Reed and R. I was looking at Mrs T — all 45 kilos of her — with somewhat puzzled thoughts. I had prescribed her capecitabine at very prudent doses, in view of her year-old kidneys and physiology. Her pain was improving and her chest mass was shrinking, as were her lung metastases… What was the secret of that response? Was her sarcopenia altering drug distribution? Was she absorbing more drug than average? Or was her tumor exquisitely sensitive to fluoropyrimidines?
Yet, there are fields where quite a lot remains to be learned. That ought to let us wonder how relevant data acquired in patients in their 60s are to a nonagenarian. Fortunately, geriatric oncologists have been stepping up to the task and have gen- ated data to help us to treat such patients. Authors: A. Balducci H. Intended for medical oncologists and health care professionals involved in managing older patients with cancer, this book presents recent developments in geriatric assessment and in cancer management for the older adult. Anyone who is diagnosed with cancer receives a frightening blow, and in many cases the diagnosis is accompanied by a bewildering array of treatment choices.
In this invaluable book, Dr. Richard C. Frank offers comfort and help to cancer patients, their families, and their caretakers. Frank empowers patients by unlocking the mysteries of the disease and explaining in plain language the ways to confront and combat it. An award-winning medical oncologist recognized for his humanitarian approach as well as his research accomplishments, Dr.
Frank understands that cancer patients and their families need insight into the disease along with a sense of control. He therefore addresses these vital topics: what cancer is and how it spreads; how cancer treatment strategies are chosen; how cancer-fighting drugs work to shut down the growth of the disease; which factors affect a patient's prognosis; how patients can visualize cancer treatments at work in the body and why this is helpful; and, how to deal with 'uncurable' cancer.
With a wealth of patient case histories, helpful coping strategies from cancer survivors, and up-to-date information on useful resources, "Fighting Cancer" is a book cancer patients and their loved ones can turn to with confidence and hope. Anemia in the elderly, known as the silent epidemic, afflicts 3 million people in the U. This reference, complete with the most recent findings, answers all the crucial questions regarding anemia in the elderly.
As the incidence and prevalence of blood disorders increases with age, these conditions are a heavy burden on healthcare systems. Blood Disorders in the Elderly will provide hematologists, geriatricians and all clinicians involved in the care of patients with blood disorders with clear clinical advice on the diagnosis and management of these conditions. The origin of the CGA dates back to the s by Dr. Marjory Warren in the United Kingdom, who noticed a need to better manage older patients in the hospital who were bedridden and chronically ill [ 49 ].
She developed one of the first geriatric units to help mobilize these patients to undergo proper medical and rehabilitative care, thereby paving the way for a more systemic means of evaluating geriatric patients. A CGA involves a methodical approach of in-depth evaluation that includes an assessment of four health domains: physical health, functional status, psychological well-being, and socioeconomic factors [ 6 ]. Many screening tools and questionnaires can be used to assess these different health domains summarized in Table 1 , although not all of them are necessarily required to perform a thorough CGA.
The use of such a systematic way to conduct a full geriatric assessment has utility in predicting survival outcomes among older patients undergoing cancer treatment [ 50 ]. For instance, better-performing older adults had improved survival following surgery for breast or colorectal cancers, whereas poorer-performing older adults had a higher postoperative mortality risk [ 50 , 51 ]. Risk-stratifying patients based on a CGA may uncover certain parameters e. In radiation therapy, conducting a CGA has the potential to predict side effects and tolerability to radiation.
A recent Turkish study found that certain parameters measured in the CGA, such as low vitamin D levels and slower 6-meter length gait speeds, are associated with postradiation esophagitis and emesis, respectively [ 53 ]. Performing a CGA can be time consuming and resource intensive, and the use of these tools may require additional training.
Several abbreviated screening tools have been proposed which identify patients who would likely benefit from a full CGA Table 2. Each of the tools has undergone assessment of its sensitivity and specificity [ 41 ]. Because of their varying rates of sensitivity and specificity, there is ongoing debate on whether these screening tools can be used alone or in conjunction with a full geriatric assessment [ 41 , 55 ].
Despite its wide variation in sensitivity range, direct comparisons between G8 and other screening tools show that G8 performs at a significantly greater or equal sensitivity [ 41 , 43 ]. G8 may be the preferred screening tool in a radiation oncology setting, given its performance and efficiency. Frailty is a well-studied geriatric syndrome considered highly relevant in cancer treatment and specifically in radiation therapy. As patients age, changes in physical health and functional abilities become increasingly complex and thereby cannot be easily attributed to a single underlying clinical condition such as cancer.
A unifying factor that can explain these multifaceted changes is the concept of frailty, which is defined by geriatricians as a vulnerable, age-related state in which one is less able to maintain homeostatic equilibrium, resulting in unfavorable outcomes such as falls and disability [ 6 , 18 , 58 , 59 ]. Phenotypically, the frail patient will exhibit a range of manifestations, such as loss in energy, physical strength, and weight, and inability to perform common functional tasks. In recent years, frailty is appreciated more broadly as a multidimensional concept of illness spanning biological, physiological, psychological, and social domains of the older adult [ 60 — 62 ].
The prevalence of frailty in the geriatric population is unclear. A systematic review by Collard et al. This wide range is attributed to the observation that a proportion of the studies defined frailty solely as a physical phenotype, which had a weighted prevalence of 9.
Several metrics have been proposed to quantify the degree of frailty in a patient [ 64 ]. The two most prominent scales are the CGA-based Frailty Index FI , which assesses the accumulation of deficits in various areas spanning physical symptoms, psychological symptoms, functional abilities, and behaviors [ 16 , 17 ], and the Fried Frailty Index FFI , which addresses frailty as solely a physical phenotype Table 3 [ 18 ]. Generally, not one tool is preferred over another, as each evaluates complementary aspects of the health and functional status of geriatric patients, which explains the wide prevalence of frailty in the systematic review by Collard et al.
Assessing frailty has importance in preparing patients for cancer treatments and radiotherapy. Frail patients are more likely than nonfrail patients to exhibit more side effects or have complications from both chemotherapeutic drugs and radiotherapy treatments and at the same time have less functional capacity with which to overcome these adverse effects. For a radiation oncologist, the construct of frailty in older patients can be considered a measure of functional reserve.
Management of lung cancer in older adults.
In this context, patients identified as frail may be less likely to recover from radiation treatments compared to their younger counterparts. The radiation oncologist can consider utilizing frailty to help better evaluate the older patient when planning their treatments. Radiotherapy-related fatigue was better predicted by the Fried frailty score than other assessments such as the Karnofsky Performance Status. Understanding the risks and toxicities associated with frailty during cancer treatments may help the older patient withstand and recover from the effects of chemotherapy and radiotherapy [ 70 ].
Frailty is a formal construct in geriatrics. In oncology, an analogous concept is that of functional reserve. Management of frailty relies first on its proper diagnosis and second on an understanding of how expected toxicities arising from cancer treatment might precipitate an event leading to an adverse outcome in a frail patient such as a fall as in the case of the patient described in the above vignette. Several management options exist for health conditions and treatment complications that might result or get worse from frailty existing at baseline.
These include pharmacologic interventions for sarcopenia, cachexia, and nutritional deficits [ 71 — 73 ] and exercise interventions [ 74 ]. Overall, management should be multidisciplinary and involve physical therapists, dieticians, nurses, caregivers, geriatricians, oncologists, and radiation oncologists [ 75 ].
Radiotherapy is an important anticancer modality and sometimes the treatment of choice for patients regardless of age or comorbid condition for example, prostate cancer. A decision to pursue radiotherapy requires a full comprehensive understanding of the goals of treatment, individual patient characteristics, and the predicted tolerability to the radiation treatment itself. Clinicians may need to be extra careful of issues or problems that might arise during radiation treatment in the older individual. These include toxicities from radiation, treatment-related burdens persisting after radiation, and synergistically related toxicities resulting from combined chemoradiation.
Older adults are susceptible to the same toxicities of radiation that affect their younger counterparts [ 78 ]. In general, radiation can cause irreversible damage to cells and tissues in the human body, resulting in acute injury manifesting a few weeks after radiation treatment, or long-term reduction in organ function manifesting months or years after [ 78 ]. Older adults, given their likelihood of having organs worse in function, are presumably more vulnerable to the toxicities of radiation therapy.
Interestingly, in vitro studies have not shown whether age has any impact on the radiosensitivity of primary human cancers cells like fibroblasts, breast cancer cells, mucosa, and vascular smooth cells [ 79 — 82 ]. Clinically, there is evidence of worsening functional impairment in older patients treated with radiotherapy [ 78 ]. Some of the most concerning toxicities that older adults may have a higher vulnerability of experiencing are fatigue [ 83 , 84 ], mucositis, xerostomia, dehydration, infections [ 78 ], and cognitive defects [ 85 — 88 ]. However, other studies have produced contradictory results regarding this subject [ 89 — 91 ].
There is continued controversy on whether a correlation exists between chronological age and incidence of radiation-related toxicities. Over the years, advances in technology have led to radiation techniques that efficiently deliver adequate amount of radiation to an area with potential for reduced toxicity. Intensity-modulated radiation therapy IMRT and image-guided radiation treatment IGRT techniques allow the delivery of higher doses in the treatment volumes with better sparing of surrounding normal tissue [ 92 ].
These techniques have been associated with lower toxicities than other forms of radiation therapy in various types of cancers including cancer of the prostate, head and neck, breast, bladder, and rectum [ 93 — 97 ].
Stereotactic body radiation therapy SBRT allows for higher dosages to be delivered to a targeted tumor region with fewer numbers of fractions [ 98 ] and has been associated with a lower incidence of toxicities [ 99 ], such as radiation pneumonitis in NSCLC treatment for instance [ ].
A recent study on brain metastases found that stereotactic radiosurgery SRS alone compared with SRS with whole brain RT can lead to a better conservation of cognitive ability and quality of life without compromising survival [ ]. The advent of more precise radiation technologies has presented safer and efficient options of radiation that can be delivered to older patients with better toxicity profiles [ 94 , — ]. Frailty can be a predictor of radiation-induced toxicity in older patients [ 68 , 69 ]. The presence of competing noncancer risk factors can negatively impact tolerance to radiotherapy.
Women with breast cancer who also have a comorbid heart condition can be at higher risk of developing cardiotoxicity to radiotherapy treated to the breast [ ]. Given their likelihood of experiencing increased toxicities, older adults are at risk of not being able to complete extended radiation treatments because of their amplified experience of side effects, decline in clinical status, or treatment burden regarding transport and financial costs [ , ].
These patients would thereby benefit from hypofractionated treatment schedules, which deliver the same total doses as that of conventional schedules, but in a smaller number of treatment sessions fewer visits to the treatment facility of hospital. There is also growing evidence that geriatric assessments may help with risk-stratifying patients receiving radiotherapy.
One study found that a Vulnerable Elders Survey VES score above 7 was associated with around 3 times greater probability for not completing a radiation treatment [ ]. Patients determined to be high-risk by the prognostic index had a significantly higher risk for fracture rate Radiation treatments can negatively impact the quality of life for older adults in ways other than acute and long-term toxicities. As described above, older patients can be encumbered by geriatric syndromes that can reduce the effectiveness of anticancer treatments.
Protocols and fractionation schedules that do not acknowledge the severity of these syndromes can subject older patients to treatment noncompliance and further deterioration in health. The efficacy of radiation treatment lies in its successful delivery. To this end, patient cooperation throughout radiation treatment procedures is necessary.
For instance, patients with hearing impairments, highly prevalent among older adults, may not be able to promptly listen to directions during dynamic e. Similarly, patients with dementia may not be able to verbalize sensations of discomfort or pain during radiation or remember instructions. Furthermore, patients with movement disorders like Parkinsonian tremors, or severe arthritis, may have difficulty with immobilization or positioning.
Those with frailty or severe physical impairment may have difficulty accomplishing stressful maneuvers such as breath-holding or abdominal compression [ ]. A focused evaluation of these potential issues upfront may allow workaround solutions to be developed that could make treatments less taxing and more manageable. Special accommodations may be made by treatment facilities or hospitals to make these techniques possible for patients with certain disabilities.
For instance, respiratory motion management techniques can have visual or auditory guides e. Over the past decade, newer approaches have been developed that can potentially address some of these technical challenges. Respiratory motion tracking allows for radiation to be delivered without the need for a breath hold [ ].
However, these techniques tend to lengthen the treatment session time, which can increase patient discomfort common in older patients, as previously mentioned. Four-dimensional computed tomography 4D-CT and image guidance 4D-IG tracks organ movement over time through frequent image capture during the radiation course [ , ]. Adaptive radiation therapy ART individualizes radiation treatment by replanning and redosing radiation daily, allowing for complicated patients who require varying treatment set-ups [ , ].
Another important consideration must be made for the socioeconomic factors that often play a role in radiotherapy effectiveness in older adults. Since older adults are vulnerable to treatment-related fatigue and deficits in physical activity, constant travel may severely impact their quality of life or may simply not be feasible [ — ].
In consideration of the socioeconomic factors and toxicities, older patients may fare better with shorter fractionation schedules without compromising tumor control. Hypofractionation has been studied to be an effective alternative to conservative fractionation in different cancers [ — ]. In breast cancer, older patients treated with hypofractionated RT Hypofractionated courses can also be useful in the palliative setting. For instance, in palliation of bone metastases, a lower incidence of acute toxicities e.
However, hypofractionated courses may present with an additional inconvenience for older patients. Although the physical dose is lower, the dose per session is higher, which may lead to a higher likelihood of acute toxicities in normal tissues if the same tolerances used in normofractionated schedules are applied.
It is important to emphasize the necessity of adjusting the dose constraints in hypofractionated schedules. A reasonable alternative to delivering radiotherapy is omitting it in favor of more supportive measures. Supportive care alone may benefit some selected cancer patients [ ]. However, caution must be made before making the decision to omit radiotherapy, as withholding adjuvant radiotherapy can risk tumor recurrence and worsening of tumor progression [ , ].
It has been shown that combined chemoradiation can improve survival in certain cancers, like that of head and neck, brain, endometrium, and lung [ — ]. However, chemotherapy adds toxicities that can compound those of radiation therapy, such as mucositis, cytopenia, and cardiotoxicity [ , ]. In addition, because of their age-related reductions in kidney and liver function, older adults are prone to increased chemotherapy potency [ 6 ].
Managing an Older Adult with Cancer: Considerations for Radiation Oncologists
Evidence has shown that older individuals receiving combined chemoradiation treatments can experience amplified toxicities leading to more frequent hospitalizations and worse survival [ ]. On the other hand, some trials have revealed that older patients may be able to tolerate chemoradiation for particular cancers similar to younger counterparts [ , ]. However, most of these trials only included older individuals who were medically fit and with few or no comorbidities [ ].
Thus, results may not be routinely generalizable to patients with an increased number of comorbidities or functional impairments. Toxicities may be better controlled by employing the use of more precise radiation technologies during chemoradiation. Chemoradiotherapy using IMRT for treatment of cervical cancer has been shown to limit spread of radiation to the bone marrow and reduce incidence of hematologic toxicity [ ].
Use of tomotherapy-based IGRT in chemoradiation for small cell lung cancer was associated with no grades 3 to 4 pneumonitis, although other toxicities like esophagitis and pulmonary embolism was still observed in some patients [ ]. Combining chemotherapy with hypofractionated radiation may be feasible without increasing overall toxicity.
A retrospective analysis examining the concurrent use of temozolomide TMZ and radiotherapy in glioblastoma found that older patients receiving hypofractionation and TMZ generally tolerated the combined regimen well [ ]. Older adults with poorer functional status may better tolerate sequential, rather than concurrent, chemoradiation [ ]. One study found that patients with nasopharyngeal carcinoma receiving sequential chemoradiation had overall less severe acute toxicities leukopenia, anemia, mucositis, and weight loss than those who underwent concurrent chemoradiotherapy; however, there was no significant difference in survival between the two modalities [ ].
The use of more precise radiation technologies, hypofractionation, and sequential chemoradiation may benefit older individuals with poor functional status. A central question is how to best utilize the skillset of specialty-level geriatrics to optimize cancer treatment for older patients.
A conceptual model utilizing four domains tumor behavior, noncancer related competing risks, functional reserve, and palliative needs described by G. Smith and B. Smith can be considered a foundation for making tailored radiation treatment plans [ ].
- Misbehaviour (Black Lace).
- Jeep, Dana & Chrysler Differentials: How to Rebuild the 8-1/4, 8-3/4, Dana 44 & 60 & AMC 20 (NONE);
- Quick Links.
- Chemotherapy for elderly patients with advanced cancer: is it worth it?;
- Cherish Desire Singles: Intensity (The Complete Five Part Series) featuring Danielle.
A comprehensive geriatric assessment and other abbreviated, easy-to-use geriatric assessment screening tools augment this model by facilitating ascertainment of objective data about competing health risks and functional reserve [ 8 , 54 ]. Routine use of these assessment tools in practice may help risk-stratify geriatric patients and guide treatment decision-making. An objective and complete assessment of an older patient may uncover potentially modifiable geriatric impairments.
At the same time, a full geriatric assessment may be time-consuming and resource intensive [ 41 ]. Not every cancer clinician may be trained to perform one, and not every older individual may require one. Quality of life and functional independence may be highly valued among older adults with cancer. At the same time, undergoing radiotherapy, like any other anticancer treatments, can be an arduous endeavor and may be associated with temporary or permanent detriments in quality of life and function that persist and even worsen at times after treatment is over.
It may be reasonable in many instances to involve extra supportive services earlier in a treatment course for older adults at higher risk e. These might include supportive oncology specialists whose role is to add a layer of support for both patients and caregivers. This type of care may be delivered by palliative care clinicians whose role is to care for any type of cancer patient regardless of cancer type, stage, intent of treatment, or age.
Incorporating supportive oncology specialists earlier in the management of cancer patients is associated with better patient-reported quality of life in multiple domains [ ]. It is important for radiation oncologists to recognize the limitations that their older patients may have in terms of completing radiation treatment courses.
Many patients may experience treatment interruptions for a variety of reasons toxicity-related, patient-related, caregiver-related, treatment machine-related, etc. The efficacy of the treatment, however, depends upon it being completed with minimal interruptions [ 76 , 77 ]. The data gathered from a geriatric assessment allows radiation oncologists to deepen their understanding of potential treatment implications for older patients in a way that can facilitate better informed shared decision-making.
A multidisciplinary supportive care approach involving geriatric expertise, social work services, visiting nurse assistance, nutritional support, physical therapy, and others can be employed in a timely manner, possibly preventing a consequence of treatment such as that described in the introductory vignette. Supportive services may also include individuals specializing in psychosocial oncology [ ]. Attention to psychosocial health is a critical aspect of comprehensive supportive care for cancer patients of all ages. The overall approach to delivering any cancer treatment for the geriatric patient, whether it consists of surgery, chemotherapy, radiotherapy, or the combination of these, requires a global understanding of physical, functional, and social well-being.
Assessment tools are available for more optimal evaluation of older individuals with cancer. Integrating abbreviated versions of these tools is feasible to do within the routine flow of a radiation oncology clinic. The decision to pursue specific treatments requires patient-centered communication of preferences, concerns, risks, and benefits among patients, caregivers, and clinicians. This work is supported by a grant from the Claude D. BioMed Research International.
Indexed in Science Citation Index Expanded. Journal Menu. Special Issues Menu. Subscribe to Table of Contents Alerts. Table of Contents Alerts. Sanders Chang , 1 Nathan E. Goldstein , 1,2 and Kavita V. Dharmarajan 1,2,3. Abstract Older adults with cancer present a unique set of management complexities for oncologists and radiation oncologists. Introduction Vignette. Phenotype of the Older Adult Aging is a coordinated process associated with many physiological and biologic changes in the human body.
Morbidity in the Older Adult With a growing population of older adults, morbidity is becoming an increasing concern in the geriatric population. Geriatric Assessment 3. Table 1: Examples of available screening tools currently used to conduct a geriatric assessment CGA , adapted from [ 8 , 9 ]. Table 2: Selected screening tools currently available to perform an abbreviated geriatric assessment, adapted from [ 41 ]. Table 3: Phenotypic criteria for the Fried Frailty Index, adapted from [ 18 ]. References J. Bourhis, J. Overgaard, H.
Management of Colorectal Cancer in Older Adults
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Age Appropriate: Treating Cancer in the Older Person | Memorial Sloan Kettering Cancer Center
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Treatment for lung cancer in the elderly and the sick
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