Practice Pearls: What is different when dealing with the older patient? A medical oncologist’s perspective. (#5)
In Australia the median age of patients at the first diagnosis of cancer is 67years. Given the ageing of the population and the successful prevention of other causes of mortality, our waiting rooms and clinics are destined to be filled with older patients. As the average medical oncologist and clinical haematologist will therefore be dealing with older patients in routine practice it could be argued that we are already “geriatric oncologists and haematologists”. However, whilst we are well trained in treating the underlying disease, Australian clinicians are not trained to assess and manage the particular needs of older patients in a comprehensive and efficient manner. It is vital to not make any decision on the basis of chronological age alone and the cornerstone of the management of the older patient is adequate assessment.
The International Society of Geriatric Oncology (SIOG) and NCCN recommend routine geriatric assessment in older adults with cancer. Whilst there is no worldwide “gold standard” it is generally accepted that a geriatric assessment should be multidimensional and contain tools that predict the functional age of older patients.
A thorough geriatric assessment and guided intervention will be able to-
1. Provide information about a patient’s functional, emotional and cognitive status.
2. Guide appropriate supportive care interventions.
3. Create a framework for multidisciplinary care.
4. Possibly be used to guide appropriate treatment and predict treatment toxicities and outcomes.
5. With the provision of targeted intervention enable improved patient outcomes such as quality of life and possibly even survival.
Investigators around the world have devised tools that can be used in the oncology setting. These range from quick screening tools (eg VES-13 and G8) to detailed comprehensive geriatric assessment (CGA).
When deciding on the type of treatment to give an older patient with cancer it is important to make an assessment of their likely life expectancy if they did not have cancer. Whilst a CGA will assist with this and uncover comorbidities there are also useful tools (eg eprognosis.org) that will aid in this process. It should be remembered that in Australia the median life expectancy of a fit 80-year-old woman is another 9.9 years.
Once an appropriate treatment is selected there are a number of supportive care measures that can be used such as routine use of growth factors in patients over 65 years receiving myelosuppressive chemotherapy (eg R-CHOP). Routine assessment of renal function with creatinine clearance rather than serum creatinine alone is also recommended. Treatment should be individualised based not only on the disease but the functional status of the patient and the patient’s preferences. It is not appropriate for older patients to be denied standard treatment on the basis of age alone but adequate assessment and support will prevent “over treatment” and toxicity.