|Year : 2019 | Volume
| Issue : 2 | Page : 226-227
Treating the older patients with ‘younger’ evidence-based therapy: Time to tailor to suit the fragility
Avinash Pandey, Anjana Singh
Department of Medical Oncology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Web Publication||20-Dec-2019|
Department of Medical Oncology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pandey A, Singh A. Treating the older patients with ‘younger’ evidence-based therapy: Time to tailor to suit the fragility. Cancer Res Stat Treat 2019;2:226-7
|How to cite this URL:|
Pandey A, Singh A. Treating the older patients with ‘younger’ evidence-based therapy: Time to tailor to suit the fragility. Cancer Res Stat Treat [serial online] 2019 [cited 2020 Feb 28];2:226-7. Available from: http://www.crstonline.com/text.asp?2019/2/2/226/273670
The older population in developing countries such as India is growing by leaps and bounds in comparison to the already developed Western world. The older population of India with age more than 65 years will soon reach to a mammoth 90 million by the year 2020. The numbers are further growing as improvement in longevity accompanied by better healthcare and economy will make people survive long enough to encounter chronic health ailments such as cardiovascular disease and cancer. More than half of the cancers currently choose the older population as their victims with mortality exceeding 70% in this vulnerable cohort., Thus, geriatric oncology has emerged as a novel global healthcare requirement. Oncology care in older patients is further compounded by the interplay of complex, poorly understood, intangible variables such as frailty, cognition, functional status, nutrition, social support, psychological status, and polypharmacy apart from multiple comorbidities and performance status.
Older patients are often not sufficiently enrolled in the majority of prospective interventional therapeutic clinical trials, but at the time of receiving therapy, they are invariably offered the same evidence-based therapy which has proved effective for the younger cohort., This often leads to heightened toxicity, premature discontinuation, or abandonment resulting in compromised outcomes, sometimes with higher mortality and worse quality of life., Chronological age and performance status measured either by the Eastern Cooperative Oncology Group or Karnofsky Performance Status Scale are grossly insufficient to predict tolerance, anticipate toxicity, or preempt outcomes of otherwise intensive standard therapy in older patients. The above discordance in the geriatric compared to the younger population is primarily due to organ-specific decline in physiological reserve with compromised functional and cognitive status coupled with multiple comorbidities thriving on polypharmacy. Routine standardized and validated Comprehensive Geriatric Assessment (CGA) addressing and accounting for the above salient variables are required to tailor the intensity and type of therapy to optimize the outcomes with the least possible toxicity. However, it is prudent to measure first the extent of awareness of the problem and highlight the rationale used for altering therapy among community oncologists for older patients with cancer, with or without the use of any CGA tools/questionnaire.
In a first of its kind cross-sectional survey, published in this issue of the journal, to comprehend and acknowledge the current level of awareness and practice pattern among Indian community oncologists toward geriatric patients, Noronha et al. conclude that more than 44% of practicing oncologists are unaware of any geriatric care guidelines available for cancer care. Among respondents, majority of them being medical oncologists (70%), only 4% believed that there is a limited clinical benefit for such assessment, but 51% of them did not assess their older patients differently than younger patients. Even among those who did, majority of them (70%) used clinical judgment rather than well-validated CGA tools to decide therapeutic options for their older patients with cancer. This means that the critical decision of choosing treatment modality and intensity was often made on the basis of physician's clinical judgment which has its own fallacies in the form of subjective, cognitive, and selection bias due to its intangible and intuitive nature. In a sample of respondents where 61% were generalist oncologists, 87% of them saw more than 10 older patients per week, and 91% did not perform any multi-dimensional geriatric assessment using available validated tools. Lack of time, resources, awareness, and staff were the common reasons mentioned for not performing routine CGA assessments. However, at least, there was uniform agreement that a separate discipline of geriatric oncology would offer potential advantages in routine clinical decision-making in older patients with cancer.
Apart from the lack of awareness among oncologists as demonstrated by the above survey, among the major hurdles of CGA tools for implementation in routine decision-making of older patients are the complexities in assessing multiple domains such as cognition, functional status, nutrition, social support, polypharmacy, and comorbidities. Moreover, the time required to perform CGA is often overwhelming, especially with constraints of limited resources and heavy patient turnover in government or community hospitals staffed by generalist oncologists in India. Attempts have been made to simplify the CGA by using abbreviated CGA or altering the mode of assessment such as patient-mailed CGA, electronic CGA, or clinical interviews, but there is no consensus to their universal use due to lack of prospective validation in larger cohorts.,, Despite a paucity of prospective randomized trials to prove survival benefit, standardized and validated CGA can influence the outcome of therapy by not only predicting complications and functional decline but also highlighting novel hidden problems and cognitive compromise which often eludes routine history-taking and clinical examination., Hence, its use is strongly recommended by the American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), and International Society of Geriatric Oncology (SIOG), to enhance and optimize the robustness of the clinical decision-making algorithms in older patients.
The results of this published survey reiterate the notion that improving awareness about geriatric oncology is urgent and is an unmet need among Indian oncologists. Either using the standard CGA tools or accepting uniform indigenous CGA tools developed after expert panel consensus, with prospective validation in our local population, is the need of the hour. Catering to the older patients with cancer in specialized geriatric oncology clinics staffed with geriatric oncologists, physicians, nurses, physiotherapists, social workers, nutritionists, and pharmacists should be made the next goal to address the surging numbers of elderly patients bound to get afflicted by the 'Emperor of all Maladies'.
| References|| |
Martin LG. The status of South Asia's growing elderly population. J Cross Cult Gerontol 1990;5:93-117.
Shrestha LB. Population aging in developing countries: The elderly populations of developing countries are now growing more rapidly than those in industrialized nations, thanks to health advances and declining fertility rates. Health Aff 2000;19:204-12.
Ries LA, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al
. SEER Cancer Statistics Review, 1975-2000. Bethesda, MD: National Cancer Institute; 2003. p. 2.
Hutchins LF, Unger JM, Crowley JJ, Coltman CA Jr., Albain KS. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N
Engl J Med 1999;341:2061-7.
Pang HH, Wang X, Stinchcombe TE, Wong ML, Cheng P, Ganti AK, et al
. Enrollment trends and disparity among patients with lung cancer in national clinical trials, 1990 to 2012. J Clin Oncol 2016;34:3992-9.
Merchant TE, McCormick B, Yahalom J, Borgen P. The influence of older age on breast cancer treatment decisions and outcome. Int J Radiat Oncol Biol Phys 1996;34:565-70.
Bergman L, Kluck HM, van Leeuwen FE, Crommelin MA, Dekker G, Hart AA, et al
. The influence of age on treatment choice and survival of elderly breast cancer patients in south-eastern Netherlands: A population-based study. Eur J Cancer 1992;28A:1475-80.
Puts MT, Santos B, Hardt J, Monette J, Girre V, Atenafu EG, et al
. An update on a systematic review of the use of geriatric assessment for older adults in oncology. Ann Oncol 2014;25:307-15.
Noronha V, Talreja V, Joshi A, Patil V, Prabhash K. Survey for geriatric assessment in practicing oncologists in India. Cancer Res Stat Treat 2019;2:232-6. [Full text]
Hurria A, Gupta S, Zauderer M, Zuckerman EL, Cohen HJ, Muss H, et al
. Developing a cancer-specific geriatric assessment: A feasibility study. Cancer 2005;104:1998-2005.5.
Hurria A, Akiba C, Kim J, Mitani D, Loscalzo M, Katheria V, et al
. Reliability, validity, and feasibility of a computer-based geriatric assessment for older adults with cancer. J Oncol Pract 2016;12:e1025-e1034.
Monfardini S, Ferrucci L, Fratino L, del Lungo I, Serraino D, Zagonel V. Validation of a multidimensional evaluation scale for use in elderly cancer patients. Cancer 1996;77:395-401.
Corre R, Greillier L, Le Caër H, Audigier-Valette C, Baize N, Bérard H, et al
. Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non-small-cell lung cancer: The phase III randomized ESOGIA-GFPC-GECP 08-02 study. J Clin Oncol 2016;34:1476-83.