Oncology treatment for seniors: a luxury?

The risk of developing cancer increases steadily over the course of a lifetime. Thus, 60% of new cancer cases occur after the age of 65 and approximately 60 to 70% of cancer-related mortality affects this age group.

With the aging of the population, particularly the baby boomers, we can expect to see an increasing number of elderly cancer patients in the coming years.

In addition, there are certain prejudices regarding the oncology of the elderly that probably explain certain delays in diagnosis and the implementation of aggressive therapy. These are essentially the trivialization of symptoms by the family and friends, the persistent belief that tumors evolve slowly in the elderly, the uncertainty of the benefits of treatment given the co-morbidities, the increased toxicity of therapies in the frail patient, and the guilt of the elderly patient with regard to the costs involved.

Faced with the increasing number of elderly cancer patients to be treated, and the societal and security pressure regarding the related health expenses, we must ask ourselves whether this type of treatment could be considered a luxury. This is certainly a luxury if the treatment is poorly targeted to the individual concerned, i.e. if a purely uniform biomedical management process is applied in this population characterized by its heterogeneity and polymorbidity.

According to oncologist Balducci, treatment of cancer in the elderly patient depends on the answers to three questions: will the patient die of cancer or with cancer? Will he or she suffer from complications from the cancer during his or her remaining lifetime? Will he/she be able to tolerate the proposed oncology treatment?

What evaluation?

The practice of a Comprehensive Geriatric Assessment ( [CGA]) can provide answers to these questions and help in decision-making.

This is a multidisciplinary assessment that includes evaluation of functional status, comorbidities, cognitive and mood status, social environment, nutritional status and a medication review. Studies have shown that CGA can detect unsuspected medical conditions that may significantly alter the response to oncology treatment in more than half of cancer patients over the age of 65.

Functional assessment refers to the ability to perform tasks of daily living. While the inability to perform an activity of daily living (e.g. dressing) is often obvious, the inability to perform a task related to the instrumental activities of daily living (e.g. managing medication) is less so. In elderly cancer patients, it has been shown that an inability to perform activities of daily living (ADL) is associated with increased one-year mortality, and that any inability to perform instrumental activities of daily living (IADL) predicts increased post-operative complications after cancer surgery, chemotherapy toxicity, and psychological distress.

The risks from co-morbidities (cardiovascular disease, diabetes, etc.) can sometimes outweigh the risks associated with cancer. An inventory of chronic diseases (half of the subjects over 65 years of age suffer from at least three chronic diseases) and geriatric syndromes (dementia, falls, depression, incontinence, polymedication, etc.) should therefore be carried out because of their known association with an unfavorable prognosis. To date, instruments for measuring comorbidities are limited to index scores adding up the various pathologies (without any screening tool being validated). Polymorbidity is mostly equivalent to polymedication. A drug review is essential in view of drug interactions and adverse side effects.

Among elderly cancer patients, 25% to 50% have cognitive impairment. Screening for dementia is therefore essential for all elderly cancer patients, given the uncertainty of possible worsening of memory problems during the administration of certain anti-cancer therapies.

According to a survey conducted by Fried on severely ill elderly subjects (notably cancer patients), 89% of them would refuse the proposed treatment if it would allow them to survive with cognitive problems!

Nutritional status must be assessed: involuntary weight loss and low body mass index (BMI) are poor prognostic factors. Nutritional interventions do not appear to have a positive impact on mortality, but they do improve quality of life and treatment tolerance.

Social isolation is an important predictor of mortality regardless of age and often leads to psychological distress and even depression in about 50% of elderly cancer patients. There is often an overlap between the symptoms of depression and those related to the side effects of treatment (sleep disorders, weight loss, fatigue, etc.).

Thus, before any therapeutic proposal, the systematic practice of a global geriatric evaluation in cancer patients over 70 years old. should make it possible to identify non-compliant medical problems and to classify patients into three categories: fragile, vulnerable or healthy (Tab. 1).

Conclusion

The comprehensive geriatric assessment helps to better target the physiological reserves and health status of the very heterogeneous elderly population before establishing an individualized therapeutic plan. In addition, it provides a common language of assessment for the family physician, oncologist and geriatrician.

The individualized treatment plan is also based on a shared decision in which the patient’s priorities are taken into account (e.g. absolute refusal to consider institutionalization).

From a certain age, the reduction of mortality is rarely an objective in itself, because for the elderly subject, it must be associated with the guarantee of a good quality of life (preservation of mobility and cognitive status). We should also mention that the elderly often seem more interested in knowing how they are going to die rather than when they are going to die, and they would like to discuss this a little more with professionals, especially with the doctor who is taking care of them!

By better implementing this type of management centered on the patient’s priorities, we could help a large number of elderly cancer patients to live their last months with an open approach to their death rather than undergo treatments often associated with disabling side effects, requiring most of the time a specific outpatient and hospital management, which isolates them from their usual environment (family doctor) and often maintains a false hope of prolonged survival, until the time of death.

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