Improved trial design, education needed to optimize geriatric oncology care
In the United States, the 65-and-older demographic — which accounts for 56% of cancer diagnoses and 70% of cancer deaths — is projected to nearly double from 43.1 million in 2012 to 83.7 million in 2050, according to census bureau estimates. That trend poses formidable challenges to the oncology community.
“We are in the midst of a rise in the number of individuals who will be diagnosed with cancer,” Arti Hurria, MD, director of the Cancer and Aging Research Program at City of Hope Comprehensive Cancer Center and HemOnc Today’s geriatric oncology section editor, said in an interview. “This rise in cancer incidence is primarily driven by the aging of the U.S. population and the association of cancer with aging. Hence, oncologists in everyday practice are caring for more and more older adults.”
Consequently, geriatric oncology “is no longer a niche field,” Stuart M. Lichtman, MD, medical oncologist at Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, wrote in Journal of Clinical Oncology. Instead, “all adult oncologists are now geriatric oncologists,” Lichtman wrote.
However, most oncologists are not adequately trained to address the more specialized treatment older patients require.
HemOnc Today spoke with several leading geriatric oncologists about the lack of clinical trial data for older patients with cancer, methods used to avoid the risks associated with polypharmacy and inappropriate medication use in this population, and how the crucial differences between actual and functional age should influence treatment options.
Because cancer care for the geriatric population — typically defined as those aged 65 years and older — is particularly nuanced, each patient requires an individualized treatment plan.
“At every stage in the treatment of older adults, a personalized treatment plan needs to be devised in the context of someone’s preferences, goals and values,” Hurria said. “Without that discussion — and understanding the risks and benefits of a specific treatment — it is very hard to understand why one treatment might be right for one older patient and completely wrong for another. The value they might place on one outcome or another might be very different.”
The care older patients with cancer receive can vary considerably based on whether they are treated by a trained geriatric oncologist or a non-geriatrician, especially regarding supportive care interventions, according to Supriya G. Mohile, MD, MS, associate professor of medicine and director of the geriatric oncology clinic at James Wilmot Cancer Center at University of Rochester.
“Although we are making some progress in the treatment of older adults, there are some significant disparities that persist,” Mohile told HemOnc Today. “Oncologists need to be better equipped to manage not only how to make treatment decisions, but how to offer day-to-day care.”
The geriatric assessment is a key component; however, its use may not be uniform due to time constraints or a lack of resources and expertise.
In an article published in American Family Physician, Elsawy and Higgins outlined how the geriatric assessment differs from standard patient assessments due to the inclusion of nonmedical domains, emphasis on quality of life and functional capacity, and evaluation by a multidisciplinary team. They created a guide to measure an older patient’s functional ability, physical health, nutrition and wellness, cognition and mental health.
The geriatric assessment — which should be used by all physicians who treat older patients with cancer — helps identify a patient’s functional age, which may differ from their chronological age, according to Holly M. Holmes, MD, MS, associate professor and division director of geriatric and palliative medicine at The University of Texas Health Science Center at Houston.