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| Care of the Older Adult with Cancer |
I. INTRODUCTION. Cancer is a disease of aging; the incidence of most malignancies increases with age. Over half of cancer diagnoses and nearly 70% of cancer deaths occur in patients over the age of 65. With the aging of the population, the number of older adults with cancer will increase by 67% by 2030. There are significant differences in cancer-specific death rates between older and younger individuals. These age-related disparities likely differ in cause among different malignancies, but contributory factors include differences in screening, more advanced stage at presentation, differences in biology of disease across the age spectrum, and less aggressive treatment in older adults.
A. Knowledge gaps in treatment of older adults with cancer. Contributing to differences in treatment between older and younger adults are the increased vulnerability of older adults to toxicity of therapy and the underrepresentation of older adults in clinical trials. Older adults are less likely to be enrolled in clinical trials owing to restrictive exclusion criteria based on organ function or comorbidities. In addition, clinicians are less likely to propose participation in a clinical trial, though, if asked, older adults are as likely as younger adults to agree to participate. This under-representation of older adults in clinical trials has resulted in substantial gaps in our knowledge about the safety and efficacy of cancer therapies when applied to older adults. With the growth in the number of older adults with cancer, thankfully, increasing attention is now being directed to the need to increase our knowledge base on treating older adults with cancer.
II. BIOLOGY OF CANCER IN OLDER ADULTS. There is a commonly held perception that, overall, cancer in older adults is less aggressive than in younger adults. Breast cancer is one example of this, being more likely to be hormone-receptor positive. Overall, however, most cancers do not exhibit substantial age-related differences in biology. In some cases, older age is actually associated with more aggressive, treatment-resistant biology, as in acute myeloid leukemia and diffuse large B-cell lymphoma. Thus, in older adults, treatment decisions are largely not driven by biology of disease, but rather by the patient’s individual health status.
III. COMPREHENSIVE GERIATRIC ASSESSMENT. Increasing chronologic age is associated with an increasing prevalence of comorbidities and functional or cognitive impairment. A comprehensive geriatric assessment (CGA) is a multidimensional assessment of geriatric domains (Table 35-1). While the screening tools used are often referred to as “CGA,” in geriatrics, CGA refers to the multidisciplinary assessment, interpretation of screening tools, and recommended tailored interventions.
Domains of a CGA |
Domain | Commonly used scales/measures |
Comorbidities | • Charlson comorbidity index • Cumulative illness rating scale—geriatrics • Adult comorbidity evaluation-27 (ACE-27) • Hematopoietic cell transplantation comorbidity index (HCT-CI) |
Physical performance | • Timed up and go • Short physical performance battery |
Functional status | • Activities of daily living • Bathing • Continence • Dressing • Toileting • Transferring • Feeding • Instrumental activities of daily living • Using telephone • Getting to places out of walking distance • Shopping for groceries • Preparing meals • Doing housework • Doing laundry • Taking medications • Managing finances • Performance status |
Cognition |
