geriatric oncology

Geriatric Oncology

Dr Shane O’HanlonConsultant in Elderly CareSurgical Liaison and OncogeriatricsRoyal Berkshire NHS Foundation Trust

Content

Incidence, mortality Age and cancer progression Prevention Clinical Profile of older cancer patients Presentation and management of cancer Oncogeriatric assessment Long-term outcomes

Incidence

People >65 years are 11 times more likely to develop cancer than those 25-44

Incidence of all cancer combined has been increasing since 1970s – but biggest increase has been in 75 and over group

Incidence increases with age until 80-84 then begins to decline 85+!

Age-specific incidence rates for all cancers

Thakkar et al 2014

Why drop in >85?

Theories! Increasing arteriosclerosis limits local

angiogenesis Age-dependent remodelling of immune

system Strongly varying exposures to carcinogens

with age Decreased proliferation rate of cells

Incidence by cancer

Melanoma peaks in 50s then plateaus Breast cancer plateaus in 80s

Colorectal, pancreatic, stomach and myelodysplastic syndromes all continue to increase…

Mortality

Overall mortality started to drop in the 1990s Mortality rates rise with advancing age, and

continue to rise in oldest group Overall survival rates improving but at slower

rate in older people -> so widening gap

UK worse outcomes than other Europe/US

Age-specific mortality rates by all cancers

Thakkar et al 2014

Age & Cancer Progression

Breast cancers more likely to be ER/PR+ve and HER-2 –ve (good prognosis)

NSCLC mets have a longer doubling time Prognosis worse for:

Acute leukaemia Lymphoma Malignant brain tumours Ovarian cancer

Cancer prevention

Smoking remains leading cause for lung cancer + also implicated in at least 14 others

Older adults lowest rates of smoking now but accumulated risk from previous smoking

Smoking cessation does confer benefit (Peto et al 2000), even in middle age – avoids much of lung cancer risk

Diet, obesity, inactivity

Screening

Has helped to reduce cancer-related mortality from breast and colon cancer in older adults

Not suitable for others, e.g. prostate – risk greater than benefit over age 69 (Moyer 2012) and no effect on life expectancy

Chemoprevention

Administering drugs to prevent cancer Aspirin, NSAIDs, finasteride, Vitamin D tried Finasteride showed 26% reduction in

prostate cancer compared to placebo (Thompson 2003)

Aspirin 15% reduction in cancer deaths but effect seems to take >3 yrs

Clinical profile of older cancer pt More likely to require assistance with ADLs Up to 70% functional dependence, 90%

comorbidity, 40% polypharmacy (Extermann 1998, Repetto 2002, Ingram 2002)

Severe comorbidity associated with higher mortality in lung, colorectal and prostate ca (Jorgensen 2012)

Common: DM, IHD, high chol

Presentation of cancers in old age Most present at later stage in older people

(Goodwin 2004) which has negative effect on survival

Common symptoms of cancer may be ascribed to old age Pain, fatigue, weight loss

In large French survey of GPs increasing age highly assoc with decision not to refer (Delva 2011)

Management of cancer in old age Well recognised that older people with cancer

are under-treated compared to younger ?Because of … Comorbidity ?...Shorter life expectancy ?...Patient choice Or could it also be due to poor communication of

risks/benefits of treatment or not treating? Study of oncologists: given cases, placed too

much emphasis on chronological age

The case for oncogeriatric care Geriatricians and MDT involved in the

decision making process for cancer treatment Only one reasonable quality study! Van de

Water 2014 42 pts oncogeriatric vs 104 standard care Oncogeriatric care group -> more intensive

treatment and trend towards increased survival

CGA

CGA affected treatment decisions in up to 82% (Chaibi 2011)

Identified geriatric problems in over 50% of pts (Kenis 2013)

ADL, IADL, performance status, depression and frailty assoc with poor health outcomes such as treatment toxicity and mortality

Short screening then CGA?

Time consuming! But no screening tool has been found to have

acceptable sensitivity or specificity for identification of frailty in older people with cancer (Smets 2014)

CGA remains gold standard

Frailty in cancer

One review of data from 20 studies, 2,916 older people with cancer, median prevalence was 42% (Handforth 2014)

More common in frailty: Treatment complications Post-operative complications Death

Treatment: Radiotherapy

Mainstay of treatment for some cancers Less likely to be used in older people

?dementia, movement disorders, difficulty tolerating or accessing

Newer therapies such as intensity modulated radiotherapy and stereotactic irradiation might help to reduce toxicity

Treatment: Chemo

Underused One cohort – 94% of <50s had it but 42% of

those >80 Concerns that won’t be tolerated

Fisher (2012): of pts recommended chemo, 81% began; 52% of those completed all cycles, 34% of treatment group received reduced dose

Sig better survival if completed chemo

Chemo cont’d

Risk assessment tools CRASH (Extermann)

Greater use of oral instead of IV Dose reductions don’t seem to affect survival,

from preliminary evidence (O’Connor 2010) But well powered studies lacking

Surgery

Mainstay for many, and confers best outcomes Those not undergoing surgery more likely to die

within 30 days (Sheridan 2014) Proportion drops off for many types of surgery

in older age groups Recent study looked at endometrial cancer

surgery: older people less likely to undergo laparoscopic but did not have higher rates of morbidity or mortality (Mahdi 2015)

Surgery (cont’d)

Minimally invasive, local/regional anaesthesia and pre-op optimisation may help

Pre-operative Assessment of Cancer in Elderly (PACE) tool combines part of CGA with surgery-specific metrics

Dependence for ADL/IADL and PS >2 associated with longer stay

Long-term health outcomes

Cancer survivors more likely to report comorbidity, limited mobility, dependence for ADLs than controls

Sequelae from chemo Cardiotoxocity Myelodysplasia & acute leukaemia Peripheral neuropathy Dementia (Heck 2008)

Research

Only 25-33% of eligible older pts enrolled to trials; barriers: Physicians perceptions Protocol criteria, esp comorbidity Functional status Lack of social support

Need no upper age limit, and flexible trial design

Conclusions

Cancer incidence increasing Mortality gap widening bt young/old group Older people undertreated Presentation can be different CGA helps identify areas to optimise Early days for the evidence base

Thanks!

Shane.ohanlon@royalberkshire.nhs.uk