Overview: Geriatric oncology: a medical sub-specialty whose time has come
Overview: Geriatric oncology: a medical sub-specialty whose time has come AUTHORS:
Dorothy Keefe and Robert Prowse
DETAILS:
University of Adelaide, South Australia and Royal Adelaide Hospital Cancer Centre, Royal Adelaide Hospital, South Australia.
EMAIL ADDRESS: dorothy.keefe@health.sa.gov.au It is a truism that cancer is a disease of older people and that as the population ages the incidence and prevalence of cancer increases. Fifty per cent of cancers occur in those over 65 years of age and the number of people over the age of 65 is increasing steadily.1Cancers such as those of the colon and lung increase dramatically with age.1
In 1981, only 9.2% of the population was aged over 65, but in 2004 that had risen to 13% and is projected to be 26-28% in 2051.2 As we prevent more deaths from other diseases such as heart disease and infection, the number of cancers will continue to rise and the number of older people with cancer will also continue to increase. Mortality from cancer in the over 65s is also increasing, while it is decreasing in the under 65s.1,3
Over the past 20 years, the upper age limit for many medical procedures and treatments has increased. This is partly due to the increase in life-expectancy that occurred throughout the 20th Century, the fact that older people are also fitter and healthier as they reach old age than they have ever been before and because techniques in anaesthesia and surgery have improved to allow safer operations and less morbid recovery. As with all treatments, performance status is a better predictor of outcome than is age.
However, not everything is completely straightforward in older people. Older people are not just “adults but older” just as children are not “adults but smaller”. There are physiological changes that occur with ageing, as well as multiple co-morbidities which can complicate management of elderly cancer patients. Some tumours, such as breast cancer and non-small cell lung cancer, are more indolent in the elderly, while others such as lymphoma and ovarian cancer may be worse.4 Undertreatment may cause poor outcomes in elderly (>60 years) patients. With aggressive lymphoma for example, older patients are less likely to be treated for cure, and are less likely to survive for five years.5 Older women with breast cancer are less likely to be offered enrolment in clinical trials and older patients tend to receive less aggressive diagnosis and treatment for lung cancer.6-8
ONCO-GERIATRICS: DO WE NEED IT?
Over the past 15 years, cancer in the older person, or onco-geriatrics, has increasingly been talked about as a coming thing, within both geriatric and oncology circles. Meetings have been held, societies formed and positions taken. Both the Clinical Oncological Society of Australia and the Medical Oncology Group of Australia have held sessions on ‘cancer in the older person’ at their annual meetings; the International Society of Geriatric Oncology held its 8th meeting in Madrid in November 2007 and there are regular sessions at the American Society of Clinical Oncology about treating elderly cancer patients. This edition of Cancer Forum is the first one dedicated to this area and covers several of the most important issues. However, in Australia we still do not have routine, protocol-based care for our older cancer patients.
Oncologists feel every patient with cancer deserves to have a consultation with an oncologist. Geriatricians judge many of their patients to be inappropriate for oncological treatment. Neither point is fully objective and onco-geriatrics has a major potential benefit in informing both specialties. Does every elderly cancer patient need to see a geriatrician? Could we reduce the ‘burden of care’ by supporting our elderly cancer patients better? A proactive approach to the management of the elderly patient with cancer reduces toxicity. We should look at general clinical measures and mange underlying health problems, treat toxicities and use prophylaxis where possible. We should also make dose adjustments for renal function and ensure that older people are adequately represented in trials of new cancer treatments.9
