Cancer is primarily a disease of the elderly and very old. Special characteristics of this age group such as multimorbidity and polypharmacy place high demands on the treatment team. Close interdisciplinary cooperation is necessary – also involving family caregivers.
Cancer is primarily a disease of older people. The median age at diagnosis of cancer is 67 years. Approximately 42,000 new cases in Switzerland in 2012 involved people older than 65 years in about 60% of cases. Particularly striking is the increase in cancer cases in very elderly people over 75 years of age (Fig. 1). Thus, the majority of oncologists and nurses inevitably work in the field of geriatric oncology – with the comorbidities and problems typical of old age. Especially the care of the very elderly (according to the WHO definition persons over 75 years of age) represents a challenge to oncological competence and requires close interprofessional cooperation.
Nevertheless, “age” should not be considered solely as a chronological phenomenon; rather, a person’s “biological age” is the focus of oncological decisions. Thus, a chronologically older “fit” individual in good general health and without comorbidities may be equivalent to a much younger age cohort with respect to oncologic treatment decisions.
Special features in the care of older people with cancer
In clinical trials, the elderly usually show the same chances of success in terms of response and survival as younger people when standard therapy is used. Accordingly, older people usually have the same hopes and expectations of therapy. Nevertheless, especially the very old are in many ways more vulnerable to adverse effects of cancer therapy in everyday life than clinical studies suggest (elderly and very old are underrepresented or positively selected with respect to low comorbidity).
Impaired organ functions: With increasing age, organ functions of the heart, liver, lungs and kidneys, among others, are usually impaired, which is not always immediately clinically apparent. Frequently, already impaired renal function or heart failure only becomes manifest under the burden of therapy. A “normal” serum creatinine may already represent a significant limitation of glomerular filtration rate (GFR) in the very elderly.
Loss of muscle mass (sarcopenia): Loss of muscle mass (sarcopenia) is prevalent in the very elderly and is not necessarily associated with weight loss or low BMI. Sarcopenia is often underestimated in clinical practice, but limits the physical reserves and resistance or resilience of very old people.
Altered pharmacology: Together with increasingly impaired organ functions, a shift in body mass in favor of a higher proportion of fat leads to a fundamentally altered pharmacology in the elderly and very old. Thus, the same dose of a cytostatic drug relative to body surface area can result in many times the drug exposure (“area under the curve”, AUC) in the very elderly compared to the younger.
Multimorbidity: With increasing age, frequent comorbidities such as cardiovascular diseases, diabetes mellitus, chronic renal insufficiency, etc. limit the possibilities of oncological therapy. The common hearing loss limits communication and further complicates care. In cases of severe comorbidity and limited life expectancy, the potential benefit of oncologic treatment must be weighed against its immediate toxicity and potential loss of quality of life on an individual basis.
Polypharmacy: The majority of older people with cancer receive five or more drugs at the same time and are therefore at higher risk of adverse drug reactions as well as a significantly increased risk of drug interactions [1]. The changing pharmacology of older people and a frequent practice of non-prescription and/or complementary self-medication reinforce this effect.
Cognitive impairment: The rate of latent or manifest cognitive impairment is increasing in the very old, making it difficult to communicate complex oncological contexts as well as to actively engage in an oncological therapy concept. Complex medication regimens and the frequent change of medications, e.g., during the transition from outpatient to inpatient care, also regularly overwhelm the ability to comply.
Functional status and social inclusion: limitations in independence and lack of social inclusion are common among older people. If everyday life could just be managed so far, the discomfort of cancer and the adverse effects of oncological therapies not infrequently lead to decompensation and loss of independence (Fig. 2).
Concept of frailty (“frailty”)
Frailty as a summary term for the above-mentioned limitations and as a conceptual representation of the particular vulnerability and reduced resilience of very old people to stresses is referred to as “frailty” in Anglo-American usage. Their importance is increasingly recognized, especially in oncology [2,3]. The lyric line “Don’t push me ’cause I am close to the egde” from the rap song “The Message” describes the concept almost perfectly. The assessment of the extent of frailty by means of standardized classifications has prognostic significance and must necessarily be included in oncological therapy planning.
“Comprehensive Geriatric Assessment.
The estimation of specific limitations in very old cancer patients with standardized tests has been “borrowed” from geriatrics and has been modified for oncology. The goals of a Comprehensive Geriatric Assessment (CGA) are outlined in Overview 1. A CGA is a multidimensional assessment of an elderly and/or very elderly person (Tab. 1) . In addition to the time-consuming procedures mostly used in geriatrics, there are various short versions that can be used well in everyday oncology practice [4,5].
Specifics of selected oncological entities
Specific recommendations for the treatment of common oncologic entities such as prostate carcinoma, breast carcinoma, lung carcinoma, and colon carcinoma have already been published [6]. As a rule, the elderly and very elderly in good general health benefit from treatment to the same extent as younger patients. However, the therapy of patients with reduced general condition and/or comorbidities must be individually adapted. This is where a CGA is helpful. Routine screening for cancer is controversial in the elderly and very old and, like adjuvant therapies, must be weighed against remaining life expectancy [7]. Nevertheless, the elderly and very elderly in good general health may well benefit from adjuvant therapy [8]. Similarly, palliative tumor therapy can improve survival and quality of life to a comparable extent as in younger people.
Specifics of selected hematologic diseases
One of the common challenges in treating cancer is to apply the right therapy to the right patient at the right intensity. This is especially true for the elderly and the very old. The decision is complex and must take into account both the tumor entity and a person’s individual situation. While the majority of the elderly and very old with acute leukemia die unchanged from the disease, a variety of new drugs are available for the treatment of chronic lymphocytic leukemia, lymphomas, myelomas, and myelodysplastic syndromes that can be used successfully in the elderly with an acceptable side effect profile [9–11].
Challenges in nursing care
The greatest challenge in caring for the elderly and the very old is for the caregivers and family caregivers. Because cancer patients are mostly cared for on an outpatient basis, the burden on family caregivers in particular is often not recognized [12]. Dependencies in personal care and daily activities, an increased incidence of incontinence, falls, and delirious reactions as adverse effects of oncological therapies, and the consequences of hearing loss or preexisting cognitive impairment (e.g., in taking medications) place caregivers and family caregivers squarely in the center of care for this patient group. This requires nursing professionals, as well as other professions, to be appropriately qualified in both oncology and geriatric care [13]. When elderly tumor patients are co-cared for by family caregivers, it is essential to integrate this fact into the therapy concept from the very beginning.
Summary
Advances in oncological diagnostics and therapy have not yet reached the elderly and the very old to the same extent as they have for younger people [14]. Both overtreatment and failure to exhaust reasonable treatments are common and lead to preventable morbidity and mortality. The special needs of older and very elderly people must therefore be given greater consideration in everyday clinical practice. Close interprofessional care by oncologists, geriatricians, nurses, physical therapists, and social workers in dedicated teams focused on cancer in the elderly and very old is still rare.
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InFo ONCOLOGY & HEMATOLOGY 2017; 5(4): 33-36.
