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When Geriatric Medicine meets Oncology

Contributor: Marina Kotsani

Origin/affiliation: Geriatrician (France, Greece)


Several times in my practice I hear older people wondering “But, how is it possible to get cancer at that age? Doesn’t everything fade away? How is it possible for a tumour to develop?...” or “I have already fought against one cancer in my life, I didn’t expect for another one to come up”. I try to hide my astonishment on the popularity of these myths and explain that cancer is, in fact, more prevalent in older people and that most patients who are newly diagnosed with cancer are age 65 years or older.

Cancer management of the older patient is complex and thus an excellent example of the need of interprofessional cooperation.

Since the number of older people with cancer constantly increases, oncologists often face the challenge of dealing with older cancer patients with multiple comorbidities and various frailty and disability levels. Clinical trials on oncological treatments typically exclude frail older patients, leaving a gap of knowledge in the management of the older patient’s cancer.

Geriatric Assessment (GA) aims at helping oncologists taking tailored clinical decisions by considering the older person’s functional, cognitive, psychological and nutritional status, comorbidity, polypharmacy, social support, objective physical performance and geriatric syndromes, as well as the values and health-related goals of the individual.

Multiple studies have demonstrated that GA often modifies the oncological treatment plan, usually towards less intensive therapeutic options (with typically no effect on the oncological outcome), triggers non-oncological interventions and enhances the physician-patient/caregiver communication about aging-related concerns. Furthermore, there is evidence that GA also leads to more tangible benefits for the patient, such as lower treatment-related complications and toxicity, greater treatment completion rate, lower health care utilisation and better quality of life, whereas other relevant outcomes such as survival and physical functioning do not seem to be substantially modified.

Definitive conclusions are difficult to draw since the population of older people is highly heterogenous, let alone the types and stages of cancer they suffer from. Co-management models by oncologists, geriatricians and, often, multidisciplinary teams largely vary across different settings and highly depend on available resources and institutional organisation. Other challenges to address are the reflexion on the most appropriate tools, methods and performers of the GA, the dynamic evolution of the cancer patient’s health status, which may warrant GA updates and the long-term management of the complex needs of aged cancer survivors.

Future research should focus on the role of GA in patient-centred relevant outcomes, such as individualized goals’ achievement and quality of life.


References

Hamaker ME, Te Molder M, Thielen N, van Munster BC, Schiphorst AH, van Huis LH. The effect of a geriatric evaluation on treatment decisions and outcome for older cancer patients - A systematic review. J Geriatr Oncol. 2018 Sep;9(5):430-440. doi: 10.1016/j.jgo.2018.03.014. Epub 2018 Apr 7. PMID: 29631898.

Mohile SG, Dale W, Somerfield MR, Schonberg MA, Boyd CM, Burhenn PS, Canin B, Cohen HJ, Holmes HM, Hopkins JO, Janelsins MC, Khorana AA, Klepin HD, Lichtman SM, Mustian KM, Tew WP, Hurria A. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol. 2018 Aug 1;36(22):2326-2347. doi: 10.1200/JCO.2018.78.8687. Epub 2018 May 21. PMID: 29782209; PMCID: PMC6063790.

Mohile SG, Epstein RM, Hurria A, Heckler CE, Canin B, Culakova E, Duberstein P, Gilmore N, Xu H, Plumb S, Wells M, Lowenstein LM, Flannery MA, Janelsins M, Magnuson A, Loh KP, Kleckner AS, Mustian KM, Hopkins JO, Liu JJ, Geer J, Gorawara-Bhat R, Morrow GR, Dale W. Communication With Older Patients With Cancer Using Geriatric Assessment: A Cluster-Randomized Clinical Trial From the National Cancer Institute Community Oncology Research Program. JAMA Oncol. 2020 Feb 1;6(2):196-204. doi: 10.1001/jamaoncol.2019.4728. PMID: 31697365; PMCID: PMC6865234.

Soto-Perez-de-Celis E, Aapro M, Muss H. ASCO 2020: The Geriatric Assessment Comes of Age. Oncologist. 2020 Nov;25(11):909-912. doi: 10.1634/theoncologist.2020-0804. Epub 2020 Sep 21. PMID: 32886421; PMCID: PMC7648345.

Wildiers H, Heeren P, Puts M, Topinkova E, Janssen-Heijnen ML, Extermann M, Falandry C, Artz A, Brain E, Colloca G, Flamaing J, Karnakis T, Kenis C, Audisio RA, Mohile S, Repetto L, Van Leeuwen B, Milisen K, Hurria A. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol. 2014 Aug 20;32(24):2595-603. doi: 10.1200/JCO.2013.54.8347. PMID: 25071125; PMCID: PMC4876338.


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