Whether elderly patients receive adjuvant therapy depends on their health status and how well the physician communicates the risks and benefits.
By 2030, the U.S. population over the age of 65 will reach 70 million, and older patients face a significantly increased risk of developing cancer and/or dying from cancer. Two-thirds of all cancer patients are over 65, and aging cancer patients are the largest recipients of chemotherapy.
Given comorbidities, mental status, and other issues, older cancer patients are not always administered the most aggressive treatment, particularly if the regimen includes adjuvant chemotherapy. The efficacy and toxicity of adjuvant therapy in patients more than 70 years of age has been the source of controversy, but recent research has indicated that adjuvant chemotherapy can be quite successful when used selectively (see "Doublet chemo proves superior to single-agent therapy in older patients with advanced non-small-cell lung cancer"). The question remains: What is the best way to decide if an older patient is a candidate for adjuvant chemotherapy?
© ASCO/Todd Buchanan 2010 "Geriatric assessment can better estimate life expectancy by focusing on functional age rather than chronologic age." - SUPRIYA GUPTA MOHILE, MD
At an ASCO 2010 education session, geriatric medicine specialists Arash Naeim, MD, and Supriya Gupta Mohile, MD, MS, highlighted strategies that oncologists can use to determine if an older patient is fit for adjuvant therapy.
Dr. Mohile, an assistant professor of medicine in the hematology/oncology unit at the University of Rochester in N.Y. outlined how to estimate life expectancy and the benefit of adjuvant therapy based on comorbidities. Dr. Naeim, who is the director of geriatric oncology at the Jonsson Comprehensive Cancer Center, University of California, Los Angeles, discussed the importance of shared decision-making for adjuvant therapy.
Estimating life expectancy
Dr. Mohile began by posing and answering the question: Why estimate life expectancy? "Life expectancy of elders at any specific chronologic age is heterogeneous," she said. "Although some fit elders benefit from therapy, not all elders-especially in the age group [75 and older] that we're discussing-will live long enough to reap benefits from treatment. So we need to focus our improvement efforts on providing evidence-based treatment to elders who are most likely to benefit from adjuvant therapy."
But that kind of evidence-based treatment knowledge is lacking, especially because clinical trials generally don't include older patients. Dr. Mohile cited data from a study that looked at the underrepresentation of older patients in multiple Southwest Oncology Group trials and found a significant discrepancy between the percentage of elderly entered into trials (25%) vs the percentage of elderly seen in the cancer community (63%). This was particularly true in breast cancer trials where only 9% of patients in clinical trials were over the age of 65, compared with 50% of the patients seen in the cancer population, Dr. Mohile pointed out (N Engl J Med 341:2061-2067, 1999).
© ASCO/Todd Buchanan 2010 "Encourage patients to use population-based risk as an aid, but not as a predictor of exact future events." - ARASH NAEIM, MD
Variable underlying health problems paired with an uncertainty about life expectancy may create a bias against the older patient, she said. The best way to get a handle on these issues is to estimate life expectancy. While there are many life expectancy tables available, Dr. Mohile expressed a preference for one developed by Louise C. Walter, MD, and Kenneth E. Covinsky, MD, MPH (JAMA 285:2750-2756, 2001).
Dr. Walter and Dr. Covinsky looked at different chronologic ages in five-year increments and then calculated the average life expectancy as a function of underlying health status. "So a 75-year-old at very poor health only has an average life expectancy of five years vs a 75-year-old who's very fit [and] has an average life expectancy of 14 years. And this variability continues as one ages," Dr. Mohile explained. "If we think about five years being an endpoint to which one needs to live in order to benefit from adjuvant therapy, you can see that the 75-year-old at the lowest health has about a five-year life expectancy. An 85-year-old in average health also has about a five-year life expectancy, and a 95-year-old who is very fit has a five-year life expectancy." The take-home message here is that it's not just age that can determine life expectancy; health status also needs to be considered.
TABLE 1 Geriatric conditions that impact life expectancy
The concurrent presence of two or more poor conditions, or one severe condition, that are usually chronic in nature.
Disability or functional impairment
Conditions that cause dependency in order to perform tasks such as managing finances, meal preparation, and managing medications. Disability may prevent the person from living in the community and caring for himself.
Conditions that render a person vulnerable and frail, including depression, dementia, delirium, falls, osteoporosis with fractures, neglect and abuse, and a failure to thrive.
Consulting a theoretical table, no matter how well done, may be insufficient to help oncologists determine the health status of the patients who they see in the clinic. It's important to look beyond comorbidities because there are other geriatric conditions that influence life expectancy in very old patients, Dr. Mohile said, going on to define comorbidities and two other important geriatric conditions (see Table 1).
Dr. Mohile stressed that all three geriatric conditions need to be evaluated separately in the clinical setting as they may overlap or be mutually exclusive. "We know that these conditions are common in older patients with newly diagnosed cancer. A study by Siran M. Koroukian, PhD, showed that about 16% of patients with newly diagnosed colon cancer had all three entities: Disability, comorbidity, and geriatric syndromes. And about 12% of breast cancer patients that are newly diagnosed had all three entities. Someone may have no comorbidity and just have disability, or may have geriatric syndromes but have neither disability nor comorbidity" (J Clin Oncol 24:2304-2310, 2006).
TABLE 2 Stages of aging
|•||Have the highest level of health|
|•||Are at the top of life expectancy tables|
|•||Do not have disability, significant comorbidity, and/or geriatric syndromes|
|•||Have some dependence in instrumental activities of daily living (using telephone, taking medications) but not activities of daily living (bathing, providing transportation)|
|•||May have comorbidities, but they are not severe and are well controlled|
|•||May have mild geriatric syndromes such as memory disorder or depression|
|•||Have dependence in activities of daily living|
|•||Have three or more severe comorbidities or one life-threatening comorbidity|
|•||Have a clinically significant geriatric syndrome|
The comprehensive geriatric assessment (CGA) is an established diagnostic tool in geriatric medicine used to fully evaluate all three entities plus cognition, nutritional status, psychological status, and social status. A paper by Lodovico Balducci, MD, and Martine Extermann, MD, PhD, outlined the parameters that oncologists should use when assessing older patients (Oncologist 5:224-237, 2000). Dr. Mohile explained how this CGA framework can be used to assess the three stages of aging (see Table 2).
"Geriatric assessment can better estimate life expectancy by focusing on functional age rather than chronologic age. All fit elders should be considered for adjuvant therapy, but once a patient gets to be 85, they have to be very fit and one cannot look only at comorbidity to determine fitness," Dr. Mohile said. "So if you ask these questions of your patients in the clinic, you'll be better able to put them in the category of health status in which they belong."
Communicating cancer risk
Once assessments have been made and clinical data gathered, the next step is imparting this information to elderly patients. Once again, the rules that apply to the general population may not hold true for older people.
The extent to which people understand what the oncologist is telling them, and can then make informed health decisions, is called health literacy. "We know that older individuals have poorer [health] literacy," Dr. Naeim said. "A study from the U.S. National Center for Education Statistics showed that, in general, as people grow older, the proportion of people who have below basic, or just basic, health literacy increases. Among those age 65 and over, about one-third have below basic skills" ("Adult literacy in America: Report of the National Adult Literacy Survey," 2003).
Survivorship may hasten geriatric limitations Survivorship issues for older patients are different than those for a younger population, Dr. Mohile said. In older patients, surviving a cancer diagnosis and treatment may increase their likelihood of having geriatric syndromes, disability, and frailty, according to a study that Dr. Mohile and colleagues conducted. "And this was an independent association after adjusting for age, comorbidity, and other factors. These issues may be increased in patients who undergo adjuvant therapy. We need more research in this area," she said (
J Natl Cancer Inst
In addition to the regular health literacy, there is also quantitative literacy, or the ability to understand and comprehend numbers. This includes the knowledge and skills to apply arithmetic operations, either alone or sequentially, by using numbers in printed materials or in oral format. And numeracy skills, which are already quite poor in the U.S. population, also degenerate with age, Dr. Naeim said. A 2008 study showed that the percentage of correct answers on any sort of standardized numeracy tests decreased with age (Ann NY Acad Sci 1128:1-7, 2008).
Sufficient numeracy is key for communicating treatment risks and uncertainty to all patients. "You have to be able to weigh the strengths of the current evidence. You need to be able to weigh the risks and the benefits and weigh them and the likelihood of the different outcomes," Dr. Naeim said. "From patients' perspective, they need to acquire the information; they need to make some calculations or inferences; they need to remember the information, which requires aspects of short-term and long-term memory. They need to weigh factors to match their own means and values. And then they need to be able to make a trade-off in order to be able to make a health decision" (Health Aff [Millwood] 26:741-748, 2007).
Older patients often have difficulty working with numbers, and they may have little to no experience with assessing probability, he added. "Numeric scales may not be the best way to go, especially if you're trying to see if patients understand the risk for cancer vs the risk from their other comorbidities. Maybe comparative scales are better that numeric scales. You can say 'What do you think your chances are of dying from breast cancer over the next 10 years, compared to dying of something else?' Posing the data comparatively can help the oncologist determine if the patient at least understands the relative magnitude of difference between the two without actually getting the number right," he explained.
TABLE 3 Communication barriers with elderly patients
|•||Memory impairment or confusion limits 7.1% of community-dwelling individuals (age ≥ 65)|
|•||Senility and dementia limits 2.4% of older adults|
|•||Hearing impairment affects 35%-50% of older adults|
|•||Vision impairment affects 15%-25% of older adults|
|•||Combination of hearing and vision impairment affects 7% of older adults (ages 65-79) and 17% of older adults (age ≥ 80)|
In addition to disability and geriatric syndromes, Dr. Naeim added two more communications barriers with older patients (see Table 3). Communicating with older patients will require more time on the part of the healthcare provider and will require a different approach, Dr. Naeim said.
"There is something called oral literacy demand, defined as the aspects of medical communication that challenge people with low literacy, including the use of technical terms, general language complexity, and structural aspects of dialogue (how fast we talk, the density of interactivity)," he said.
Debra L. Roter and colleagues conducted a modeling study that looked at oral literacy demand. These models have been applied mainly in genetic counseling but can be transferred to oncology counseling as well, Dr. Naeim said.
Caregivers need consideration Many older patients come to their visits with a caregiver or companion, Dr. Naeim said, and most cancer patients share their diagnosis or current condition with this other person. Patients with low health literacy are more likely to be influenced by a caregiver or companion, he said. Companions can be autonomy-enhancing, so that they facilitate the patient's understanding of the situation, or distracting if they try to build a relationship directly with the physician or control the decision-making process. Oncologists should also keep in mind the health literacy capabilities of the companion.
Ms. Roter's group found that the more counselors used technical terms and dense, less interactive dialogue, the less satisfied the simulated clients were. Providers that monitor their vocabulary and language, as well as the structural characteristics of interaction, lower the literacy demand of routine medical dialogue, they recommended (Soc Sci Med 65:1442-1457, 2007).
Dr. Naeim offered some ways that cancer care specialists can improve their communication with older patients. First, recognize that the translation of data from population-based trials to personal risk may be puzzling for the patient. "Encourage patients to use [population-based] risk as an aid, but not as a predictor of exact future events," he said.
Consider using risk graphics such as simplified survival-only pictographs. He cited Adjuvant! Online as an example of how to present complex data. The program generates a single graphic that depicts four possible outcomes: survival, mortality from the cancer, mortality from other causes, and incremental survival with adjuvant treatment.
Finally, framing is always important, whether treatment will lead to a loss or a gain, he stressed. "You really want to frame things in many different ways to allow the patient to understand what you're trying to communicate. . . in general, it's insufficient to provide patients with objective probabilities. They need to be in some way contextualized in terms of implications for that particular patient or his life."