Caring for Geriatric Oncology Patients: Clinical Considerations and Roles of the Geriatrician and Oncologist

INTRODUCTION

Cancer is a major cause of morbidity and mortality among older persons. In both men and women, the incidence of cancer begins to rise sharply at age 50 and peaks by age 80 (Figure).¹ As a result, 58% of all cancers are diagnosed in persons who are 65 years of age or older, and the median age of diagnosis is 65 years or older for many cancers, including colorectal, prostate, bladder, non–Hodgkin’s lymphoma, myeloma, and several forms of leukemia.¹ Moreover, cancer is the second (to heart disease) leading cause of death among persons in this age group.² Frequently, the management of the older patient with cancer will be a collaborative effort between the primary care geriatrician and the oncologist. In this article, some of the key issues in this collaborative effort are outlined. These include prognosis, comorbidity, decision making, and interactions between physicians providing concurrent care. Finally, suggestions are provided for optimizing the management of older patients with cancer.

PROGNOSIS

The impact of a cancer diagnosis on older persons is more complicated than in younger persons. Patient characteristics (eg, life expectancy, baseline functional status, comorbidity) that may be unrelated to the malignancy, the natural history of the tumor in older persons, and the response of the older patient to treatment of the tumor all affect the course of treatment and eventual outcomes. With advancing age, life expectancy decreases. For example, a 75-year-old man can be expected to live 10.1 years, whereas an 85-year-old man will be expected to live only 5.6 years.³ Moreover, life expectancy is influenced substantially by functional status.⁴ Such wide variations in prognosis independent of cancer must be brought to the individual level when making decisions about whether or not to treat the malignancy, the type of treatment to be employed, and the goals of therapy.

A second key factor in prognosis is the type of tumor (primary site) and stage of disease. Some tumors (eg, prostate, breast) generally have less dramatic impact on survival than others (eg, ovary, lung).¹ For certain malignancies such as breast cancer, the biology of the tumor is different and the prognosis is better in very advanced age.⁵ As a result, some cancers (eg, breast, prostate, chronic myelogenous leukemia, and chronic lymphocytic leukemia) may assume the status of chronic diseases in older persons. Other malignancies like lung cancer have very little impact on survival if detected early and treated with successful surgery.

The stage of a tumor is also a major factor influencing survival. For example, 8-year survival for Stage I breast cancer exceeds 90%, whereas for Stage IV disease it is approximately 10%.¹ Finally, patient response to cancer treatment may vary by age. The reasons for differential response include treatment plans that deviate from protocols with demonstrated efficacy in younger populations, inability of older persons to tolerate the side effects of treatment, and less responsiveness of the tumor in older persons. Unfortunately, few studies have been conducted that can provide further insight on treatment responsiveness in older persons.

Older persons have frequently been excluded from clinical trials aimed at establishing effective doses (Phase II) and determining efficacy (Phase III). In a recent review of National Cancer Institute–sponsored trials, only 32% of participants were over the age of 65, even though this age group represented 61% of the incident cancers studied in these trials.⁶ Some efforts have been made to integrate prognostic elements for an individual patient so that providers can communicate the risks of outcomes, the likely effect of treatment, and the risk of adverse effects. One example that focuses on adjuvant therapy for breast and colon cancers can be found at www.adjuvantonline.com. Nevertheless, these prognostic estimates are limited by the amount and quality of data available.

COMORBIDITY

Most clinical research focuses on studying a single disease, and the findings are most valid when research participants have only that disease. By selecting participants with no comorbidities, the effect of treatment on the natural history of the disease can be examined without consideration of other diseases on the outcomes of interest. Despite the scientific advantages of this approach, rigorous selection criteria limit application of the findings beyond the specific population studied. This problem is especially important when considering treatment decision making in older persons who usually have at least one chronic disease in addition to cancer. For example, the decision about using doxorubicin for breast cancer may vary depending upon whether the woman also has heart failure. Moreover, the severity of the comorbid disease (eg, mild vs end-stage kidney disease) is also a consideration.

Recently, the concept of comorbidity is being extended beyond overt disease to include subclinical processes that have prognostic value, such as pre-diabetes or inflammation. Age-related physiologic changes (eg, declines in kidney function and increases in the amount of body fat) must also be considered. Finally, the issue of multiple drugs (including cancer treatments) used to treat comorbid diseases and the potential for drug–drug and drug–disease interactions must be considered. Comorbid illnesses represent competing causes of mortality. A study of 936 patients with breast cancer demonstrated that those with more than three major comorbidities had a 20-fold increase in non–breast cancer mortality and a fourfold increase in all-cause mortality compared to those individuals with fewer comorbid illnesses.⁷ In addition, a study of 1610 patients with colon cancer, the risk ratio for mortality at 2 years was 1.5 for those individuals with more than five comorbid illnesses, even when controlling for age, stage of disease, and gender.⁸

DECISION MAKING

Cancer treatment options are frequently complicated. Often there is no single “best choice.” Decision making requires incorporation of individual preferences and values, as well as the benefits, harms, and costs of different treatment options.⁹ Other considerations include short-term and long-term quality of life, personal risk and risk tolerance, and treatment response uncertainty.^10,11 One of the physician’s roles is to solicit patients’ values regarding treatment options and then incorporate these into the decision-making process.¹² However, such discussions require time that is usually beyond the amount allotted for office visits in most practices.¹³

Time constraints are magnified in caring for older individuals who commonly have visual, hearing, or cognitive impairments.¹⁴ The issues described above (prognosis, comorbidity, incomplete information about the effectiveness of treatment) are all important considerations in cancer treatment decision making for older persons. In addition, patient preferences assume a central role in the decision-making process. Among younger persons, the focus is usually on extending the quantity of life (ie, survival or disease-free survival). In contrast, the quantity of life remaining for older persons, particularly the very old, is more limited and may not be affected substantially by treatment. Hence, the focus frequently shifts toward quality of life and whether one treatment or another will lead to a more desirable state for the patient.

Among the important considerations are pain and other symptoms, bother associated with therapy (eg, toxicity and convenience of treatments), and burden on family. The need for older patients with cancer to participate in the decision-making process is derived from studies that have shown that: (1) many older patients want to be involved in treatment decision making,¹⁵ and (2) treatment approaches and goals of therapy differ between younger and older patients with cancer.¹⁶

More important, the care of older patients with cancer frequently needs to be individualized based on the clinician’s experience and the patient’s preferences because accurate estimates of benefit and harm are not available.¹⁷ Older individuals must consider the expected outcomes, which are often based on studies in other populations, according to their own values and preferences as the final step for making informed decisions.¹⁸ Complicating the decision-making process is the inability of some older patients to participate because of cognitive or physical impairment. In such cases, surrogates must be involved in the process. Although surrogates may have specific instructions from the patient for some decisions (eg, whether to resuscitate) and may know the patient’s values, they rarely have discussed decisions about specific future cancer treatments.

INTERACTIONS BETWEEN PHYSICIANS PROVIDING CONCURRENT CARE

Geriatricians and oncologists both provide substantial care for older patients with cancer. However, there are currently approximately 7600 board-certified geriatricians, which is roughly half the number of board-certified oncologists and far short of the estimated current need for 14,000 geriatricians.¹⁹ As a result, most older patients with cancer do not have a geriatrician involved in their care. Rather, primary care physicians (often family physicians and general internists) commonly co-manage patients with oncologists. Nevertheless, many of the principles described below for collaborative care are applicable. In some instances, older patients with cancer see multiple specialists, and no primary care physician is involved to oversee the care. In these cases, oncologists are the primary providers for older patients with cancer when their malignancies are active, even though it is not always comprehensive care.

As the number of older persons increases to 70 million by 2030, the discrepancy between needed and available geriatricians will widen.¹⁹ Thus, oncologists can expect to play an increasing role in the care of older Americans. In response to the increasing recognition of the importance of cancer in older persons, a new discipline of geriatric oncology has been established, and ten combined fellowships have been established nationwide with support from the American Society of Clinical Oncology and the John A. Hartford Foundation.

The American Board of Internal Medicine has established requirements that allow fellows to become eligible for certification in both specialties after 36 months of training. Both the American Geriatrics Society and the American Society of Clinical Oncology have featured presentations on geriatric oncology at their annual meetings. Nevertheless, the numbers of physicians who will receive formal training in both specialties will be few, and graduates will likely be based at academic health centers. Accordingly, the bulk of geriatric oncology care will rely on the collaboration between geriatricians (and other primary care physicians) and oncologists.

Although the goals and expertise of geriatricians and oncologists have much in common, there are also some notable differences (Table I). Both utilize interdisciplinary team care that often includes a nurse, a social worker, a nutritionist, and a pharmacist. Social workers (either on oncology or geriatrics teams) are particularly valuable in addressing caregiver issues (eg, stress/burden, assisting with in-home and community resources), though physicians and other members of the team must also be attentive to these issues. Geriatrics teams tend to be larger and reflect the rehabilitation needs that are common among older persons, particularly among those who have been hospitalized. Hence, geriatrics teams may include occupational and physical therapists, speech therapists, psychologists, and dentists. Both geriatricians and oncologists recognize the importance of function and quality of life.

Traditionally, oncology research has placed greater emphasis on outcomes such as survival, disease-free survival, response rates, and time to progression. In contrast, quality of life as a primary outcome has been common in geriatrics research. With the advent of targeted therapies and their use in more advanced disease stages, oncologists have increasingly recognized the value of incorporating quality of life as an outcome measure. In clinical care, oncologists tend to focus on whether the functional limitation and quality of life is directly due to the cancer and whether functional impairment will limit the ability of the older patient to tolerate treatment. Some geriatric issues such as incontinence, which affect both function and quality of life, are usually not addressed by the oncologist.

Typically, the geriatrician will establish the cancer diagnosis and follow the patient throughout his or her course. Nevertheless, there are stages in managing the patient’s cancer where the oncologist (and other specialists) will assume a primary role (Table II). When more than one physician is providing care, such care needs to be coordinated among providers. In general, the key issues are which provider manages the patient’s comorbid conditions, who should the patient call first if there are problems (this may vary depending upon the type of problem), and which inpatient service should care for the patient if hospitalization is necessary. In addition, issues such as end-of-life discussions and preferences for resuscitation are often neglected due to a lack of clear designation as to which provider is responsible for addressing these issues.

Frequently, the primary care geriatrician will reassume the lead role in providing end-of-life care. The oncologist may, however, play an important role in providing a realistic portrayal of prognosis during the course of treatment, and indicating to the patient and geriatrician when the potential of meaningful response to treatment has been exhausted. Responsibilities at this point include conveying a realistic picture of the future, managing symptoms, helping coordinate resources, and providing emotional support. Discussions about hospice care are an integral component and can be raised by either the oncologist or geriatrician.

Although most geriatricians follow their patients throughout hospice care, oncologists often allow the hospice director to manage their patients after referral. Other examples of clinical issues where oncology and geriatrics may interact include management of oncologic emergencies and complications of chemotherapy (eg, hypertension caused by bevacizumab). Collaborative care across the two disciplines is especially important in the management of cancer in the frail older patient. Regardless of who is taking a lead role in providing care for the older patient, communication among treating physicians is critical.

With advances in technology, e-mail communication (with adequate safeguards for patient privacy) is increasingly being utilized. Sometimes telephone communication may be more efficient if the issues are complex and, occasionally, an in-person meeting between the oncologist and primary care geriatrician is needed. Usually, in-person communication occurs in the context of preparing for or conducting a family conference. Good communication between geriatric and oncologic providers is also essential to provide consistent and reliable information to the patient.

Cancer-related decision making is often difficult. Patients are faced with choices that are risky with uncertain outcomes, which often causes “decisional conflict.”¹² These choices require individuals to make value judgments about the losses and gains from treatment, while recognizing that they may regret their decision in the future, or have “decisional regret.” Both decisional conflict and decisional regret can increase when patients receive different perspectives and advice from their geriatricians and oncologists. By discussing the treatment options and rationale with the primary care provider prior to making the recommendation to the patient, such mixed messages can be avoided.

CONCLUSIONS

Caring for the older patient with cancer requires the expertise of both the geriatrician and the oncologist. When optimally coordinated, the care provided is comprehensive, continuous, and seamless across providers, guided by evidence, appropriate for the individual patient, and compassionate. Improvement of cancer care for older persons will require better understanding of the biology of cancer in this age group, development of new treatments with increased effectiveness and less toxicity, enhanced decision-making methods and approaches to communication, and well-organized health care systems.