The world’s population is aging. Older age is associated with an increase in the incidence of cancer, especially cancer of the breast, lung, prostate, and colon. The management of older patients with cancer is biased by the
Dr. B.J. Kennedy provides a general review of theimpending collision between a poorly prepared health-care system and an agingpopulation. As the older component of the population grows, critical managementdecisions will increase. The physiologic variability of the elderly populationoften results in ad hoc cancer management decisions that are poorly informed bythe integration of knowledge between geriatricians and oncologists. As noted inthe article, the incidence and prevalence of cancer will dramatically increase.
The Geriatrician vs the Oncologist
Oncologists make decisions based on evidence of efficacy in the detection andtreatment of cancerevidence generated from studies of younger populations.Geriatricians focus their efforts on "reducing disability and helping olderpeople remain at home while recognizing the needs of family." Althoughmost oncologists view themselves as generalists, their primary focus is oncancer treatment. Geriatricians concentrate their efforts on the chronicdiseases of the elderly (neurovascular, musculoskeletal, cardiorespiratory, anddiabetes).
This article points out the desirability of collaborative research thatfocuses on the elderly. Research and educational cooperation between oncologistsand geriatricians are minimal.
The Up-and-Coming ‘Geriatric Oncologist’
Some would quarrel with the designation of the title, "geriatriconcology," because in the coming decades, most oncologists will have tobecome more conversant with geriatric medicine. Assessments and interventionsaimed at optimal patient care for the elderly will require some merging ofapplicable information.
Cancer research protocols often exclude the elderly through stringenteligibility criteria, citing abnormal laboratory values that may not always berelevant. Geriatricians are often suspicious of the ability of subspecialists,such as oncologists, to provide a holistic understanding of the concomitantproblems facing older people. The resultant lack of collaboration andshortage of these specialists have often made bilateral consultation difficult.The deficiency of meaningful prospective studies of the elderly with cancercontributes to the lack of good screening and management guidelines.
Dr. Kennedy seems to present the position that the "new era of geriatriconcology" will somehow improve training, communication, and cancer care.However, given the present shortage of trainees and practitioners for bothspecialties, the lack of incentives for growth in combined-specialty trainingprograms, and the common geographic separation of these respective specialtypractices, combined-specialty training will be difficult. The diagnosis,treatment decisions, and follow-up are not likely to occur in an acute-carehospital setting, which in the past could have fostered these interactions.
Multidisciplinary case management is the answer, but team efforts requiregeographic proximity and adequate reimbursement for the time of teamparticipants. Enhanced communications through electronic consultations or"teaching rounds" that address generalized patient problems mayprovide some answers for the future. Collaborative research efforts betweenoncologists and geriatricians could prosper, with targeted funding designed toenhance interaction between these specialties in teaching institutions.Educational programs would likely follow these research efforts.
Dr. Kennedy continues to emphasize the real need for more effectivemanagement strategies that are applicable to the special oncologic problems ofthe older population. A few successful programs have been designed to improveboth educational and research collaborations for these specialties, but they areinadequate to meet the needs of the rapid changes in the demography of thepopulation. I would hope that those of us in both specialties would worktogether to explore other opportunities and practical solutions that will behelpful in dealing with the increasing cancer burden in the elderly over thenext few decades.
1. Young J, Philp I: Future directions for geriatric medicine: Geriatriciansmust move with their patients into the community. BMJ 320:133-134, 2000.
2. Jefferys M: Geriatricians: Past, present and future. J R Soc Med 90:2-4,1997.