In his concise and to-the-point review, Dr. Balducci covers key principles that should govern our approach to cancer in older patients. Although we are uncertain as to why the incidence of cancer increases with aging, there is no question that it does. This observation has major implications. First, in affluent nations such as the United States, we are living longer and the absolute number and percentage of our population who are elderly continue to increase. Second, treating cancer is an expensive endeavor, and with an increased incidence in older patients as well as more elderly at risk, more and more resources will be needed to care for these patients. Last, most oncologists have little training in caring for older patients and cannot accurately predict the role of comorbidity and its effect on treatment and life expectancy.
Dr. Balducci has also provided us with a wonderful history of geriatric oncology. When I finished my oncology fellowship in 1974, I was unaware of cancer issues in elders. Much has happened. No endeavors thrive without passionate leaders, and Drs. Paul Calabresi, B.J. Kennedy, William Hazzard, Jerome Yates, Rosemary Yancik, John Bennett, and Lodovico Balducci are just a few of the pioneers who have championed cancer care in elders.
Numerous other groups both in the United States and elsewhere have also been instrumental in establishing geriatric oncology as a major area of cancer research. The John A. Hartford foundation has been most supportive, as has the National Institute of Aging, the National Cancer Institute, the American Geriatric Society, the American Society of Clinical Oncology, and the American Association of Cancer Research. More recently, the development of multidisciplinary consortia has added to the critical mass of research support including the Geriatric Oncology Consortium and the International Society of Cancer Research.
Much has come from these efforts. We now have major trials focused on cancer in elders, federal grant support for laboratory and translational research, and a fertile training ground for future geriatric oncologists. We have come far, but we have far to go. I will discuss below some of the key issues facing us now in this emerging and rapidly expanding field of geriatric oncology.
Prevention and Screening
That fact that cancer incidence increases with age mandates that appropriate prevention and screening strategies be optimized. Smoking cessation and moderation in the use of alcohol are just as important in older as in younger patients. Likewise, screening mammography, Papanicolaou tests, and sigmoidoscopy and colonoscopy all have a role in the screening of older patients to detect breast, cervical, and colorectal cancer at an early, more likely curable stage.
Like all prevention and screening strategies, there is a need for balance and common sense when applying this technology to older patients. Frail patients and those with significant comorbidity are unlikely to gain from prevention and screening; in fact, detecting an early cancer in such an individual may be unimportant or even detrimental. Finding a small breast cancer in an 83-year-old woman with dementia and cardiac disease is not a diagnostic coup. Prevention and screening strategies are best used in patients with a reasonable life expectancy—at least 5 years, in my opinion. In elders with a serious disease before the diagnosis of cancer, a new diagnosis of cancer might be a comorbidity with much less impact than an active non-cancer-related illness.
Treatment of Potentially Curable Cancer in Older Patients
Once cancer is diagnosed in an elderly patient, the oncologist is faced with a major challenge. The majority of older patients with cancer will have a "solid tumor," most commonly lung, colorectal, breast, or prostate cancer. Except for prostate cancer, surgery is frequently the mainstay of early treatment. A large body of literature consistently shows that older patients who are in reasonable health tolerate surgery—including the risks of operative and perioperative mortality and complications—as well as younger patients. Likewise, radiation is well tolerated in healthy older adults and is a key component of therapy for breast cancer patients undergoing breast-conservation therapy as well as patients with rectal cancer, head and neck cancer, and many patients with prostate cancer.
Dr. Muss is a consultant for a Pfizer DSMB, Ortho Biotech, Genentech, and Amgen; has ownership interest in Amgen; has received research grants from AstraZeneca, Aventis, Bristol-Myers Squibb, Merck, GlaxoSmithKline, Ortho Biotech/Tibotech, Aureon, Celgene, Coley, Genentech, Genetics Institute, Imclone, Ligand, Lilly, Novartis, Pfizer, Sandoz, and Schering; fellowship support from Ortho, Amgen, Sanofi-Aventis, and MGI; honoraria from Network Oncology Communication, Neil Love Communications, Medidigm, American Pharmaceutical, and Meditech Ltd; and is on the board of directors and advisory committees of the American Society of Clinical Oncology.
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