Cancer in the elderly
Research fails to keep up with increasingly ageing population
New research showing that almost half of 13 000 patients with head and neck cancers had other health-related problems at the same time is one of the presentations in a special session at the 31st Conference of the European Society for Radiotherapy and Oncology (ESTRO 31). This year the ESTRO Conference is held in parallel with the World Congress of Brachytherapy in Barcelona, Spain from May 9-13. The session highlighted the effect of the demographic changes caused by an increasingly ageing population.
Dr Charlotte Rotbøl Bøje, from the Aarhus University Hospital, Denmark, presented the analysis of co-morbidities in 12 956 patients registered in the DAHANCA database of all Danish head and neck cancers diagnosed between 1992 and 2008. She found that 44% had at least one co-morbidity.
It is essential that doctors make a proper assessment of co-morbidities when deciding on the correct treatment for elderly patients with head and neck cancer. These patients are often long-term users of tobacco and/or alcohol, which, besides having a carcinogenic effect, can also cause other medical disorders.
It has never been more important to find evidence-based treatment strategies for elderly patients
The analysis by Dr Rotbøl Bøje and Professor Jens Overgaard found that the most common co-morbidities were cerebrovascular disease (11%), chronic pulmonary disease (11%), and cardiovascular disease (10%). Increasing age was significantly associated with co-morbidities, although there was no difference between genders. Survival rates and risk of death were also strongly associated with co-morbidities. The median age of the patients was 62; the youngest was 10 and the oldest 100. Men made up 73% of the total cohort. Information on co-morbidities was obtained from the National Patient Registry, which contains discharge diagnoses from all Danish hospital admissions and outpatient visits.
The analysis has shown how important it is to take a multidisciplinary approach to cancer in the elderly, particularly when recruiting them into trials. The design of trials needs to take into account other medical conditions, and there is a need for trials that focus on both, fit and frail elderly patients.
There are some problems in treating older patients with radiotherapy, but this is not only due to their chronological age but also to the fact that there is more co-morbidity among the elderly. This can affect quality of life and can lead to treatment interruptions and hospitalisation. An accurate assessment of co-morbidities before starting treatment in elderly patients is essential in order to decide on the best and most appropriate treatment for this patient group.
Lack of clinical trials in elderly patients
In developed countries, half of all cancers already occur in patients aged 70 and over, and by 2050 the majority of older people will live in developing countries. Yet the session highlighted not only the problem of co-morbidities but also how little research is conducted specifically into cancer patients over the age of 70 and the lack of clinical trials for this age group.
In another presentation, Professor David Sebag-Montefiore, from St. James's Institute of Oncology, University of Leeds, UK, provided further evidence of the need to undertake such an assessment in older patients. Further research is needed to determine the optimal treatments for ageing population and their associated co-morbid conditions. There is a need for balancing right and avoid inappropriate under- and over-treatments.
Doctors currently rely on clinical experience, knowledge of the complete medical history of the patient, and an assessment of the severity of co-morbidities when deciding whether a patient is sufficiently fit to undergo a particular treatment. But this is not always enough, and further studies are required to help clinicians define the best way of selecting patients for specific treatment.
Although a patient's treatment should not be determined purely on the basis of age, it is needed to take into account the fact that the length of treatment, and the travel time to cancer centres can weigh much more heavily on an older person. And although most trials do not have an upper age limit, many studies exclude patients with co-morbidities and usually the median age in such trials is significantly lower than that of the general population.
Best evidence-based treatment to an ageing population
Chemotherapy also poses problems for older people, according to Dr Laura Biganzoli, from the Hospital of Prato, Istituto Toscano Tumori, Italy. Recommendations for treatment are largely based on limited retrospective subgroup analyses from larger trials and the extrapolation of study results from younger patients. This is clearly inappropriate, since breast cancer biology differs in older patients, treatment tolerance varies, and there are the ever-present problems of co-morbidities.
Only two published studies have prospectively evaluated the role of chemotherapy in elderly breast cancer patients, and a retrospective study has found a higher risk of treatment-related deaths in older women. In radiotherapy under-treatment after breast conserving surgery is common.
The Cancer and Leukaemia Group (CALGB) trial 9343 showed that not giving radiotherapy to women with early stage breast cancer with oestrogen receptor positive tumours who had breast conserving surgery and were taking tamoxifen had no impact on survival but was associated with an increased risk of local relapse. The authors concluded that it was a reasonable choice to omit radiation in women in such a group of patients aged over 70. However, it is important to discuss these data with patients and that the final decision should take into account their individual preferences.
Dr. Biganzoli's hospital unit works in close collaboration with geriatricians in order to carry out a proper pre-treatment evaluation of elderly patients. They are also running clinical trials to identify accurate screening tools for geriatric impairment and to find biomarkers of frailty.
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