geriatric oncology
TRANSCRIPT
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
