Older cancer patients constitute a majority of the patients we evaluate and treat. They need to become the focus of our endeavors.
—Stuart M. Lichtman, MD
The ASCO Post announces a new department on geriatric oncology to be published on an occasional basis. 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.
It is a great privilege to introduce the first article in this recurring series on Geriatrics for the Oncologist. Each article will highlight a specific topic to bring readers up to date on current research and activities in the field. The aging of the population makes the initiation of the series particularly timely.
Most patients seen in the subspecialties of oncology are older individuals. The majority of cancer deaths occur in patients older than 70 years of age. Despite this, older patients are still underrepresented on clinical trials, making it difficult to reach evidence-based decisions. Clinicians still need to extrapolate data derived from studies of younger, fit patients. This lack of information from older patients may be contributing to the increased risk of toxicity and poor outcomes seen in this vulnerable group.
Most oncologists are geriatric oncologists in that they are already seeing older patients, or they will be as the expected lifespan increases and the population ages. They need the tools to evaluate and treat this expanding population. Researchers in geriatric oncology are developing objective and validated instruments to help evaluate patients and aid in decision-making. ASCO has been particularly supportive in these efforts. The Society has a geriatric oncology track and a Clinical Science Symposium at the Annual Meeting, an ongoing Special Interest Group, and resources including ASCO University and The ASCO Post providing helpful information on geriatric oncology.
The Alliance for Clinical Trials in Oncology, the Gynecologic Oncology Group, and the European Society for Medical Oncology (ESMO) also contribute to the research effort. The Cancer and Aging Research Group has developed a predictive tool for toxicity, and this tool is now being prospectively validated in various clinical situations.
In this first installment of the series, I would like to highlight the International Society of Geriatric Oncology (SIOG; www.siog.org) as well, for its work in educating physicians and providing a forum for the dissemination of research and promotion of new ideas.
International Society of Geriatric Oncology
Founded in 2000, SIOG has a worldwide membership and has had yearly meetings to bring together clinical and nonclinical researchers. The organization has its own journal, the Journal of Geriatric Oncology, which is in its sixth volume and indexed in PubMed. Arti Hurria, MD, Director of the Cancer and Aging Program at the City of Hope Comprehensive Cancer Center in Duarte, California, is a founding member of the Cancer and Aging Research Group and the founding and current editor of the journal. SIOG has various task forces, which have published a series of recommendations and guidelines and a “top 10” priorities list to focus research.
The 2014 meeting held this past fall in Lisbon had 400 attendees from over 40 countries and covered five major tracts: (1) solid tumors, (2) hematologic malignancies, (3) new therapies and basic science, (4) nursing, supportive care, and geriatric assessment, and (5) advocacy and socioeconomic issues. Presentations covered a broad range of topics, from basic science, addressing the interaction of cancer and aging, to the impact of cancer on the caregiver. There was an emphasis on clinical care in varying cancer types, geriatric assessment, cancer screening, nutrition, sarcopenia and cachexia, and clinical trials.
The Plenary Session was dedicated to advances in the field of geriatric oncology, including progress in medical oncology (Vesa Kataja, MD, Kuopio University Hospital, Finland), geriatrics (Muriel Rainfray, MD, Bordeaux Segalen University, Finland), surgery (Kwok-Leung Cheung, MD, University of Nottingham, United Kingdom), psycho-oncology (Jimmie C. Holland, MD, Memorial Sloan Kettering Cancer Center, New York), and hematology (Reinhard Stauder, MD, MSc, Innsbruck Medical University, Austria).
Screening Recommendations for Elderly Individuals
In the session on cancer screening, the challenges of optimal strategies for early identification of four common tumor types in older adults were discussed: colorectal, lung, breast, and prostate cancer. Overall, there is agreement that age is not appropriate as a primary basis of screening recommendations and that there is significant overscreening in low-risk cancers like breast and prostate cancers.
For each tumor type, there are multiple challenges to screening in older adults, due to the difficulty of showing survival benefits in patients with lower life expectancy; the risks from screening, follow-up testing, and treatments; the differential testing performance of screening tests in older patients; patient preferences for care; and the paucity of high-quality data to guide recommendations.
Treatment in the Adjuvant Setting
In a session dedicated to the role of adjuvant chemotherapy in elderly patients, common themes were noted in adjuvant decision-making in breast, lung, and colon cancers. With improvements in perioperative care, surgical resection with curative intent is more common in older adults. However, there is a dearth of prospective trials addressing the role of adjuvant chemotherapy, with the knowledge gap being especially wide in those over age 75 years. Much of the information is gleaned from outcomes of older participants in age-unspecified trials or analyses of large population databases.
Older adults do achieve benefit from adjuvant chemotherapy but are at higher risk for chemotherapy-associated toxicity. It may be important to modify regimens that exclude agents with demonstrable poor tolerance in older adults (eg, cisplatin for lung cancer and oxaliplatin in colon cancer). The decision for adjuvant chemotherapy should balance the risk of cancer recurrence against toxicity and competing causes for mortality. Ongoing and future research should focus on the use of geriatric assessment and other predictive tools in decision-making.
A session on treatment updates for solid tumors highlighted studies showing that, for the most part, newer therapies are associated with similar benefits and toxicities in younger and older patients included in these clinical trials. Further research should include tools such as geriatric assessment, which can help clinicians identify fit older patients who are candidates for standard treatments.
Interdisciplinary Models of Care
To emphasize the universality of the field, there was a session on interdisciplinary geriatric oncology models of care—the international perspective. There were talks by experts from the United States, United Kingdom, and Brazil. It was noted that geriatric oncology is organized differently across the continents.
In general, geriatric oncology is gaining increased international interest, and there are efforts to implement geriatric assessment into the standard care of older cancer patients, with modifications for the uniqueness of the individual regions. The session highlighted the recognition and evaluation of frailty, which included weight loss, polypharmacy, and poor performance status. In his presidential address, Etienne Brain, MD, PhD (Institut Curie, Saint-Cloud, France) presented the idea of expanding international outreach and dimension as a key strategic goal of SIOG for the next 2 years.
Collaborations and Awards
In conjunction with the International Psycho-Oncology Society (IPOS), SIOG had a session on social and cultural determinants of health in elderly cancer patients. The current concept of coping, coping styles, and special data on elderly patients were presented. At the same time, incoming President Dr. Brain gave a lecture at the 16th Annual Meeting of IPOS on “Geriatric Oncology and Psycho-Oncology, Why Does It Matter?”
SIOG established a Young Investigators Interest Group to provide a forum for young researchers in geriatric oncology to collaborate, help identify topics of interest, provide exposure of young researchers to SIOG, improve active participation, and help advocate for geriatric oncology.
Awards were presented to outstanding investigators at the meeting. The SIOG 2014 Paul Calabresi Award was given to Martine Extermann, MD, PhD (Moffitt Cancer Center, Tampa, Florida) for her longstanding and major achievements. The Nursing and Allied Health Investigator Award was given to Cindy Kenis, RN, MSN (UZ Leuven, Belgium) for her work on the prognostic value of geriatric screening and assessment for overall survival in older patients with cancer.
The SIOG 2014 Young Investigator Award was given to Maria José Molina-Garrido, MD, PhD (General Hospital Virgen de la Luz, Cuenca, Spain), for her work on methods to detect and evaluate frailty. The SIOG 2014 Best Poster award was given to Emilie Ferrat, MD (Université Paris Est Créteil, France) for her poster “Predictors of One-Year Mortality in a Prospective Cohort of Elderly Patients with Cancer.” The National Representative of the Year award was given to Ravindran Kanesvaran, MD, MRCP (National Cancer Centre, Singapore).
The comprehensive nature of the meeting demonstrates the myriad problems faced by older cancer patients. It also emphasizes the vitality of the field and the need for further study.
The next annual meeting will take place in Prague in November 2015. It will be chaired by Christopher Steer, MD (Border Medical Oncology, Wodonga, Australia). The meeting will be associated with the Multinational Association of Supportive Care in Cancer (MASCC), and will have the theme “Geriatric Oncology and Supportive Care: A Global Approach to Advance the Science.”
To increase awareness and stimulate interest in the United States, there will be an SIOG Forum at the Moffitt Cancer Center in Tampa on April 11, 2015. Also, Memorial Sloan Kettering Cancer Center in New York will be holding a symposium, Cancer Care of the Older Adult Across the Cancer Continuum, on May 1, 2015.
Older cancer patients constitute a majority of the patients we evaluate and treat. They need to become the focus of our endeavors. We all must become well-educated geriatric oncologists. Our elders deserve nothing less. ■
Watch future issues of The ASCO Post for continued discussion on geriatrics for the oncologist and practical tools to use with your older patients.
Dr. Lichtman is an Attending Physician at Memorial Sloan Kettering Cancer Center, Commack, New York, and Professor of Medicine, Weill Cornell Medical College, New York. He is also President Elect of the International Society of Geriatric Oncology (www.siog.org).