“GERIATRICS MOVES TO FOREFRONT IN ONCOLOGY”

1. “GERIATRICS MOVES TO FOREFRONT IN ONCOLOGY” • “ASCO takes a leadership role in educating physicians, policymakers, and the public about unique aspects of caring for older patients with cancer” • ASCO News Forum, Oct. 2006

3. A 99-year-old sprinter is one of the stars of the World Masters Games in Australia. Charles Booth carried the torch down an avenue of honour at the opening ceremony in Melbourne. The event has attracted more than 25,000 competitors aged between 24 and 99 from 97 countries. The athletics track and field competition is to feature many competitors in their 80s. They include former 400 metre world record holder Mike Johnston, who is 81. Weightlifting competitors include 90-year-old Vladimir Younger, who aims to beat relative youngsters to clinch gold. The squash event is expected to be dominated by 87-year-old Vic Hunt, the father of seven-times squash world champion Geoff Hunt. The state of Victoria hopes to gain a ?44.74 million boost from the games, which close on October 13.

4. CANCER IN THE ELDERLY G. Luiken, MD 04/29/08 Noon Conference

5. Neoplasia in the Elderly: dimension of the problem P.Boyle-Joint NCI-EORTC Meeting 1990, Venice: Prediction for 2004 >60% of all tumors occur in persons > 65 years >45% of all tumors occur in persons > 70 years

6. Predicting Surgical Outcomes

7. PACE morbidity

8. Conclusions II Hospital stay PACE variables associated with prolonged hospital stay: IADL (dependent) x 1.64 BFI x 5.08 No PACE variable correlated with Mortality (observed mortality small)

11. Keller, SM; ASCO 2006

17. It is estimated that by the year 2030, 20% of the US population will be > 65 yr • By 2020 the population will have increased 12% but because of the aging of the population the incidence of cancer in the overall population is expected to increase by 60% • The median age at which cancer occurs is 68 yrs • More than 60% of all cancers are dx’d in individuals >65 yr • Pt.s with cancer who are >65 are 16x more likely to die of their cancer

18. Biology • Telomere shortening and defective DNA repair mechanisms are common to both aging and cancer and may partially explain the higher incidence of cancer in the elderly • The functional decline begins at age 30 and is est. to occur at 1%/yr • Illness and medical interventions can change this process • Renin, aldosterone, DHEA, sex hormones, T3 decr. • Insulin, NE, PTH, vasopressin and atrial naturietic peptide increase • Decr. protein synthesis, loss of muscle strength and mascle mass occur • Loss of connective tissue and thinning of the skin lead to fragility of the skin, bruising, etc.

19. Decreased GI motility, decreased hepatic and renal function • Decreased CNS neurotransmitters • Immunologic dysregulation (multiple aspects from increased Ig levels but decr. antibody responses, decr. lymphocyte response to mitogens, etc.) • Marrow reserve is decreased • Increased susceptibility to infections

20. Pharmacology • Decreased volume of distribution Vd may result from a decr. in total body water and hyponatremia • Lower levels of albumin lead to higher levels of free drugs and increased toxicity • Anemia may also decr. volume of distribution Vd for drugs like etoposide and anthracyclines that bind to rbcs • Metabolism by P450 (CYP) enzymes in the liver is decreased and drugs that require these enzymes for metabolism or elimination should be used with caution

22. What are the advantages of a CGA • Useful for predicting complications and side effects from treatment • Estimating survival • Detecting problems not found by routine history and physical examination in the initial evaluation • Identifying and treating of new problems during the follow-up care • Improving mental health and well-being • Better pain control • UpToDate

23. evaluation of functional status • comorbid medical conditions, • cognitive status, • psychological state, • social support, • nutritional status • review of the medication list • UpToDate Typical CGA Includes the following:

29. Clinical Geriatric Assessment • Function: • ADLs (eating, dressing,continence, grooming, transfers, toilet function) • Instrumental ADLs (IADL): (use of transportation, $ management, shopping, laundry, and household chores, telephone) • Comorbidity: • Number and seriousness of comorbid conditions i.e. cardiac, pulm., renal, vascular, CNS (a low albumin level, Hb<12 have been associated with a decr. survival, and anemia has been linked to incr. risk for dementia, CHF and cardiac death)

30. Impact of Comorbidities on Survival • Comorbidities with high impact: • Cardiac arrest, CHF, COPD, CKD • Conditions requiring active tx; • Angina, arrhythmia, MI, valvular d., TI DM, prior cancer • Comorbidities with moderate impact: • Cardiac hx. (angina, MI, valvular d) • Conditions requiring active tx • ETOH abuse, anemia, asthma, DVT, dpression, HTN, HLP, liver d, mental illness, CVA or TIA

31. Geriatric Syndromes: • Dementia (30-40% of pt.s >80) • Depression • Delirium • Falls (1 or more/month) • Osteoporosis (spontaneous fractures) • Neglect and abuse • FTT • Socioeconomic Issues • Living conditions • Presence and capability of caregiver • Income • Access to transportation

32. Medication Review : • Number of medications • Drug-drug interactions • Nutrition: • Nutritional status and • Nutritional risk • Access to adequate nutrition

34. Treatment Approaches • Pain is consistently undertreated in the elderly (esp. in women and underserved minorities) • Pt.s may have an increased pain threshold • Identifying the source and severity of pain may be complicated by confusion and dementia and comorbid conditions may complicate or magnify pain issues • Persistent pain may contribute to depression and depression may amplify the pain (necessitating treating both pain and depression) • Older patients may be very sensitive to opioids and their use may aggravate cognitive function • Delirium and agitation are side effects of opioids • Sedatives may incr. agitation

35. Chemotherapy and Radiation Therapy • Oral cytotoxics are adequately absorbed • Renally excreted drugs (MTX, Bleo, CDDP, Cytoxan, Ifos) should be given with caution • Peripheral neuropathy may occur more frequently (vincristine, vinblastine, paclitaxel, oxaliplatin, thalidomide, revlimid,) • Cardiotoxicity (anthracyclines, i.e. Adria, DNR, Mitoxantrone, Epirubicin) • Mucositis is more common; 5FU, • Combined chemo/XRT is more toxic in the elderly

36. Special Considerations in Common Malignant Diseases • In the absence of substantial functional decline, cancers in the elderly should be treated in the same manner as in the young • The benefits for adjuvant chemotherapy for breast and colon cancer in the elderly are similar to those seen in younger patients • Chemotherapy may improve survival and QOL for elderly pts with extensive NSCLCa

39. Colon Cancer in the Elderly

40. More than 2/3 of all colon cancers develop in pt.s over 65 • Lesions are more common on the R and anemia is more common than pain • Surgery for possible cure or for palliation is appropriate • Because of the mortality and morbidity associated with emergency surgery in pt.s >70, palliative surgery should be considered even in advanced d. (to prevent obstr.) • Adjuvant chemo yields the same survival benefit for pt.s >70 as for those younger • Palliative chemo for adv. d. should be offered for the elderly as well as for the young • Screening colonoscopy q 10 yr up to age 85