of the treatment decisions.

That is the Holy Grail that we are all in search of. Dr. Richard Rosenbluth

"Conceptually, the CGA is the gold standard. There are many variations of it, but even the simplest takes about an hour," Dr. Rosenbluth noted. "In the context of a busy practice, we need a brief assessment tool that does not take too long, is efficient, and can be validated experimentally," he said. "That is the Holy Grail that we are all in search of."

In his own practice, Dr. Rosenbluth consults with a geriatrician, a psychosocial professional, and a nutritionist to assess the older patient. The aim is to decide which category the patient fits into: fit, vulnerable, or frail. This is a classification system was developed by Lodovico Balducci, MD, from the H. Lee Moffitt Cancer Center in Tampa, Florida (Hematol Oncol Clin North Am. 2000;14;235-250), who Dr. Rosenbluth described as "one of the founding fathers of geriatric oncology."

A fit older patient with cancer should be treated as a younger adult, Dr. Rosenbluth explained. With chemotherapy aiming to cure the disease, the only proviso would be a minor modification of dose to take into account reduced organ function. He emphasized this point because he suspects that many older patients with cancer are being undertreated by general oncologists. There are now data from subset analyses of clinical trials that show that fit elderly patients who are enrolled in studies do just as well as younger adults. "Even though we didn't set out to find this, these are the data that we have managed to retrieve, so I think the case is closed," he said.

An elderly fit patient can be treated exactly the same as a younger adult, he emphasized, at least in the case of breast, prostate, and colon cancer.

However, in the case of a frail patient, life expectancy can be short, so the cancer would not appreciatively reduce survival beyond their expected survival, he continued. For instance, an 85-year-old wheelchair-bound woman with mild cognitive dysfunction would be expected to live for an average of 4 years. If she is also frail, that could be reduced to 2 years.

"Breast cancer would kill her in 5 years, but she is not expected to live that long, so there is nothing to be gained but everything to be lost by subjecting her to aggressive treatment," Dr. Rosenbluth explained.

In such a cases, he would offer endocrine treatment instead, which is relatively benign.

"At the other end of the spectrum, you could have a very fit 85-year-old woman who could live to be 100...so you would want to be aggressive in the treatment of a breast cancer that could kill in 5 years," he said.

"It is very important to determine how long the patient is expected to live without the cancer," he emphasized. "This is extremely difficult, which is where the geriatric assessment comes in," he explained.

12th International Society of Geriatric Oncology (SIOG) Meeting.