wider interest in geriatric oncology,
there remains a "clear pattern of undertreatment"
of elderly cancer patients
in the US, manifested in dose
reductions and delays that may compromise
patient outcomes, according
to William B. Ershler, MD.
"Undertreatment must be avoided
if the best possible outcomes are to be
achieved," said Dr. Ershler, Director
of the Institute for Advanced Studies
in Aging and Geriatric Medicine, Geriatric
Oncology Consortium (GOC),
Speaking at an Amgen-sponsored
satellite symposium held in conjunction
with the GOC first annual multidisciplinary
Cancer Care in the Elderly, Dr. Ershler
said undertreatment of elderly cancer
patients appears to be independent of
patient health status. A major factor
driving this bias is the fear that older
patients, because of decreased hematopoietic
reserves, are somehow less able
to tolerate standard chemotherapy.
However, as described by other presenters
at the satellite symposium, correcting
myelosuppression can make
standard-dose chemotherapy possible
in older patients, potentially leadingto better outcomes (see the report on
the presentation by Stuart Lichtman,
MD, on page 8 of this issue).
To illustrate the negative impact of
undertreatment bias, Dr. Ershler described
the actual case of a 74-yearold
woman with cough and weight
loss of 3 months' duration. Physical
examination showed remarkablecachexia, mild dementia, and dehydration.
Bronchoscopy revealed smallcell
After receiving combined chemoradiation
therapy, the woman gained
weight and her mental status improved.
Three years after therapy, there
was no evidence of disease.
"The point is that this woman's
illness was producing cachexia," Dr.
Ershler said. "It wasn't the fact that she
was 74 years old. The tumor somehowmetabolically was influencing her performance."
The elderly woman's case underscores
that clinicians "have to...resist
the temptation to take an ageist perspective,"
he added. "The case actually
supports the notion of geriatric oncology.
This would be the person you
would want to treat."
Part of the problem may be the
perception that older cancer patients
have poorer survival because of their
cancer. It may be hard for oncologists
to reconcile perception with reality,
given certain statistics, for example,
breast cancer registry data showing
that survival is greatest in women up
to the age of 50 years, with a distinct
In fact, "tumors are not a priori
more aggressive in older people," Dr.
Ershler said. He explained that over
the years, clinicians have claimed that
observed functional problems have less
to do with the tumor as much as with
comorbidities or all the other problems
older people may have, which
diminish their chances of getting the
optimal chemotherapy dose and
Research has shown an overt bias
against the administration of cancerdrugs to older people. Published data
support the notion that there is understaging
in older patients, particularly
those with lung cancer and lymphoma.
In addition, older patients may receive
less informational support and
relevant communication regarding the
disease. In a recent study of older patients
with breast cancer (Cancer
97:1517-1527, 2003), researchers
found a negative association between
the patient's age and physician provision
of interactive informational support
(eg, whether a physician discussed
recurrence risk or treatment options).
One barrier to the appropriate
treatment of elderly cancer patients is
the lack of studies specific to that population.
A PubMed search for articles
on breast cancer, encompassing the
last 20 years, yielded more than 20,000
results, Dr. Ershler said. By contrast, a
similar search for aging and cancer
yielded only 1,707 entries; of those,
less than 10% were primary clinical
research and only 14 were randomized
"This tells me that as the field is
evolving, we are writing a lot of review
papers and extracting from studies
without an aging perspective," he said.
"What we really need is primary research."
Data on elderly cancer patients will
become more important as the population
ages. Sometime within the next
few decades, the portion of the population
in the geriatric age group will
climb to 20%, according to Dr. Ershler.
By the year 2020, individuals aged
65 years and older will comprise onequarter
of the US electorate. "This
age group has the highest turnout at
the polls," Dr. Ershler said. "If you
could mobilize this 25% to start addressing
issues related to health care,
they might be able to get some political