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Table of Contents
EDITORIAL
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 296-299

Geriatric oncology landscape in India – Current scenario and future projections


1 Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra, India
2 Department of Medical Oncology, MNJIO RCC, Hyderabad, Telangana, India
3 Department of Medical Oncology, Krishna Institute of Medical Sciences Hospitals, Secunderabad, Telangana, India
4 Department of Oncology, Aster MIMS, Kannur, Kerala, India
5 Department of Medical Oncology, PSG IMSR Superspeciality Hospital, Coimbatore, Tamil Nadu, India

Date of Submission11-Apr-2020
Date of Decision15-Apr-2020
Date of Acceptance15-Apr-2020
Date of Web Publication19-May-2020

Correspondence Address:
Purvish M Parikh
Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_150_20

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How to cite this article:
Parikh PM, Chaitanya K, Boppana M, Kumar M S, Shankar K. Geriatric oncology landscape in India – Current scenario and future projections. Cancer Res Stat Treat 2020;3:296-9

How to cite this URL:
Parikh PM, Chaitanya K, Boppana M, Kumar M S, Shankar K. Geriatric oncology landscape in India – Current scenario and future projections. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 9];3:296-9. Available from: http://www.crstonline.com/text.asp?2020/3/2/296/287209



“The longer I live, the more beautiful life becomes.”

–Frank Lloyd Wright

Aging is an inevitable part of our lives. The process of aging is associated with multiple biological mechanisms which include attrition of telomeres, epigenetic modifications, cellular senescence, altered metabolism, and genetic mutations. Coincidentally, these are the same steps that lead to the development of cancer. No wonder, aging acts as the biggest risk factor for cancer.[1],[2]

In India and other low- and middle-income countries (LMIC), there is a steady improvement in the life expectancy of both men and women. In India, the current life expectancy is 70.4 years (71.8 years for women and 69.2 years for men), which is a significant improvement over the life expectancy of 37 years that existed in the year 1950.[3] In fact, projections indicate that it will improve further to 75 years when we reach the year 2030. Today, about 30% of our population is aged >60 years (the figure being 50% for some states such as Kerala).[4] No wonder the incidence of cancers among the geriatric population is increasing and expected to double in just a few years from now. Couple this with better medical and health-care facilities as well as an overall improvement in the socioeconomic conditions, and we can start having a peek at the future of geriatric oncology in India. This will also be similar to what is likely to happen in other LMIC.

How prepared are we to optimize geriatric oncology care is the important question we face today.[5]

As modifiable risk factors such as smoking, alcoholism, and obesity are tackled, awareness leads to a significant proportion of our population adopting a healthier lifestyle. This, in turn, increases the impact of non-modifiable risk factors, including aging! Initiatives taken to address geriatric oncology practice should, therefore, be appreciated and given wide publicity. One such publication is included in this issue of the Journal.[5] Given that 18% of the world's population is residing in India, these data are applicable to the entire developing world, with LMIC facing >50% of the global oncology burden. Officials involved in the development of policies for the three pillars of geriatric oncology, namely education, clinical practice, and research, will benefit immensely from the experience of the Tata Memorial Hospital, Mumbai, India.[6],[7]


  Expectations of Older Patients With Cancer Top


Let us take the example of some hypothetical geriatric oncology cases inspired by the real-life practice.

  1. A 92-year-old female from rural India is diagnosed with diffuse, large B-cell lymphoma. She has an extranodal lesion on her cheek, causing cosmetic disfigurement. She says, “Doctor, please get rid of this swelling on my face. I cannot meet others looking like this. I am willing to tolerate anything for its treatment. I also do not care how long I live, as long as I can have a normal appearance”
  2. An 84-year-old fit gentleman retired from government service and eligible for entirely free treatment even at private centers (e.g., central government health scheme/ex-servicemen central health scheme) is diagnosed with a locally advanced, unresectable carcinoma of the gallbladder. He says, “Look Doctor, I have lived a decent life, and by God's grace, I no longer have any more responsibilities. I would prefer you plan my treatment in such a way that my quality of life is maintained without having to face too many side effects. The main relief I want is from my abdominal pain”
  3. A 77-year-old gentleman with Stage III colon cancer who underwent an R0 surgical resection of his tumor is referred for adjuvant chemotherapy planning. He expresses, “Doctor, I have three children who live abroad and are very busy with their lives. My wife's no more, and I live alone with part-time domestic help. I do not want to keep coming to the hospital again and again. If there is any oral treatment you can give me, it would be best.”


The stories of these older patients highlight one of the most neglected aspects of geriatric oncology, which are the patient's preferences and expectations.

How many of us take the time to discuss and incorporate patients' preferences and expectations into the treatment plan? Even younger adult patients are shocked when faced with the diagnosis of cancer. For older patients, it is even more challenging because a caregiver often makes crucial decisions. Most of us will have witnessed a tussle between one son in India with whom the patient is living and another in the United States of America (USA), for instance. The son in India knows he has to be the primary caregiver, balancing his job with his parent's cancer management requirements; he takes a pragmatic approach. The son in the USA might feel guilty about not being able to contribute (physically or mentally), is not in a position to fly home, and therefore, justifies aggressively pushing for the latest treatment based on what he has read on social media (often claiming that this is the advice given to him by a world-class oncologist in his neighborhood). The patient is usually helpless and simply nods his head without having any clue about what is going on. The family often makes comments about the patient being frail and weak and that the real diagnosis should not be disclosed.[8] Even when the patients are educated, have a thorough understanding of disease implications, and want to discuss personal preferences, they hesitate to take the opportunity to share their thoughts.

Respecting the autonomy of older patients with cancer is an art that requires commitment, time, and patience.[9] When we encourage them to express their treatment priorities in a conducive atmosphere (with privacy and patience), we get an insight into what they really want. They, like their younger counterparts, might want the best chance of cure; they might want a prolonged life while preserving their independence (e.g., going to the temple, kitty parties, etc.). Others might wish for the best quality of life – minimal hospital visits, investigations, or toxicities. Still others only want symptomatic relief, especially those with pain, vomiting, diarrhea, or dyspnea. A few patients might even have very specific personal goals or milestones like living to see their first grandchild, enjoying a daughter's wedding, visiting a holy place, or meeting a school friend. In addition, financial implications are always at the back of their minds – be it a debt that needs to be repaid or preventing their child from going into debt due to medical bills.

One of the important questions the patients have is how long will they live with and/or without treatment offered. Here, we need to use validated scoring systems and scales that can assist us in gauging the potential risks and benefits of cancer therapy as accurately as possible.[10],[11] Unfortunately, none of them seem to factor in the patients' preferences.

These expectations and concerns are quite variable, and to a large extent, dependent on their level of education and social background.[12] Besides conducting a comprehensive geriatric assessment (CGA), rooting out misconceptions about cancer and its treatment plays a vital role.[13]

Oncologists who wish to specialize in geriatric oncology will, therefore, need to reinvent themselves by developing the new skills mentioned above.


  Medications and Their Implications in the Older Patients With Cancer Top


  1. Polypharmacy – Extermann et al. have pointed out that 50% of their study population received five or more drugs.[7] Polyphamacy is present to a similar degree in older Indian patients with cancer, as reported by Noronha et al.[6] Drug interactions can impact chemotherapy-related efficacy and toxicity. Use of the Cancer and Aging Research Group (CARG) online tool will help in a better understanding of such interactions [14]
  2. Pharmacokinetics (PK) and age – In older patients, the PK profiles of drugs are altered with respect to distribution, metabolism, and elimination parameters.[15],[16] Changes in the gastric pH may have variable impacts on the absorption of anticancer drugs; absorption of drugs such as tyrosine kinase inhibitors, endocrine agents, and capecitabine having a linear correlation. Altered PK of taxanes, anthracyclines, vinorelbine, and platinum compounds have also been documented in the geriatric age group [17]
  3. Pharmacogenomics and age – While normal genetic variations in the cytochrome p450 enzymes and drug metabolism are well known, the use of tests to predict an increased risk of toxicity (and prevent it by dose adjustment/drug replacement) is crucial in “frail” older patient with cancers.[18],[19] Accidental falls and fractures are frequent causes of morbidity and mortality in the later stages of life. Several classes of drugs (sedatives, antidepressants, antipsychotics, and anti-Parkinson's drugs) increase this risk. In fact, 50% of all such drugs are substrates of functionally highly polymorphic drug membrane transporters and drug-metabolizing enzymes, such as CYP2C19 or CYP2D6.[18],[19] Chronic pain and inflammation reduce the quality of life in older patients who are often treated with non-steroidal anti-inflammatory drugs (NSAIDs) for prolonged periods of time. The risk for gastrointestinal bleeding due to NSAIDs is up to ten-fold higher in the geriatric population and increases even further if the patient is simultaneously consuming anticoagulants. For the older patients with the CYP2C9*3/*3 (homozygous) or *2/*3 (heterozygous) genotypes, the risk of bleeding is increased three-fold [19]
  4. Alternative medicines and age – The use of complementary and alternative medicine is increasing globally, including the Western world. This was also documented in about 1/4th of their study population by Noronha et al.[6] Doctors of modern medicine (allopathy) are usually uncomfortable dealing with alternative medicines, mainly because they are unfamiliar with the finer details (name, constituents/nature of ingredients, manufacturing quality, dosage, etc.). In fact, such details are usually not known even to the patients receiving them and their caregivers. It has been previously reported that many such medicines contain significant amounts of heavy metals that could lead to renal toxicity.[20] No data exist on how these would influence the efficacy and toxicity of the chemotherapy medication, especially in older patients who have attenuated organ function reserve.


Noronha et al. are most likely correct when they state that 70% of the geriatric oncology patients have a potential risk of developing Grade 3 or higher toxicities if treated with combination chemotherapy in doses and schedules that are routinely used for young adults.[6] As 60% of their study population received palliative intent therapy, could it be that clinically significant toxicities (severity, duration, and incidence) would be less if single-agent chemotherapy were used?

Of course, such an approach should be considered only for biologically unfit patients (remember age is only a number!). Hence, the CGA is necessary, and we congratulate Noronha et al. for the same.[6] However, their study documented that CGA takes about 50 min to complete and its practical implementation in busy practices is limited. The Chemotherapy Risk Assessment Scale for High-Age Patients and CARG toxicity scores are two promising diagnostic tools that could serve as good alternatives.[17] Apart from the usual biochemical parameters, hypoalbuminemia has been given prognostic importance in such tools. It would be interesting to know about chemotherapy-associated toxicities among patients with serum albumin levels <3 (moderate hypoalbuminemia) or 2.5 g/dL (severe hypoalbuminemia).


  Training and Technology in the Connected World Top


The International Society of Geriatric Oncology was established in the year 2000.[21] To the best of our knowledge, no such medical body exists in India. There is an urgent need to provide systematic training in geriatric oncology for key health-care professionals. Noronha et al. have taken the initiative to set up one such fellowship training program as well as provide the services of a dedicated geriatric oncology outpatient department.[6] As most oncologists also care for older patients with cancer in their regular practice, regular training opportunities will help us learn the finer aspects of the palliative care for older patients-specifically practical tips on comprehensive assessment, optimal management of pain and other symptoms, communication skills, and coordination of care with other stakeholders.[22] Community outreach programs for geriatric oncology will enable expertise to be provided at the doorstep of those who have mobility challenges.[23],[24],[25] Available resources also include smartphone and mobile device applications that are intuitive to use in the connected world.[26] Let us take the example of one such home health-care delivery service provider-HealWell24.[27] It provides application-based, technology-enabled health-care services (with build in artificial intelligence analytics). Now geriatric oncology (as well as other home health-care) services can be provided at the doorstep of the patients. The use of remote monitors and the connected world technology allows the patients to benefit from expertise as well as remain in touch with their family and friends globally. No wonder investment funders seek out such organizations and provide them the financial resources to expand exponentially.[28]


  Dying With Dignity Top


We are well aware of the need to ensure that palliative care is incorporated early in the overall management of patients with cancer.[29],[30] Palliative care referrals should be based on need rather than diagnosis or prognosis.[31],[32],[33] This will prevent insufficient understanding of goals of care, poor care coordination, or repeated hospitalizations. Early documentation of a customized advanced care plan should be based on family preferences.[31],[32] This will help to reduce unwanted and potentially burdensome medical interventions in compliance with applicable laws (Writ Petition [Civil] No. 215 of 2005 in the Supreme Court of India, Common Cause vs. Union of India, order dated March 9, 2018).[33]

We might find that, if given a choice, most terminally ill geriatric oncology patients would prefer to breathe their last at home, with their loved family members. Home care programs with the help of professional services can provide pain and symptom management as well as psychosocial and spiritual care to the patients while guiding and empowering the families to play an active role. If the home/family circumstances do not allow such an approach, or if the patient is very sick/has complex medical complaints, the use of hospice facilities could be beneficial.[34],[35]



 
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