Although age is the major risk factor for developing cancer, geriatric oncology is still a relatively new discipline within the oncology community. To gain insight into this evolving component of cancer care, The ASCO Post recently spoke with a leader in the field, Stuart M. Lichtman, MD, of the Clinical Geriatric Program, Memorial Sloan-Kettering Cancer Center, New York.
Beginnings of Geriatric Oncology
The International Society of Geriatric Oncology (SIOG) held its 11th annual meeting in Paris last year. When did awareness of geriatric oncology begin?
The pre-SIOG impetus began in the early 1990s, when ad hoc meetings were held in Europe and the United States discussing cancer in the elderly. In 1995, I joined a Cancer and Leukemia Group B (CALGB) committee on elder cancer care, and I’ve been on the committee ever since. Prior to that, Drs. B.J. Kennedy and Rosemary Yancik starting defining the research agenda for the future.
However, during the first decade of its evolution, the vast majority of geriatric oncologists were European. Geriatric oncology in the United States is gaining momentum, but it still involves a relatively small group. We all know each other.
How has the perception of geriatric oncology changed since the first SIOG meeting?
The first few SIOG meetings were basically like educational symposia conducted at ASCO, reviewing what we knew about elderly patients with cancer, but without trial data—no one was doing studies in this area. In contrast, I was one of the chairs at the most recent SIOG meeting, and we presented a lot of clinical data.
Fortunately, we’ve been doing more studies over the past 3 to 5 years, looking at assessment scales and treatment options in the elderly. Everyone finally agrees that oncologists need to be aware of new data and ideas regarding the biology of aging and the various treatment programs relevant to geriatric patients with cancer. That awareness has been a long time coming, but it’s changed the perception of geriatric oncology.
To that end, how do we increase research in the elderly?
One chief barrier is physician concern about whether their older patients can tolerate the side effects of therapies. Moreover, for many drug studies, investigators want patients with normal kidney and liver function, and no prior heart disease, ie, no comorbidity. Those criteria exclude a lot of older patients. To move past the current 5% enrollment of elderly persons, we would need to alter clinical trial design and the way the government and Pharma support trial enrollment. There needs to be financial support, for both community doctors and patients.
Key Clinical Issues
How does the lack of trials in the elderly affect the practice of geriatric oncology?
We rely on assessment scales and a general sense of the older patient’s health status. I recently saw a 92-year-old man who’d had surgery for colon cancer. Is there a study to tell me how to treat this patient? Of course not. He told me that he’d fallen five times in the past month; he’s incontinent, along with some other issues. This patient is not a candidate for chemotherapy. On the other hand, if I saw an 80-year-old patient with colon cancer who was otherwise healthy, I would give that patient adjuvant therapy.
Medically speaking, older patients are generally in better condition than they used to be. They exercise and are not as frail, and their comorbid illnesses are often well controlled. So if a patient is in his 70s and even 80s, as long as his functional status is good and he is not measurably weakened by disease, I will treat him as I would a younger patient with cancer. We’ve learned that aging is highly individualized and that chronologic age is not always a predictor of a patient’s therapeutic needs.
What are some of the clinical issues that oncologists need to be aware of in their older patients?
First,prior to delivering any treatment in geriatric patients, the oncologist must determine all the comorbidities and assess the patient’s functional status. Another issue is clinical pharmacology. Geriatric patients are the largest users of pharmaceutical agents, which can complicate a doctor’s decisions regarding dosing and drug toxicity. Being mindful of polypharmacy and knowledge of pharmacokinetics is important in the elderly. Also, older patients may be more sensitive to opioids used in pain control because of liver and kidney issues, so one must be careful when initiating analgesic treatment. And there’s the compliance problem, especially with the growing emphasis on oral agents.
In general, management of the elderly can be based largely on an assessment of the patient’s frailty and life expectancy. Some patients need palliative care, but those whose potential life expectancy exceeds survival from cancer without therapy should receive standard treatment. This is really where the art of oncology comes into clinical decisions.
Our aging population and an impending workforce shortage weigh heavily on the future of oncology. Is the International Society of Geriatric Oncology thinking of addressing this issue?
The impending oncology workforce shortage will have greater effects on geriatric care because there’s already a shortage in that area. SIOG’s position is that we have to give community oncologists the tools to efficiently and expeditiously evaluate their geriatric patients. Some assessment tools exist; however, we need to standardize the best aspect of current instruments and validate them for widespread use.
Then we need to integrate more nurses, nurse practitioners, physical and occupational therapists, and social workers into the clinical care mix. Older patients with cancer often need a lot of assistance and support, and in order to address the challenge ahead, we’re essentially going to have to rethink the way we organize and deliver care.
Any last thoughts about the future of geriatric oncology?
Despite all the challenges, the future of geriatric oncology looks good for a couple of reasons. One reason is that the work done by the Cancer and Aging Research Group led by Dr. Arti Hurria—who is also the Medical Editor-in-Chief of the Journal of Geriatric Oncology—is really advancing the field. The newly formed Alliance made up of the former CALGB, North Central Cancer Treatment Group, and American College of Surgeons Oncology Group has a dynamic geriatric oncology committee, and the Gynecologic Oncology Group has formed a task force on elderly patients.
SIOG will continue to be very active with its annual meetings, task forces, and educational events. So in geriatric oncology, we have a small but dedicated group of physicians with several talented and driven leaders. The field is growing, not only in numbers but also in our scientific and sociologic understanding about the relationship between advanced age and cancer. ■
Disclosure: Dr. Lichtman reported no potential conflicts of interest.