Undertreatment may contribute to deaths of older cancer patients

Some older adults with cancer might be dying because their oncologists withhold effective treatment solely on the basis of age, according to a founder of the field of geriatric oncology. Each year, some 120,000 accidental deaths in the United States are caused by physicians, Lodovico Balducci, MD, told attendees at the conference. “If I can leave you with a message today, it’s that doctors may kill people not because they treat them too much, but because they don’t treat them enough,” he asserted.

As shown about 25 years ago, when oncologists feared giving full-dose CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) to older adults with lymphoma and routinely reduced the dose by 25%, the complete response rate was 50% lower than that in younger patients (J Clin Oncol 1986;4:295−305). However, when older adults receive the same full dose of chemotherapy, they may have similar response rates and survival, too (Cancer 2003;98:2651−2656). 

Age as a risk factor
“I am wondering whether age is not a risk factor for [poor outcome in] lymphoma in general; it’s more a risk factor for not receiving proper treatment,” reflected Dr. Balducci, a professor of oncologic sciences at the University of South Florida College of Medicine and leader of the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute in Tampa.

“Age should not—and I underline, should not—be a factor by itself that should discourage proper treatment of cancer patients,” he stressed. “This is very important because cancer is essentially a disease of aging; it’s essentially a geriatric disease.” To be sure, treatment decisions in the senior population must take into consideration individual factors such as life expectancy and likely treatment tolerance. And here, clinical assessment provides the most information.

Oncologists should assess patients’ activities of daily living (ADL), such as the ability to eat and bathe. “If you are dependent in one or more of these activities, you are definitely not a good candidate for…any adjuvant treatment,” Dr. Balducci said.

“The instrumental activities of daily living (IADL) are probably more important,” he continued. They include, for example, the ability to make telephone calls, shop, and take medications. “If you are dependent in any one of these activities…your death rate increases by 50%, and your risk of chemotherapy toxicity increases by 100%.” However, if a patient has been able to compensate for a disability—such as learning to use a wheelchair effectively to get around if he or she can’t walk—the patient is not considered to be dependent for that activity.

Comorbid geriatric syndromes
Comorbidities must also be ascertained because of their potential impact on overall prognosis, treatment toxicity, drug interactions, and even cancer growth. Oncologists should look for features of so-called geriatric syndromes, such as spontaneous fractures, falls, or delirium precipitated by minor infections. “They generally are signs that indicate that the patient has not only low life expectancy, but also a poor tolerance of treatment,” he commented.

The best validated measure of life expectancy in the older population in general, according to Dr. Balducci, is a prognostic index that incorporates chronologic age, comorbidities, and functional measures (JAMA 2006;295:801−808). This index permits identification, for example, of 80-year-olds who have a lower 4-year mortality risk than some 60-year-olds.

When it comes to chemotherapy, two studies reported this past year at the annual meeting of the American Society of Clinical Oncology showed that some of the aforementioned factors help to predict the likelihood of serious adverse effects and discussed risk-stratification systems (J Clin Oncol 2010;28[15S]:9000; J Clin Oncol 2010;28[15S]:9001). “These studies are the first clear demonstration that the geriatric assessment is important to establish the risk of toxicity in older patients with cancer,” Dr. Balducci commented. 

Frailty is another key consideration. The term now has a specific meaning in geriatrics, referring to patients who are independent but become dependent after experiencing a stressor such as surgery to resect their cancer. “At that point, you start [down] a slippery slope,” he commented. Thus, “the concept of frailty helps us identify people at risk.”

On average, older adults are more likely than younger adults to experience a variety of adverse effects from chemotherapy, including myelosuppression, mucositis, peripheral neurotoxicity, and cardiotoxicity. “We must remember that age is also a risk factor for long-term complications of chemotherapy toxicity,” Dr. Balducci added, such as myelodysplasia and acute myelogenous leukemia from anthracyclines. At the same time, however, seniors often derive a similar benefit as their younger counterparts from interventions such as the use of growth factors to prevent chemotherapy-induced myelotoxicity. 

Refining chemotherapy
Oncologists should refer to the National Comprehensive Cancer Network (NCCN) clinical practice guidelines to help tailor chemotherapy in patients aged 65 years or older. Such recommendations include, for example, that the first dose be adjusted for renal function and that prophylactic filgrastim (Neupogen) or pegfilgrastim (Neulasta) be given to patients receiving moderately toxic regimens.

“Some form of geriatric assessment should be done in all patients aged 70 and older to estimate life expectancy and risk of chemotherapy toxicity,” Dr. Balducci further noted. “And of course, when you can, you should use safer agents.”

Older patients today are likely to be taking multiple medications for other conditions, which can be problematic when it comes to their chemotherapy, especially given the increasing use of oral agents. Here, oncologists can refer to the STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria, which enable identification of unnecessary or redundant medications a patient may be taking (Int J Clin Pharmacol Ther 2008;46:72−83). “These criteria are very helpful to manage the polypharmacy,” he said.

Dr. Balducci is a consultant for Cephalon and serves on the speakers bureau for Amgen, Cephalon, Novartis, and sanofi-aventis U.S.

Some older adults with cancer might be dying because their oncologists withhold effective treatment solely on the basis of age, according to a founder of the field of geriatric oncology. Each year, some 120,000 accidental deaths in the United States are caused by physicians, Lodovico Balducci, MD, told attendees at the conference. “If I can leave you with a message today, it’s that doctors may kill people not because they treat them too much, but because they don’t treat them enough,” he asserted.

As shown about 25 years ago, when oncologists feared giving full-dose CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) to older adults with lymphoma and routinely reduced the dose by 25%, the complete response rate was 50% lower than that in younger patients (J Clin Oncol 1986;4:295−305). However, when older adults receive the same full dose of chemotherapy, they may have similar response rates and survival, too (Cancer 2003;98:2651−2656). 

Age as a risk factor
“I am wondering whether age is not a risk factor for [poor outcome in] lymphoma in general; it’s more a risk factor for not receiving proper treatment,” reflected Dr. Balducci, a professor of oncologic sciences at the University of South Florida College of Medicine and leader of the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute in Tampa.

“Age should not—and I underline, should not—be a factor by itself that should discourage proper treatment of cancer patients,” he stressed. “This is very important because cancer is essentially a disease of aging; it’s essentially a geriatric disease.” To be sure, treatment decisions in the senior population must take into consideration individual factors such as life expectancy and likely treatment tolerance. And here, clinical assessment provides the most information.

Oncologists should assess patients’ activities of daily living (ADL), such as the ability to eat and bathe. “If you are dependent in one or more of these activities, you are definitely not a good candidate for…any adjuvant treatment,” Dr. Balducci said.

“The instrumental activities of daily living (IADL) are probably more important,” he continued. They include, for example, the ability to make telephone calls, shop, and take medications. “If you are dependent in any one of these activities…your death rate increases by 50%, and your risk of chemotherapy toxicity increases by 100%.” However, if a patient has been able to compensate for a disability—such as learning to use a wheelchair effectively to get around if he or she can’t walk—the patient is not considered to be dependent for that activity.

Comorbid geriatric syndromes
Comorbidities must also be ascertained because of their potential impact on overall prognosis, treatment toxicity, drug interactions, and even cancer growth. Oncologists should look for features of so-called geriatric syndromes, such as spontaneous fractures, falls, or delirium precipitated by minor infections. “They generally are signs that indicate that the patient has not only low life expectancy, but also a poor tolerance of treatment,” he commented.

The best validated measure of life expectancy in the older population in general, according to Dr. Balducci, is a prognostic index that incorporates chronologic age, comorbidities, and functional measures (JAMA 2006;295:801−808). This index permits identification, for example, of 80-year-olds who have a lower 4-year mortality risk than some 60-year-olds.

When it comes to chemotherapy, two studies reported this past year at the annual meeting of the American Society of Clinical Oncology showed that some of the aforementioned factors help to predict the likelihood of serious adverse effects and discussed risk-stratification systems (J Clin Oncol 2010;28[15S]:9000; J Clin Oncol 2010;28[15S]:9001). “These studies are the first clear demonstration that the geriatric assessment is important to establish the risk of toxicity in older patients with cancer,” Dr. Balducci commented. 

Frailty is another key consideration. The term now has a specific meaning in geriatrics, referring to patients who are independent but become dependent after experiencing a stressor such as surgery to resect their cancer. “At that point, you start [down] a slippery slope,” he commented. Thus, “the concept of frailty helps us identify people at risk.”

On average, older adults are more likely than younger adults to experience a variety of adverse effects from chemotherapy, including myelosuppression, mucositis, peripheral neurotoxicity, and cardiotoxicity. “We must remember that age is also a risk factor for long-term complications of chemotherapy toxicity,” Dr. Balducci added, such as myelodysplasia and acute myelogenous leukemia from anthracyclines. At the same time, however, seniors often derive a similar benefit as their younger counterparts from interventions such as the use of growth factors to prevent chemotherapy-induced myelotoxicity. 

Refining chemotherapy
Oncologists should refer to the National Comprehensive Cancer Network (NCCN) clinical practice guidelines to help tailor chemotherapy in patients aged 65 years or older. Such recommendations include, for example, that the first dose be adjusted for renal function and that prophylactic filgrastim (Neupogen) or pegfilgrastim (Neulasta) be given to patients receiving moderately toxic regimens.

“Some form of geriatric assessment should be done in all patients aged 70 and older to estimate life expectancy and risk of chemotherapy toxicity,” Dr. Balducci further noted. “And of course, when you can, you should use safer agents.”

Older patients today are likely to be taking multiple medications for other conditions, which can be problematic when it comes to their chemotherapy, especially given the increasing use of oral agents. Here, oncologists can refer to the STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria, which enable identification of unnecessary or redundant medications a patient may be taking (Int J Clin Pharmacol Ther 2008;46:72−83). “These criteria are very helpful to manage the polypharmacy,” he said.

Dr. Balducci is a consultant for Cephalon and serves on the speakers bureau for Amgen, Cephalon, Novartis, and sanofi-aventis U.S.

Some older adults with cancer might be dying because their oncologists withhold effective treatment solely on the basis of age, according to a founder of the field of geriatric oncology. Each year, some 120,000 accidental deaths in the United States are caused by physicians, Lodovico Balducci, MD, told attendees at the conference. “If I can leave you with a message today, it’s that doctors may kill people not because they treat them too much, but because they don’t treat them enough,” he asserted.

As shown about 25 years ago, when oncologists feared giving full-dose CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) to older adults with lymphoma and routinely reduced the dose by 25%, the complete response rate was 50% lower than that in younger patients (J Clin Oncol 1986;4:295−305). However, when older adults receive the same full dose of chemotherapy, they may have similar response rates and survival, too (Cancer 2003;98:2651−2656). 

Age as a risk factor
“I am wondering whether age is not a risk factor for [poor outcome in] lymphoma in general; it’s more a risk factor for not receiving proper treatment,” reflected Dr. Balducci, a professor of oncologic sciences at the University of South Florida College of Medicine and leader of the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute in Tampa.

“Age should not—and I underline, should not—be a factor by itself that should discourage proper treatment of cancer patients,” he stressed. “This is very important because cancer is essentially a disease of aging; it’s essentially a geriatric disease.” To be sure, treatment decisions in the senior population must take into consideration individual factors such as life expectancy and likely treatment tolerance. And here, clinical assessment provides the most information.

Oncologists should assess patients’ activities of daily living (ADL), such as the ability to eat and bathe. “If you are dependent in one or more of these activities, you are definitely not a good candidate for…any adjuvant treatment,” Dr. Balducci said.

“The instrumental activities of daily living (IADL) are probably more important,” he continued. They include, for example, the ability to make telephone calls, shop, and take medications. “If you are dependent in any one of these activities…your death rate increases by 50%, and your risk of chemotherapy toxicity increases by 100%.” However, if a patient has been able to compensate for a disability—such as learning to use a wheelchair effectively to get around if he or she can’t walk—the patient is not considered to be dependent for that activity.

Comorbid geriatric syndromes
Comorbidities must also be ascertained because of their potential impact on overall prognosis, treatment toxicity, drug interactions, and even cancer growth. Oncologists should look for features of so-called geriatric syndromes, such as spontaneous fractures, falls, or delirium precipitated by minor infections. “They generally are signs that indicate that the patient has not only low life expectancy, but also a poor tolerance of treatment,” he commented.

The best validated measure of life expectancy in the older population in general, according to Dr. Balducci, is a prognostic index that incorporates chronologic age, comorbidities, and functional measures (JAMA 2006;295:801−808). This index permits identification, for example, of 80-year-olds who have a lower 4-year mortality risk than some 60-year-olds.

When it comes to chemotherapy, two studies reported this past year at the annual meeting of the American Society of Clinical Oncology showed that some of the aforementioned factors help to predict the likelihood of serious adverse effects and discussed risk-stratification systems (J Clin Oncol 2010;28[15S]:9000; J Clin Oncol 2010;28[15S]:9001). “These studies are the first clear demonstration that the geriatric assessment is important to establish the risk of toxicity in older patients with cancer,” Dr. Balducci commented. 

Frailty is another key consideration. The term now has a specific meaning in geriatrics, referring to patients who are independent but become dependent after experiencing a stressor such as surgery to resect their cancer. “At that point, you start [down] a slippery slope,” he commented. Thus, “the concept of frailty helps us identify people at risk.”

On average, older adults are more likely than younger adults to experience a variety of adverse effects from chemotherapy, including myelosuppression, mucositis, peripheral neurotoxicity, and cardiotoxicity. “We must remember that age is also a risk factor for long-term complications of chemotherapy toxicity,” Dr. Balducci added, such as myelodysplasia and acute myelogenous leukemia from anthracyclines. At the same time, however, seniors often derive a similar benefit as their younger counterparts from interventions such as the use of growth factors to prevent chemotherapy-induced myelotoxicity. 

Refining chemotherapy
Oncologists should refer to the National Comprehensive Cancer Network (NCCN) clinical practice guidelines to help tailor chemotherapy in patients aged 65 years or older. Such recommendations include, for example, that the first dose be adjusted for renal function and that prophylactic filgrastim (Neupogen) or pegfilgrastim (Neulasta) be given to patients receiving moderately toxic regimens.

“Some form of geriatric assessment should be done in all patients aged 70 and older to estimate life expectancy and risk of chemotherapy toxicity,” Dr. Balducci further noted. “And of course, when you can, you should use safer agents.”

Older patients today are likely to be taking multiple medications for other conditions, which can be problematic when it comes to their chemotherapy, especially given the increasing use of oral agents. Here, oncologists can refer to the STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria, which enable identification of unnecessary or redundant medications a patient may be taking (Int J Clin Pharmacol Ther 2008;46:72−83). “These criteria are very helpful to manage the polypharmacy,” he said.

Dr. Balducci is a consultant for Cephalon and serves on the speakers bureau for Amgen, Cephalon, Novartis, and sanofi-aventis U.S.