Balancing risk and life expectancy when treating the elderly
Prof Arti Hurria - SIOG President and City of Hope Hospital, Duarte, USA
The top issues are that cancer is clearly a disease associated with aging; that there is going to be an incredible growth in the number of older adults with cancer worldwide and there is a critical need right now to improve both our research base as well as our education about how to really best take care of this growing population. This is a healthcare epidemic, I would say, and it’s something that really needs to have some focus.
What has gone wrong in the past?
The critical issue is really understanding who is that older adult in front of you. Not making a treatment decision based upon that individual’s passport age or their chronologic age, as we call it, but really looking beyond that and understanding what is someone’s functional age. There can be a 60 year old who might be impacted by many different medical conditions and might be a functional 80 year old versus an 80 year old who might be a functional 60 year old and making that distinction as you’re seeing and treating that patient.
How do you advise the cancer clinician in this instance?
There is a tool called the geriatric assessment that is a tool that has been used by geriatricians for years. That’s exactly what they do, is they do this assessment of the patient’s function, their comorbid medical conditions, their cognition, their psychological state, their nutritional status, their social support, all of these factors that really can impact how an individual would tolerate therapy. So it’s really looking at age as one factor but several other things that go into the equation of who is going to tolerate that treatment.
What examples can you provide?
In breast cancer we’re always thinking of the concept of adjuvant therapy – should therapy be given to decrease the risk of the breast cancer coming back? And understanding whether or not there’s benefit has something to do with what is the life expectancy of that individual and how can they tolerate that therapy. So there’s a beautiful paper by Walters and colleagues that really shows that at each age life expectancy varies significantly based upon how healthy that individual is. So do they appear healthier than their chronologic age, younger than their chronologic age or average for their age? And we often talk about that as clinicians – are you a young 70 year old, an older 70 year old? That sort of idea. So when you take that you really have to think about that when you’re making these treatment decisions because understanding someone’s life expectancy places into context whether or not they would derive benefit from that therapy.
How does this affect your risk-benefit assessment?
Life expectancy helps you think about are you going to realise the potential benefit of that adjuvant treatment in that patient’s life expectancy. The other part of the equation which you’ve just brought up, which is critical, is what’s the risk that we’re taking at the same time? That’s really what you’re going to see highlighted here at this SIOG meeting is a lot of research that really is focussing on how do you predict a risk? How do you identify that patient who seems perfectly fine but would have significant side effects from cancer therapy versus that patient who actually seems like maybe they’re frail but they would do just fine? So there have been some publications that have come out that can really help clinicians in a very short period of time fine tune that risk assessment. What they do is there’s one that has come out of the Cancer and Aging Research Group that I was involved in which really takes only eleven items that a clinician needs to ask, one of which includes age, and there are five geriatric assessment questions in there; there are measures of is the person anaemic, what’s their creatinine clearance and what are the treatments you might give the person? So eleven things that the doctor would ask that can stratify risk of low, medium or high for someone developing a significant side effect. Then when we talk about significant side effects we’re not talking about a cold, we’re talking about what we call grade 3 through 5 toxicities, so these are the types of side effects that can place the patient in the hospital. But you can predict this, that’s what we’ve shown. There has been also data from the CRASH score that’s done the exact same thing. It’s simple, these are online tools where you can put this into the computer and really understand in a much better sense what’s the risk of toxicity.
What did the recent report from the Institute of Medicine highlight on this matter?
What it highlighted was why we need societies like SIOG that really focus on education, clinical care, research, how are we going to move the field forward in this aging population? It really was a call to action that to have quality cancer care we have to address the aging population, the issues specific to an aging population. And how can we really best serve those groups of individuals who, unfortunately, have been under-represented on research today. So at this meeting what you’re going to see is really the latest research, individuals who are really focussing in this field about what are the latest issues facing older adults with cancer. I think you’re going to find it to be an incredible few days.
What are the key messages for cancer doctors?
The key messages are that chronological age does not equal functional age and that there are now tools that are out there that can help that busy clinician to identify what the functional age of an individual is, to understand what their life expectancy is and to make cancer decisions in the context of that. Of course those are tools that can be used but the ultimate thing is to really sit with the patient, understand what are their wishes, what are their preferences and how do these risk-benefit ratios sit in the context of that. This is the ultimate of personalised medicine; geriatric oncology is all about personalised medicine.