Treating Cancer Differently in Older Patients
By Michael O. Schroeder20 hours ago
A diagnosis of cancer inevitably raises myriad questions for patients, family members and clinicians trying to decide what to do next. For older patients, there's even more to consider.
Experts say cancer patients age 70 and up, and people in poor health who are getting older, frequently must evaluate, along with their oncologists, factors unique to their demographic. For example, how will an aged body tolerate treatment, since the organ system doesn't metabolize drugs as it would in more youthful stages? Will age-related chronic conditions, such as heart disease and diabetes, make a patient less able to undergo cancer therapy or increase side effects from that treatment? What about dangerous drug interactions, since the overall number of medications the average patient takes rises with age?
The seemingly mundane, too, can prove critically important, doctors say: Does a patient have someone to take him to and from treatment? Could aggressive therapy, such as regular radiation, render her unable to live independently? On top of it all, a limited life expectancy for some patients can turn the life-and-death question on its head: "Are you going to die of cancer or with cancer?" says Dr. Stuart Lichtman, an attending physician at Memorial Sloan Kettering Cancer Center in New York City, and president-elect of the International Society of Geriatric Oncology. There's even a term for having a disease that falls into the former category: indolent cancers.
It's not that these cancers can't kill, Lichtman explains, but for some patients diagnosed at an advance age, the disease may not shorten their life or affect their quality of life. Rather, they're far more likely to die from something else. He highlights the example of someone who is 85 and has advanced heart disease, kidney disease or diabetes, or who has a low-grade, typically slow-growing prostate cancer or lymphoma. "Maybe the treatment will kill you, but the cancer won't," Lichtman says. "So that's where the patients have to resist therapy ... because those are the patients where if you treat them, you will probably do them more harm than good."
In such cases, doctors may recommend "watchful waiting" -- monitoring cancer progression, without surgery, chemotherapy or other treatment. However, oncologists say, the majority of older patients diagnosed with cancer still undergo some form of treatment.
"We can usually provide benefit: longer life, less pain, a higher quality of life -- those would be our goals for most diseases in oncology," says Dr. Edward Libby, a hematologist-oncologist with Seattle Cancer Care Alliance and professor of medical oncology at the University of Washington.
In gauging how to approach care for older patients, Libby says oncologists often talk about "physiologic age" -- or how old patients are based on their overall health, rather than chronological age. "People may be numerically 70 and physiologically they're 90. Or they could even be 70 years of age and really be physiologically 50. They're playing tennis, they're traveling, they're still working full time," he says. "I have many patients like that."
In addition to evaluating the likelihood that treatment could successfully eradicate cancer, experts also consider the health of a patient to help determine whether more aggressive therapy is appropriate. That may include recommending surgery followed by daily radiation to keep the cancer from coming back in healthier patients. For patients already in poor health with a limited life expectancy before receiving a cancer diagnosis, the focus might be on managing pain to improve quality of life.
The most difficult decisions for doctors and patients occur when cancer could shorten a patient's life but age and other compounding factors, like chronic disease, could make the patient more vulnerable to treatment side effects from infection to nerve damage. Oncologists say that in such instances, one option may be to start with a lower dosage of drugs, such as chemotherapy, then increase the dose if patients are physically able to handle more medicine. But that must be carefully balanced against the efficacy of a modified treatment -- the chance it will actually work effectively at a lower dose.
"You worry a lot about compromising the treatment, say, by decreasing the dose and/or the frequency of the treatment," Libby says. "So if there's any way you can get the patient through the treatment safely, then you're probably not going to adjust the therapy because your goal is to cure."
Further clouding the issue is lack of research on cancer treatment in older patients, who are underrepresented in clinical trials, Lichtman says. He says the International Society of Geriatric Oncology, based in France, has worked to change that over the past decade or so, including by publishing research in the area. At present, he says, Western Europe, including countries such as France and Italy, are ahead of the U.S. on this front. "We're trying ... to give clinicians tools and knowledge to make as close to an evidenced-based decision as you can," he says.
Libby, who specializes in treating multiple myeloma -- a type of cancer that affects plasma cells in bone marrow -- among other cancers, utilizes a system for treating older patients with incurable cancer that's based on patients' risk factors, from whether they're over 75 to if they have chronic conditions, such as heart or kidney dysfunction, to determine drug dosing. The system was devised by the European Myeloma Network, established to support novel diagnostics and treatment for multiple myeloma.
Patients with no risk factors are "go-go," indicating that a standard, full dose of chemotherapy drug treatment is appropriate. Those with at least one risk factor, such as those considered frailand needing help with household tasks and personal care, would be labeled "moderate-go" and started on half the normal dose. While dosages and frequency vary by the drug, the highest-risk patients would be listed as "slow-go" and started on one-quarter of the standard dose. "I'm worried about complications, so I'm going to reduce the dose and slowly increase and see how they tolerate it," Libby says of the approach to treating patients who fall into the "slow-go" group.
Dr. George Sledge, a medical oncologist and professor of medicine and chief of the division of oncology at Stanford University in Stanford, California, says the fact that dementia rates increase with age should also be considered in treating older patients with cancer. "You have to think more seriously in terms of informed consent, and whether or not the patient can give appropriate informed consent for what can be fairly aggressive and, indeed, somewhat dangerous treatments," he says.
In addition, he stresses the importance of knowing whether a patient is mobile or has the support to get to appointments. Experts say that while older patients are typically covered by Medicare, socioeconomic issues, including whether they can afford transportation, as well as copays onexpensive drugs, can impact care. In addition to helping with transportation, having a significant other or another designated caregiver present can be critical; they can provide additional information to doctors that could affect care decisions and give consent for treatment if the patient is unable. Sledge adds that it's important for seniors who are seeing multiple doctors to ensure all doctors are communicating with one another about care.
"I think it's always a good plan, a good recommendation to get a second opinion," Libby adds. "Insurance plans, I think, invariably will pay for that. So you have little to lose except perhaps a day." Experts typically recommend going to a major hospital or treatment center that specializes in cancer care.
By getting a second opinion, Libby says, patients of any age and their families can feel more at ease that they've explored all their options and are getting the most current approach to cancer therapy.
Today, as many patients live longer with cancer, some are able to live not only years, but decades, with the disease when it's properly managed. "We actually are [making] breakthroughs on a regular basis in our understanding of cancer," Libby says. "We're really making tremendous strides."
Michael Schroeder is a health editor at U.S. News. You can follow him on Twitter or email him atmschroeder@usnews.com.
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