Managing Elderly Cancer Patients: Quality of Life, Polypharmacy, and Survivorship

Kate M. O'Rourke

Disclosures

November 24, 2015

In This Article

During a presentation at the 2015 European Cancer Congress (ECC), a clinician displayed a photo collage of seniors, including an 85-year-old woman swinging from the parallel bars and a group of women in motorized scooters. Her point was clear: The elderly are a very heterogeneous population. At the ECC, clinicians discussed this heterogeneity, polypharmacy, and other factors that complicate the treatment of older people with cancer.

The Importance of Geriatric Assessment

Cindy Kenis, RN, MScN, PhD, a geriatric oncology nurse at University Hospitals Leuven in Leuven, Belgium, pointed out that there is a huge difference between chronologic age and biological age. While age may affect physiologic, physical, and cognitive, functioning, at least 20% of the elderly have no disabilities or medical problems.[1]

at least 20% of the elderly have no disabilities or medical problems.

Determining where patients fall on the spectrum of old age is one of the challenges of treating older persons with cancer. Will further diagnostic examinations have therapeutic implications for a patient? What is his or her life expectancy? Will he/she tolerate therapy? Does the patient have enough social support to maintain therapy?

According to Dr Kenis, geriatric assessments are key to managing older cancer patients. "A geriatric assessment is a multidimensional, interdisciplinary patient evaluation that leads to the identification of the general health status, including medical, but also functional, cognitive, social, nutritional, and psychological parameters," said Dr Kenis.

In the last year and a half, the International Society of Geriatric Oncology has updated their geriatric assessment guidelines by issuing a new guideline on geriatric screening and another on geriatric assessment.[2,3] According to Dr Kenis, the most important recommendation coming out of the updated screening guideline is that there are more than 20 different screening tools investigated in older patients with cancer, and there is no clear recommendation about which screening tool is the most appropriate.[2] The G8 and the Flemish version of the Triage Risk Screening Tool (fTRST) are supported by the most robust data, having been extensively studied in the cancer population, according to the guidelines. Both tools have a high sensitivity with acceptable specificity, and they are prognostic/predictive for several outcome measures, such as the presence of a geriatric risk profile, functional decline, and overall survival. The choice of screening tool is heavily influenced by region, country, and hospital preference. It may also depend on the clinical situation, said Dr Kenis.

The goal of a screening is to determine which patients are in need of further geriatric assessment.[2] A geriatric assessment evaluates the patient's social support, functional status, fatigue, comorbidity, cognition, mental health, nutrition, and other geriatric syndromes (eg, use of medications including polypharmacy).[3]

Geriatric assessments are important for four reasons.[3] First, they can detect geriatric problems, including those that are not routinely evaluated by treating physicians. Second, they provide prognostic value. "Geriatric parameters independently predict overall survival in various settings and various diseases," said Dr Kenis. "Nutritional status and functional status are, for example, two prognostic parameters for overall survival." Third, geriatric assessments have predictive value, independent from classic oncologic predictors, for severe treatment-related toxicity. "The optimal geriatric parameters, including cut-off points, to predict severe treatment-related toxicity or modify the therapeutic approach have not yet been established for the different cancer types or treatment options," said Dr Kenis. Finally, geriatric assessments influence treatment decisions, helping clinicians choose the appropriate treatment intensity, as well as interventions for improving quality of life (QOL). Input from general practitioners is crucial, said Dr Kenis.

"It is better to do some kind of imperfect geriatric screening and assessment than no screening and assessment at all," said Dr Kenis. "Healthcare workers, nurses, physicians, and others need to be watchful for age-related aspects in oncology."

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