ESMO Commentary: The variable access to best cancer care in Europe may affect clinical outcomes and survival in older patients

VIENNA, Austria – Cancer commonly occurs in old people. Results from EURECCA studies2 presented at the European Cancer Congress (ECC 2015) in Vienna, showed that this population of patients still suffer from variable access to treatment across European countries. As a consequence, clinical outcomes and survival rates may be poor. Today more efforts are needed to ensure elderly patients are properly treated, according to Professor Silvio Monfardini, Director of the Geriatric Oncology Programme at the Don Carlo Gnocchi Foundation in Milan, Italy.

Why does old age still influence access to the best care?

Monfardini: Cancer is a disease of old age, with patients aged 65 years and above making up 60% of the total population of cancer patients. But studies are lacking or at least only retrospective ones are conducted. Conducting a study in older patients requires more time because you have to collect information on all of the conditions associated with old age through a multidimensional geriatric evaluation and/or through close cooperation with geriatricians. Another limiting factor is physician bias. Sometimes general practitioners don’t think older patients can be usefully treated and do not refer them to oncology services. There is uncertainty about some therapies that have not been tested in older patients, but if they are sent to the right place the oncologists will know if treatment can be applied or not.

Finally, advanced age may be a relevant obstacle if a patient is not self sufficient and does not have the support of relatives or other caregivers. Cancer diagnosis and treatment requires many trips to the hospital and this is practically impossible for older patients with functional impairments to manage on their own.

What are the major discrepancies in treatment coming from the recent studies across Europe?

Monfardini: The EURECCA international comparison of treatment and survival in metastatic rectal cancer for patients over the age of 80 years revealed major discrepancies in the proportion of patients who received surgery and chemotherapy among European countries. Whether this is due to unequal access to optimal care or a different strategic approach remains to be determined.

Differences in the percentage of older patients with colon cancer receiving adjuvant chemotherapy and of older breast cancer patients being treated with adjuvant endocrine therapy among different European countries are reported in two further EURECCA studies. Probably this is due to a different strategic approach, but I am convinced that unequal access to optimal care may have had a role.

How could dedicated programmes change this scenario as the general life expectancy is increasing?

Monfardini: Guidelines for the management of older patients have been prepared by geriatric oncologists from the International Society of Geriatric Oncology (SIOG) on all solid tumours and haematological neoplasia as well as on specific issues related to treatment of older cancer patients. But these guidelines are primarily followed in institutions with geriatric oncology programmes. These programmes exist in just a small number of European countries. ESMO offers advice on how to care for older cancer patients, for example how to assess reserves and the use of targeted therapy.1

Clinical oncologists in Europe need to conduct prospective studies in older patients. Most of the valuable studies in older cancer patients have been conducted in collaboration with geriatricians, within the framework of multidisciplinary programmes for older patients. The strategy and hope for the future is to construct and extend to all cancer institutes specific activities dedicated to older cancer patients. This will increase the level of care and allow better research.

Cancer commonly occurs in older people and more efforts are needed to ensure they are properly treated. This includes establishing geriatric oncology programmes in all cancer institutes, adoption of guidelines for the management of older patients, and conducting prospective research. 

ESMO and others are putting more efforts into this. For example, educational symposia on cancer in the elderly are organised at ESMO meetings, providing a good first step to raise awareness of issues in this special population.

Notes

1ESMO advice:

http://www.esmo.org/Oncology-News/The-Impact-of-Personalised-Medicine-in-Elderly-Patients-with-Cancer

2Abstracts presented at ECC 2015, held 25–29 September in Vienna, Austria:

1808: Treatment patterns for older patients with non-metastatic breast cancer in four European countries – preliminary data from a EURECCA international comparison. M.Derks, the Netherlands. Sunday 27th September 2015 – 09:00-10:50 Proffered Paper Session HALL D1

P110 - 1323: Differences in proportion adjuvant chemotherapy are not associated with relative survival for stage II colon cancer patients aged 75 years and older – a EURECCA international comparison. A.J. Breugom, the Netherlands. P110 - Sunday 27th September 2015 – 16:45-18:45 Poster Session HALL C

P111 - 1324: EURECCA international comparison of treatment and survival in metastatic rectal cancer for patients over the age of 80 years. E. Bastiaannet, the Netherlands. P111 - Sunday 27th September 2015 – 16:45-18:45 Poster Session HALL C

Information contained in this commentary was provided by the interviewee.