'But we are already geriatric oncologists' - why older patients need a special approach (a view from a UK Cancer Centre.) Dr A Cree, Dr L Pemberton, Dr T ...
'But we are already geriatric oncologists' - why older patients need a special approach (a view from a UK Cancer Centre.) Dr A Cree, Dr L Pemberton, Dr T Hawthorne, Professor R Cowan, Dr A Choudhury Cancer incidence increases in the elderly, with over half of cancers in the United Kingdom (UK) diagnosed in patients over the age of 70 years. Over the last decade, the number of people aged over 85 years has increased by a third to 1.5 million1. In our centre, 46% of patients undergoing radiotherapy last year were over 68 years old with 10% over the age of 80. Older patients are a heterogeneous group ranging from very fit to frail. Unlike some other European countries, there is no formal geriatric oncology structure within the UK. However, the UK system has some innate strengths. All oncologists undergo training in general internal medicine prior to specialisation and clinical oncologists are trained to deliver radiotherapy, radio-isotopes and chemotherapy. This provides clinicians with a variety of skills and expertise to assess and treat older patients without a specific geriatric oncology programme. The other strength is that every patient with a potential cancer diagnosis is discussed in a structured multi-disciplinary team meeting or tumor board which includes a non-surgical oncologist. This allows all possible treatment options to be considered even for frail older patients. An audit of the 78 patients aged 80 or over undergoing adjuvant or radical radiotherapy in our institution in January 2016 showed that it was well tolerated with 98% of patients completing treatment and a 90 day mortality of 4%. This may suggest that the UK does not require specialist services for older patients but there is significant room for improvement. This has been highlighted in the national cancer strategy2 and a task force has been set up by Macmillan, a national cancer charity. Outcomes for patients over the age of 75 are significantly worse than for younger patients and are not improving. Older patients are less likely to receive radical surgery or radiotherapy treatment with 25% of patients between 65-69 years treated with radiotherapy compared to 16% between 80-84 years2. Increasing rates of frailty in older patients explain some but not all of these differences. Curative radiotherapy is of especial benefit to those who do not have other treatment options; however, even low grade side-effects may have a significant impact on older patients who may have poor reserve. Advanced radiotherapy techniques such as stereotactic ablative body radiotherapy (SABR) for early lung cancer have reduced toxicity and improved survival in those patients who are unfit to undergo surgery3. Selecting the correct patients for aggressive treatment is a challenge, research in this age group is limited and there are few trials looking at comprehensive geriatric assessment in patients undergoing radiotherapy4. Treatment decisions especially those surrounding the use of concurrent chemo-radiotherapy are often based on meta-analyses showing little
benefit in very small subgroups of older patients5. Currently clinical assessment of patients is not standardised and physical, social and cognitive problems may not be identified. Preliminary research at our institution showed that 12.8% of patients with head and neck cancer over the age of 75 years had cognitive impairment. Our institution has areas of best practice. A Macmillan Dementia Nurse Consultant leads education and supports patients during treatment. A multi-disciplinary group has been developed to focus both research and service improvement in this area. Our aims are to improve selection of patients for treatment, ensuring that patients are not excluded on grounds of age, but also that they are well prepared and supported to allow successful completion of therapy. As an oncologist near the start of my career I know that I will see more and more patients in their 80s and 90s and am convinced that we can do better. References: 1. Office for national statistics. Population Estimates for UK, England and Wales, Scotland and Northern Ireland: mid-2015 2. Independent Cancer Taskforce. Achieving world class cancer outcomes. A strategy for England 2015-2020 3. Stereotactic Ablative Body Radiation Therapy for Octogenarians With Non-Small Cell Lung Cancer Takeda, Atsuya et al.International Journal of Radiation Oncology • Biology • Physics , Volume 86 , Issue 2 , 257 - 263 4. Review of current best practice and priorities for research in radiation oncology for
elderly patients with cancer: the International Society of Geriatric Oncology (SIOG) task force I. H. Kunkler, R. Audisio, Y. Belkacemi, M. Betz, E. Gore, S. Hoffe, Y. Kirova, P. Koper, J.-L. Lagrange, A. Markouizou, R. Pfeffer, S. Villa On behalf of the SIOG Radiotherapy Task Force Ann Oncol (2014) 25 (11): 2134-2146 5. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): an update on
93 randomised trials and 17,346 patients; Pignon JP, le Maître A, Maillard E, Bourhis J, MACH-NC Collaborative Group; Radiother Oncol. 2009;92(1):4.
