Age Biases and Lack of Appropriate Studies Leave Elderly Cancer Patients Undertreated

WASHINGTON, DC-Despite 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), Washington, DC. Speaking at an Amgen-sponsored satellite symposium held in conjunction with the GOC first annual multidisciplinary conference, Advancing 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 lung cancer. 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 drop-off thereafter. 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 schedule. 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 clinical trials. "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 clout."