Overview of Chemotherapeutic Considerations for Older Patients

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Overview of Chemotherapeutic Considerations for Older Patients

Preface

I would like to introduce a new series of E-updates that will cover the area of geriatric oncology. There has been an epidemiologic shift occurring with the aging of our society. It has long been recognized that the most significant risk factor for the development of cancer is aging. This, together with the epidemiologic shift, has resulted in a marked increase in the number of older patients with cancer. All the subspecialties of oncology are rapidly becoming a field that will be primarily concerned with the care of older patients. 

Cancer and its treatment may appear as a prime cause of disability, not only mortality, in older individuals. The traditional ways in which cancer is studied, ie, clinical trials focusing on younger, healthier patients, have left us with a void in available data to manage the older patients in an evidence-based fashion. Not only do these trials fail to establish the validity of cancer treatment in the elderly, they also fail to provide information related to the long-term complications of treatment, including decline in function.

Over the past 10 to 15 years, studies of older cancer patients have revealed a significant amount of important clinical information, including the degree and severity of comorbidity and its effect on treatment, the role of polypharmacy, and the various social and financial problems facing older patients with cancer. The underrepresentation of older patients in clinical trials has been amply documented.¹ The adverse outcomes of inadequate dosing and supportive care in both curative and palliative treatments have been demonstrated in a number of treatment settings.² Even when clinical trials are available, barriers to participation of older patients have shown to be primarily due to reluctance by physicians due to fear of toxicity, limited expectation of benefit, or ageism.³

A number of important strides have been made in the evaluation of older patients through various methodologies of geriatric assessment. The comprehensive geriatric assessment (CGA) developed by geriatricians is a multidisciplinary evaluation of the older patient encompassing a number of important clinical domains.⁴ Researchers in this area have shown that traditional oncology measures of performance are not adequate in older patients and that geriatric-specific measures (ie, Activities of Daily Living and Instrumental Activities of Daily Living) have a much greater predictive value.⁵

There has been major interest in this area by a number of professional oncology societies and organizations. In 1995, the Cancer and Leukemia Group B organized a Cancer in the Elderly Committee.⁶ The other national cooperative groups have also developed geriatric oncology interest groups. The American Society of Clinical Oncology (ASCO) sponsored a clinical practice forum in 2000, a symposium at the Annual Meeting in 2002, and a publication “Cancer Care in the Older Patient” as part of its curriculum series. The ASCO annual meeting has included a number of educational sessions and oral presentations emphasizing geriatric oncology. In the US, the National Comprehensive Cancer Network (NCCN) has published practice guidelines for Senior Adult Oncology,⁷ and the Geriatric Oncology Consortium (GOC; www.thegoc.org) has been founded to initiate clinical trials and raise awareness of problems in elderly patients. 

Our European colleagues have been among the first to bring the needs of the elderly to the attention of the medical community.^8,9 Many of the clinically significant prospective trials in older cancer patients have originated in Europe.^10-12 The International Society of Geriatric Oncology (SIOG; www.cancerworld.org/siog), with its headquarters in Switzerland, has implemented a number of taskforces to evaluate the current literature and to make treatment recommendations.^13-16

This E-update series will consist of four publications. The first focuses on the use of chemotherapy in the elderly and offers an algorithm for decision-making. There will be subsequent articles on breast, lung, and colorectal cancers. Each will provide data and help guide clinicians in making meaningful decisions for their elderly patients. I hope this series will also stimulate interest in further research in the area of geriatric oncology. Because older patients will become the majority of the patients we evaluate and treat, they need to become the focus of our endeavors.

Stuart M. Lichtman, MD
Associate Attending
Clinical Geriatric Program
Memorial Sloan-Kettering Cancer Center
Commack and New York, NY
lichtmas@mskcc.org

References

1. Hutchins LF, Unger JM, Crowley JJ, Coltman CA Jr, Albain KS: Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 1999;341:2061-2067.

2. Dixon DO, Neilan B, Jones SE, et al: Effect of age on therapeutic outcome in advanced diffuse histiocytic lymphoma: The Southwest Oncology Group experience. J Clin Oncol 1986;4:295-305.

3. Kemeny MM, Peterson BL, Kornblith AB, et al: Barriers to clinical trial participation by older women with breast cancer. J Clin Oncol 2003;21:2268-2275.

4. Cohen HJ, Feussner JR, Weinberger M, et al: A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002;346:905-912.

5. Extermann M, Overcash J, Lyman GH, Parr J, Balducci L: Comorbidity and functional status are independent in older cancer patients. J Clin Oncol 1998;16:1582-1587.

6. Cohen HJ, Muss HB: The cancer and leukemia group B cancer in the elderly committee: Addressing a major cancer need. Clin Cancer Res 2006;12:3606s-3611s.

7. Balducci L: NCCN Clinical Practice Guidelines in Oncology. Senior Adult Oncology. Available at: http://www.nccn.org/professionals/physicians_gls/f_guidelines.asp?button=1+Agree#care. Accessed June 27, 2007.

8. Fentiman IS, Tirelli U, Monfardini S, et al: Cancer in the elderly: Why so badly treated? Lancet 1990;355:1020-1022.

9. Monfardini S, Chabner B: Joint NCI-EORTC consensus meeting on neoplasia in the elderly, San Servolo Island, Venice, 15-16, October 1990. Eur J Cancer 1991;27:653-654.

10. Feugier P, Van Hoof A, Sebban C, et al: Long-term results of the R-CHOP study in the treatment of elderly patients with diffuse large B-cell lymphoma: A study by the Groupe d’Etude des Lymphomes de l’Adulte. J Clin Oncol 2005;23:4117-4126.

11. Gridelli C: The ELVIS trial: A phase III study of single-agent vinorelbine as first-line treatment in elderly patients with advanced non-small cell lung cancer. Elderly Lung Cancer Vinorelbine Italian Study. Oncologist 2001;6(suppl 1):4-7.

12. Gridelli C, Aapro M, Ardizzoni A, et al: Treatment of advanced non-small-cell lung cancer in the elderly: Results of an international expert panel. J Clin Oncol 2005;23:3125-3137.

13. Audisio RA, Bozzetti F, Gennari R, et al: The surgical management of elderly cancer patients: Recommendations of the SIOG surgical task force. Eur J Cancer 2004;40:926-938.

14. Repetto L, Carreca I, Maraninchi D, Aapro M, Calabresi P, Balducci L: Use of growth factors in the elderly patient with cancer: A report from the Second International Society for Geriatric Oncology (SIOG) 2001 meeting. Crit Rev Oncol Hematol 2003;45:123-128.

15. Extermann M, Aapro M, Bernabei R, et al: Use of comprehensive geriatric assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005;55:241-252.

16. Aapro M, Launay-Vacher V, Lichtman S, Chatelut E, Wildiers H: A Report from a SIOG Task Force on Renal Safety in the Elderly. Available at: www.cancerworld.org/cancerworldadmin/getStaticModFile.aspx?id=893. Accessed July 11, 2007.