Geriatric Oncology: An Overview of Progresses and Challenges

Abstract

I n t r o d u c t i o nThanks to the global improvement of health care and living conditions, the world population is aging. Already, in developed countries, half of the cancers occur in patients aged 70 and older. In booming Asian nations, such as South Korea, the aging trend is particularly striking, and therefore geriatric oncology is rapidly coming at the foreground of oncology practice. In this article, we plan to review the main acquisitions of this field over the last decades, as well as the areas of present critical research. C o n c e p t u a l F r a m e w o r k sThe notion of geriatric oncology was first articulated in the eighties by pioneers such as Rosemary Yancik, Paul Carbone and Jerry Yates (1). Some of the early studies, mostly retrospective reviews of study data, also started in the eighties (2,3). Over the last twenty years, the framework of the research has been mainly to define the characteristics of older cancer patients, analyze how they were tolerating cancer treatments, and how to best integrate geriatric tools and expertise (mostly the CGA) into cancer care.The following concepts are presently under very active investigation: -A two steps approach to the initial evaluation of older cancer patients is becoming the paradigm of choice. A short screening tool applied in the oncology practice, followed by a more comprehensive geriatric assessment and an integrated approach by a multidisciplinary team for those who screen positive. A range of short screening tools are becoming available for use (see below).-The integration of geriatric instruments as decision tools in the treatment of cancer. At this year's ASCO meeting, two scores for predicting toxicity from chemotherapy were presented (4,5). These Thanks to the global improvement of health care and living conditions, the world population is aging. Already, in developed countries half of the cancers occur in patients aged 70 and older. In booming Asian nations, such as South Korea, the aging trend is particularly striking, and therefore geriatric oncology is rapidly coming at the foreground of oncology practice. As older patients have a very variable health status, the need for proper integration of an oncologic and a geriatric approach has become increasingly clear. The last two decades have seen the development of geriatric oncology programs and research, which we review here. An increasing amount of data is making clear that a geriatric assessment identifies many problems in older people with cancer, adds prognostic information, and might improve the outcomes of these patients. The near future will likely deliver the following: Operationalization of geriatric assessment into assessment and decision tools, as well as multidisciplinary interventions, in oncology; cooperation of aging and cancer research in the understanding of cancer biology, aging physiology, pharmacology of anticancer drugs; improved clinical study designs; development of geriatric oncology programs, and screening tools accessible to the private practitioner.

The impact of age on complications, survival, and cause of death following colon cancer surgery.

“…The benefits of CGA, which measure activities of daily living (ADLs), instrumental ADLs (IADLs), depression, cognition, nutrition, and physical performance, have been demonstrated for elderly patients admitted to the hospital (Extermann, 2010;Ellis et al, 2011). In a Cochrane metaanalysis of 10 315 patients from 22 trials comparing CGA with standard care, patients who received CGA were less likely to suffer death or deterioration (OR ¼ 0.76, 95% CI ¼ 0.64-0.90), less likely to be institutionalised (OR ¼ 0.79, 95% CI ¼ 0.69-0.88), and more likely to be alive and in their own homes after 12 months of follow-up (OR ¼ 1.16, 95% CI ¼ 1.05-1.28; Ellis et al, 2011).…”

Therapeutic options in older patients with metastatic non-small cell lung cancer

“…All these evaluations are part of the comprehensive geriatric assessment, which is a very time-consuming procedure. Screening tests have been developed to select patients who should really undergo a complete comprehensive geriatric assessment [Extermann, 2010].…”

Major clinical research advances in gynecologic cancer in 2010

“…Furthermore, a quarter to a third are expected to develop cancer in some form, i.e., 250-300 million people. 78 Why is it important to focus on geriatric oncology separate from general oncology? What is the problem with elderly cancer patients?…”

“…In addition, they exhibit variable pharmacokinetics/pharmacodynamics of cancer drugs, which can result in high rate of toxicity, a decrease in the functional status and a likelihood of developing second cancers. 78,79 This often results in the under-treatment older female ovarian cancer patients. 80 Older women with ovarian cancer are likely to undergo complete debulking surgery less frequently and receive adjuvant chemotherapy less frequently than their younger counterparts, which partly accounts for increased disease-specific mortality in older patients.…”

“…A two step approach to the initial evaluation is becoming a paradigm of choice. 78 At this year's ASCO meeting, two scores for predicting the toxicity from chemotherapy were presented. The first one, the CRASH score (chemotherapy risk assessment score for high age patients), which comprised of grade 4 hematologic and grade 3-4 non-hematologic toxicity, was found to offer a validated, clinically applicable mean of predicting significant differences in the risk of severe toxicity.…”