CANCER CARE FOR THE ELDERLY

An elderly, healthy gentle man, Mr Rajan Maini, comes in the OPD with his son and wife. Dressed in casual attire, he looks cheerful and content. He has no complaints at all, but he has been diagnosed with a carcinoma, which is curable and in its early stages. He does have some comorbidities, COPD being one. How familiar is this scene in any clinic? How often have we seen the dilemma among the family members and probably among doctors too, for whether to treat him or let him be on his own? Afterall, how long a life does he have? Will he be able to tolerate the ruthless anticancer treatment?

We are in an era when life expectancy has increased significantly due to improved lifestyle, better health care and medical support. According to the United Nations, by 2050, the world population of 60 years and older would reach 2 billion, from 900 million in 2015. Today 125 million people are aged 80 year or older.

With advancing age, the incidence of cancer too has been increasing. More than 12‑23% of all cancers occur after the age of 65 years (NCCP 2002, NCRP 2001). Yet this group of patients have been under- represented in our clinical practice. They have also not been studied well in any research and have been customarily considered unsuitable for treatment, hence denying them of the chance of a curative approach.

Barriers to Optimum Cancer Care in the Elderly

There is probably some truth in the concerns raised. Treating older patients for cancer may be quite challenging most of the times; not only because of their advanced age, but also because they are more likely to suffer from chronic health conditions, such as diabetes or heart or kidney disease. Apart from the fact that, they may respond in a different way than their younger counterparts, to the various modalities of cancer treatment offered to them, they may also bear some unique challenges:

Increased financial burdens, lack of support at home and sometimes the stress of being under the care of someone else. Our elderly patients may need extra support for their nonmedical needs too, which may be financial, psychological, social.

But should age be the only factor to be considered during treatment decisions?

Chronological Age vs. Physiological Age

Age is just a number, as a saying goes.

Advancing age comes with varied challenges which may be cognitive, allied health conditions, decrease in physiologic reserve. Physiologic reserve is the ability to recover from something that’s difficult, whether it’s cancer and its symptoms or cancer treatment. But this is far from being a rule.

We have seen elderly octogenarians going through cancer treatment successfully with some extra care and support. At the same time there have been younger patients who failed to continue through the treatment.

One size does not fit all. Some treatment adjustments, if needed should be considered to reduce the side effects. Fortunately there are several treatment options available today for avoiding or minimizing drug interactions, for personalising treatment for the older patients. Hence there are no reasons to deny any form of cancer treatment to them.

Biomarkers of Ageing

The words sound appealing. This conceptualizes identification of biomarkers of ageing that would assess the physiological reserves of the patient, guiding medical interventions. The big epidemiological ageing studies, NHANES III, and the Dunedin study, determine the physiological age of an individual. Geriatric research has identified several biological markers potentially able to reflect the physiological age of a person. The diagnostic and prognostic value of these markers has yet to be prospectively proven.

Geriatric Assessment Tools

Geriatric Assessments Tools can potentially identify those older adults who are at higher risk of serious side effects from cancer treatment. Studies show that people who received assessment-guided care, not only fared fewer side effects, but they were also less likely to experience falls in their homes during treatment when compared with people who didn’t receive Geriatric Assessment–guided care. However, no differences in survival were seen between the two treatment groups in this particular study. The results were published in The Lancet in November 2021. They concluded that a “geriatric assessment intervention for older patients with advanced cancer reduced serious toxic effects from cancer treatment. Geriatric assessment with management should be integrated into the clinical care of older patients with advanced cancer and ageing-related conditions.”

A Geriatric Assessment Tool collects all health-related information, comorbidities, and impairments that otherwise may not be captured as part of routine cancer care and evaluates them to identify patients who are likely to experience serious side effects. The table below is an example.

Components of A Geriatric Assessment

Comprehensive Geriatric Assessment CGA probably originates way back in the 1940s by Dr. Marjory Warren in the United Kingdom, who noticed a need to better manage older patients in the hospital who were bedridden and chronically ill. This has been considered as the “Gold Standard” for evaluating older adults.

Today, there is a rising need for designing innovative health care models to synchronize geriatric principles with oncology care.  Multidisciplinary geriatric oncology clinic can be created where a detailed description of our geriatric oncology practice can be outlined, taking into consideration the various barriers, challenges associated with the advanced age and provide practical solutions. Competent geriatric nursing education is also an essential part of management of care in older adults with cancer.

Survivorship in Elderly Cancers

Our Responsibility as Oncologists does not end here. For any cancer treatment, managing post treatment adverse effects is equally imperative. While a decision is being made whether or not to treat an elderly patient, it is important to consider his quality of life that we impart after curing his cancer. Among the elderly survivors, physical and psychological issues like, fatigue, pain, osteoporosis, cardiac toxicity, weight and nutritional changes, cognitive changes, depression, anxiety, and neuropathy, may be more perplexing. Over time, diminished social and economic resources may also impact the survivorship experience. Addressing survivorship among older adults requires a comprehensive approach considering recommended follow-up care, managing multi-morbidity and medications, deciphering between age- or cancer-related physical and mental symptoms, and coordinating care from multiple physicians.

Ending Thought

For now, chronological age alone is not the best indicator to determine responses to treatment among older cancer patients. When carefully selected, older patients can benefit from both curative treatment and palliation. It has been proved that Geriatric Assessment tools do help selecting a patient for Cancer treatment. A complete assessment of the elderly patient covers each of the domains: like physical condition, cognitive function, functional status, nutritional status, psychosocial health, economic status, physical environment, caregiver support, and spirituality.

We need to work diligently to understand which group of older adults would benefit most from the assessment. More studies are required to determine the components of the assessment which would be most useful in a particular patient or Cancer type. The assessment tools also have to be made more accessible and streamlined so that both the patients and Physicians benefit from it.

An extra support to the patients and their care givers with psychological training assist, emotional counselling, nutrition advice and guidance in transportation for appointments would help more Geriatric patients avail treatment for Cancer.

Mr Rajan Maini completed his entire treatment very successfully with personalization of care, with lots of support and encouragement from his family members, notwithstanding multiple admissions, multiple treatment. But the treatment allowed him a happy fruitful life with his dear ones, doing everything he always loved to do.

Acknowledgement ‑ We are grateful to Mrs. Maini and her family for sharing their thoughts and photographs.

Dr. Swarupa Mitra
Chief of Gynecological and Genitourinary

Radiation Oncology Services