Supportive Care in the Older Adult With Cancer: What You Need to Know
Geriatrics for the Oncologist is guest edited by Stuart Lichtman, MD, and developed in collaboration with the International Society of Geriatric Oncology (SIOG). Visit SIOG.org for more on geriatric oncology.
The median age of patients at the first diagnosis of cancer in the United States is 65 years, and the majority of patients with cancer are older adults.1 As we have learned from previous articles in this series, older patients with cancer require more complex care. Older adults are more likely to suffer from comorbidities, underlying geriatric syndromes, functional disability, and social isolation. The aging process can also make patients more vulnerable to treatment toxicities. Supportive care is thus crucial to the appropriate management of the older adult with cancer.
MASCC and Supportive Care
The Multinational Association for Supportive Care in Cancer (MASCC) uses a definition of supportive care that goes beyond the cancer and its treatment:
Supportive care in cancer is the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side effects across the continuum of the cancer experience from diagnosis through treatment to post-treatment care. Supportive care aims to improve the quality of rehabilitation, secondary cancer prevention, survivorship, and end-of-life care.2
Christopher Steer, MBBS, FRACP
Supportive care therefore encompasses all aspects of care that are not directly related to anticancer treatment and is important throughout the patient’s cancer journey.
MASCC is dedicated to research and education in all aspects of supportive care in patients with a cancer diagnosis. The motto used by MASCC—“supportive care makes excellent cancer care possible”—highlights the fact that cancer care entails much more than just surgery, radiation, and systemic anticancer treatments.
MASCC is divided into 17 study groups that promote and organize research and education within their specialties. The study groups address topics ranging from treatment-related toxicities such as infection/myelosuppression, neurologic complications, and mucositis to general issues such as palliative care, fatigue, nutrition, rehabilitation, survivorship, and quality of life.3
The Geriatrics Study Group of MASCC was established in 2012 under the leadership of Ira Parker, DDS, MA, MPH, Associate Clinical Professor of Medicine, Division of Geriatric Medicine, University of California, San Diego.4 The intention of the study group is to increase the visibility of this important issue in the supportive care community and to serve as an expertise resource for MASCC study groups and leadership. Cancer care in the older adult requires a multidisciplinary team approach, and the diverse nature of the MASCC membership provides the opportunity for interdisciplinary collaboration.
Older adults are more likely to suffer from comorbidities, underlying geriatric syndromes, functional disability, and social isolation. The aging process can also make patients more vulnerable to treatment toxicities. Supportive care is thus crucial to the appropriate management of the older adult with cancer.
— Christopher Steer, MBBS, FRACP
The International Society of Geriatric Oncology (SIOG) plays an important role as the principal global organization dedicated to optimizing the care of older adults with cancer. Given the vital role that supportive care plays in the care of older adults with cancer, SIOG and MASCC are natural partners. The two organizations regularly collaborate in educational activities and joint sessions at annual scientific meetings. Supportive care was the theme of the 2015 SIOG Annual Conference, an event that attracted a record number of delegates and abstracts.5
Supportive care is important across the cancer continuum, throughout the patient’s cancer journey. Issues that are particularly important in older patients include the prevention and management of treatment toxicity, management of functional impairment, and support for the patient with comorbidities and social isolation.
Older patients are more likely to suffer from geriatric syndromes such as cognitive impairment, incontinence, falls, and general frailty. It could be argued that the assessment and management of these issues constitute supportive care—ie, care that, strictly speaking, is not directly part of anticancer therapy.
Geriatric assessment comprises validated tools to assess areas of health referred to as domains.6 Potential domains include: (1) medical (evaluation of comorbidity, polypharmacy, and nutritional status), (2) functional status (assessment of activities of daily living, instrumental activities of daily living, physical performance [mobility], and falls, (3) mental health (evaluation of cognition, depression, and delirium) and (4) social (evaluation of environment, resources, and social support).
The detection of issues during the assessment process allows targeted intervention with the aim of reducing morbidity and treatment-related toxicity and the enhancement of well-being. Thus, a geriatric assessment followed by targeted intervention is a sophisticated approach to providing optimal supportive care in older adults with cancer.
The strategy of using geriatric assessment in older adults with cancer was addressed by Mohile et al with the publication of a Delphi consensus statement generated by 30 specialist geriatric oncologists.7 The experts reached a consensus that geriatric assessment should be used in “all patients aged 75 years or older and those who are younger with age-related health concerns.”
The panel concluded that all geriatric assessment domains should be utilized and that geriatric assessment could guide nononcologic interventions and cancer treatment decisions. Consensus was also achieved on an algorithm for geriatric assessment–guided care processes across multiple geriatric assessment domains—essentially a map of guided supportive care.
Supportive Care Without Geriatric Assessment
While the ideal situation would be that all older adults with cancer undergo geriatric assessment–guided intervention, an optimal supportive care strategy can still be enacted outside a dedicated geriatric oncology clinic. Issues of particular relevance to older adults include myelosuppression, nausea and vomiting, cognitive impairment, depression, bone health, nutrition, polypharmacy, fatigue, and insomnia.8 Acknowledgment that the patient’s caregiver may also be older and need caregiver support is also important.
Multidisciplinary management with a team including oncologists, nurses, pharmacists, social workers, dieticians, and physical therapists, with strategic referral to aged care services, can be utilized to tackle these issues. Such an approach remains the cornerstone of supportive care delivery.
Myelotoxicity: It is generally accepted that older adults are more at risk of bone marrow toxicity than younger patients. International guidelines recommend that patients over the age of 65 years should routinely receive prophylactic colony-stimulating factors if they are being treated with chemotherapy regimens with a febrile neutropenia risk > 20%.9
In patients who develop febrile neutropenia, the MASCC febrile neutropenia risk score can be used to potentially identify patients who may be at increased risk of complications.10,11 It has been used to identify “low-risk” patients who could be managed as outpatients. This index uses age over 60 years as a risk factor for febrile neutropenia complications.
Nausea and Vomiting: The risk of adverse consequences of chemotherapy-induced nausea and vomiting is higher in older patients due to the increased likelihood of comorbidities. Fortunately, the incidence of chemotherapy-induced nausea and vomiting is less common in older adults.12
Antiemetic therapy is highly effective in preventing chemotherapy-induced nausea and vomiting, but care needs to be taken in specific circumstances. With some antiemetic agents, the potential for drug-drug interactions is a theoretical problem that rarely arises in practice. More of a concern is the increased likelihood of side effects with the use of adjunctive corticosteroids and the increased risk of constipation with 5HT3 antagonists. Careful counseling on the use of laxatives around the time of chemotherapy is an important supportive care strategy.
Cognition/Delirium: It is important to identify cognitive impairment as part of a geriatric assessment–guided supportive care management plan.7 The Mini-Mental State Exam13 and Montreal Cognitive Assessment14 are available screening tools for cognitive impairment.
The detection of cognitive impairment is likely to significantly influence treatment decisions and should trigger a number of supportive care interventions. They include formal cognitive assessment and investigation of reversible causes, caregiver support, social work review, medication assessment, functional assessment, and recognition of the need for delirium prevention.7
Adequate supportive care truly “makes excellent cancer care possible” and is crucial to the appropriate management of the older adult with cancer. Older adults are at increased risk of treatment toxicity and often require specialist assessment and intervention. The dedicated individuals at SIOG and MASCC strive to optimize the cancer journey for all older adults and welcome collaboration and assistance in achieving this goal. ■
Disclosure: Dr. Steer reported no potential conflicts of interest.
Acknowledgment: Thanks to Holly Holmes MD, MS, Co-Chair of the MASCC Geriatric Study Group, for assistance and support with this manuscript.
ASCO invited MASCC to cosponsor the Palliative Care in Oncology Symposium in 2014, enabling an ongoing discussion between clinicians and researchers dedicated to supportive care. Another meeting is planned for September 2016 (www.pallonc.org).
- National Cancer Institute: SEER stat fact sheets: All cancer sites. Available at seer.cancer.gov/statfacts/html/all.html. Accessed April 11, 2016.
- Multinational Association for Supportive Care in Cancer: What is MASCC? Available at www.mascc.org/about-mascc. Accessed April 11, 2016.
- Multinational Association for Supportive Care in Cancer: MASCC Study Groups. Available at www.mascc.org/study-groups. Accessed April 11, 2016.
- Multinational Association for Supportive Care in Cancer. MASCC Geriatrics Study Group. Available at www.mascc.org/geriatrics. Accessed April 11, 2016.
- Stepney R: Supportive care vital in elderly cancer patients: A report from the 2015 annual conference of the International Society of Geriatric Oncology (SIOG) which focused on the role of supportive care in geriatric oncology. Support Care Cancer. March 16, 2016 (early release online).
- Wildiers H, Heeren P, Puts M, et al: International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 32:2595-2603, 2014.
- Mohile SG, Velarde C, Hurria A, et al: Geriatric assessment-guided care processes for older adults: A Delphi consensus of geriatric oncology experts. J Natl Compr Canc Netw 13:1120-1130, 2015.
- Naeim A, Aapro M, Subbarao R, et al: Supportive care considerations for older adults with cancer. J Clin Oncol 32:2627-2634, 2014.
- National Comprehensive Cancer Network: Myeloid growth factors, version 1.2016. Available at www.nccn.org/professionals/physician_gls/pdf/myeloid_growth.pdf. Accessed April 11, 2016.
- Klastersky J, Paesmans M: The Multinational Association for Supportive Care in Cancer (MASCC) risk index score: 10 years of use for identifying low-risk febrile neutropenic cancer patients. Support Care Cancer 21:1487-1495, 2013.
- Klastersky J, Paesmans M, Rubenstein EB, et al: The Multinational Association for Supportive Care in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol 18:3038-3051, 2000.
- Molassiotis A, Aapro M, Dicato M, et al: Evaluation of risk factors predicting chemotherapy-related nausea and vomiting: Results from a European prospective observational study. J Pain Symptom Manage 47:839-848, 2014.
- Tombaugh TN, McIntyre NJ: The mini-mental state examination: A comprehensive review. J Am Geriatr Soc 40:922-935, 1992.
- Nasreddine ZS, Phillips NA, Bedirian V, et al: The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53:695-699, 2015.