FT. LAUDERDALE, FlaOlder cancer patients are at increased risk
for complications of chemotherapy, and such risks must be weighed
against the potential benefits of treatment. However, chronologic age
is an imprecise gauge of physical condition. A geriatric assessment
can help the physician determine the best approach to cancer
treatment, Lodovico Balducci, MD, said at the fifth annual conference
of the National Comprehensive Cancer Network (NCCN).
Dr. Balducci is co-chair of the NCCN Senior Adult Care Task Force,
along with Jerome W. Yates, MD, MPH, of Roswell Park Cancer
Institute. Dr. Balducci is professor of medicine and program leader
of the Senior Adult Oncology Program, H. Lee Moffitt Cancer Center
& Research Institute of the University of South Florida, Tampa.
Age by itself is not a contraindication to cancer
treatment, Dr. Balducci said. However, in frail individuals who
are already barely able to dress and bathe themselves, cancer
treatment may hasten the loss of independence, he noted.
Very old patients with a limited life expectancy stand to gain less
from cancer treatment than other senior adults. This is the
difficulty, Dr. Balducci said. As you age, the benefits
do decline, and the risks do increase. Here stands the knot of our decisions.
A geriatric age assessment can help the physician evaluate the risks
of cancer treatment for a particular patient. This is important
because chronologic age is a poor predictor of functionality.
The elderly are a very diverse population, and we need to have
a uniform assessment to allow patients to be stratified according to
risk, Dr. Balducci said.
Not every patient will need a comprehensive geriatric assessment, but
screening for such an assessment should begin at age 70. The
geriatric evaluation can provide us with some evidence about survival
and also tolerance of treatment in these older people, Dr.
Screening involves simply asking each patient a number of questions
directed at determining emotional status, ability to perform
activities of daily living, and social support. Comorbid conditions
would also be evaluated at this time. The screening test proposed by
the task force is modified from a screening instrument described by
Lachs et al (Ann Intern Med 112:699-706, 1990).
Depending upon the results of the screening test, a more extensive
geriatric assessment may be needed. The assessment does not
have to be provided by an oncologist, but if nobody else has done it,
I think it behooves the oncologist to do it, Dr. Balducci said.
The assessment will identify frail persons who have exhausted most of
their functional reserves and are best served by palliative rather
than curative treatment.
Frailty is said to exist when a person exhibits dependence in one or
more activities of daily living, or at least three comorbid
conditions, or at least one geriatric syndrome. Geriatric syndromes
include spontaneous fractures, frequent falls, severe dementia,
severe depression, and incontinence.
A number of questions arise when elderly patients undergo
chemotherapy, he said. Should hematopoietic growth
factors be used? At what level should hemoglobin be maintained?
Should chemotherapy doses be adjusted?
Studies have shown that routine prophylactic use of hematopoietic
growth factors (G-CSF, GM-CSF) can reduce the risk of myelodepression
in patients receiving myelotoxic chemotherapy regimens, Dr. Balducci
said. For this reason, the task force is proposing guidelines that
recommend the use of hematopoietic growth factors in patients aged 70
and over receiving moderately toxic chemotherapy regimens.
The task force is also recommending hematopoietic growth factors for
patients aged 60 and over who are receiving induction or
consolidation chemotherapy for acute myelogenous leukemia (AML).
Studies have shown that the use of growth factors in these patients
reduces the duration of hospitalization and may increase therapeutic
response, Dr. Balducci said.
Anemia-related fatigue should be prevented by maintaining hemoglobin
levels at or above 12 g/dL with an erythropoietin preparation, the
task force proposed. Two studies presented at the 1999 annual meeting
of the American Society of Clinical Oncology support this approach.
The forthcoming NCCNs guidelines for the management of cancer
in older persons will offer a step-by-step decision tree to help
physicians individualize cancer treatment for elderly patients.
The task force encouraged physicians to consider adjusting the dose
of drugs excreted through the kidneys to the measured glomerular
filtration rate. However, it urged clinicians to escalate dosages if
no toxicity occurs at lower dosages in order to ensure the
effectiveness of the therapy.
The task force also recommended the use of less toxic alternatives to
doxorubicin in patients aged 70 and over.