Lupine Publishers | Journal of Surgery and Case Studies
Abstract
Oncological treatments of elderly patients are extremely complex; so far
there’s no agreement even on the definition of “geriatric patient”. From the
point of view of global health, the problem is of the outmost importance as the
number of older patients will increase dramatically in the next years, leading
to a change in world epidemiology with a significant increase of
chronic-degenerative diseases such as cancer. For this reason, it’s mandatory
to provide clinical oncologists with multidisciplinary algorithms aiming at the
best treatment of older cancer patients.
Materials and Methods
The complexity of oncological treatments for elderly patients starts from
the very beginning, since the definition of “geriatric patient” is not
univocal. From the point of view of public health, the problem is of the
outmost importance. since nowadays there are 600 million people over 65, in 10
years their number will overcome 1 billion and in 2050 there will be nearly
half billion people over 80 [1-3]. Such an increase of longevity will lead to a
change in world epidemiology with a significant increase of non-communicable
disease such as cancer. In 2030 the annual incidence of new cases of cancer in
aged people will be 13,7 million and, which is even more important, nearly half
of such cases will be in low-income countries [4]. Very few clinical trials
(which are the cornerstone of Oncology) take older patient into account, and
usually they are very selected cases [5-8], quite differently from every day’s
practice, so there’s paucity of data about care of older patients, which makes
clinical oncologist’s task even harder [5].Moreover, at least till few years
ago, most guidelines and recommendations only consider chronological age in
order to determinate the treatment’s choice, and this policy has led to over-
or under-treatments [5]. With the purpose of optimizing the treatment’s choice
it is imperative to focus on the concept of biological or functional age, in
opposition to merely chronological age [6,7].
We should briefly review the physiological modifications caused by aging,
which affects every organ and apparatus. Considering for instance Nervous
System, there is a decrease of cortical volume and of synaptic density, which
leads to a weaker memory and attention. Cardiovascular system is strongly
affected, with a diminished cardiac output, increased arterial stiffness,
slower modulation of cardiac frequency etc. [9]. Osteo-muscular apparatus is
involved too, with a decrease of bone density leading to an increased risk of
fracture and a sarchopenia which causes decreased physical activity with
parallel increased fatigue and asthenia [10]. Additionally, for most of
oncologic treatments, liver and kidney’s function is crucial; with their
reduction, drug toxicity increases. In some aged patients an aforementioned
change is plain; in other they can be silent in conditions of balance, becoming
evident in stress situations such as a malignant disease and its treatments
[1].
Biomolecular Markers of Aging
Aging is an extremely complex phenomenon, showing deep differences among individuals,
consequently so far, it’s difficult to identify biological markers which enable
us to divide subjects of the same chronological age into different functional
ages. Several markers have been suggested, starting with markers of systemic
inflammation such as CRP, D-dimer, IL 6 [8]. They are easily quantifiable, and
they’ve been associated with functional decline in aged people, but their
levels are influenced also by frankly pathological conditions like infections
and cancer itself [11,12]. Markers of cellular aging have been considered too,
such as telomeres or cell cycle components [8]. Dosing such markers is anyway
extremely expensive, and moreover they have a significant interindividual
variability. Another marker which could document a link between cancer and
aging is P16 INK 4A, which has been showed to increase in aged breast cancer
patients receiving chemotherapy [13]. Nevertheless, all of these markers are,
so far, not completely validated and reliable.
Geriatric Assessment
As long as validated and reliable biomarkers are not established, the best
way to assess a geriatric cancer patient is clinical evaluation [14-17].
Geriatric assessment is a multidisciplinary and multi parametric evaluation
which takes into account physical aspect, nutritional status, neurological and
cognitive status and even social support [18,19].
Comorbidities
When planning an oncological treatment at any age it’s mandatory to take
into account comorbidities. This is mainly true in aged patient, beginning from
the commonest pathologies such as cardiovascular diseases, diabetes, chronic
renal failure, collagenopathies [20].
Polypharmacy
About 50% of aged patients are on 5 or more different medical therapies
before undertaking an oncologic treatment, so it’s mandatory to evaluate all of
these therapies and their potential interaction\interference with anticancer
therapy [21].
Nutritional Status
Malnutrition and weight loss are deeply connected with cancer and its
treatments and they have been shown to be linked to increased risk of toxicity
and mortality [22].
Functional Status
All oncologists are familiar with ECOG and KPS scoring systems. In aged
cancer patients it’s appropriate to integrate them with other evaluation
systems [5,8] such as ADL (Activities of Daily Living) and IADL (instrumental
activities of daily living). For instance, an extremely simple and reliable
indicator of functional status is the number of falls. They are seldom taken
into account, but they seem to be connected with oncological treatments’ toxicity.
Cognitive Status
The risk of cognitive decline increases with age. During anticancer
treatment, it can cause for instance a diminished comprehension of its side
effects which can be communicated with a delay, increasing the toxicity of the
treatment itself, even in a serious way [1].
Psychological Status
Anxiety and depression worsen quality of life and precipitate functional
decline, with a lower adherence to therapies [23].
Social Support
Many older people, so even aged cancer patients, live alone. It’s been
documented that social isolation is linked to a significant higher mortality in
cancer patients [24].
Screening Tools
Many screening tools have been validated with the purpose of identifying
aged cancer patients who can take advantage of a multidimensional geriatric
assessment [25,26]. Among the commonest ones we mention G8 and Vulnerable
Elderly Survey 13 [18]. The final result of these screening and of the
subsequent geriatric evaluation is the final decision to perform an oncological
treatment (and its intensity) or not [7]. Sometimes it could be appropriate not
to perform a treatment with curative purpose in an aged patient because of
multiple comorbidities (which could lead to increased toxicities and a
reduction in life expectancy). In other circumstances, on the opposite side, it
could be an error not to undertake a treatment only because of chronological
age. Patient’s preferences must be taken into account too; main international
guidelines recommend to including patient in the therapeutic decision [27]. In
this setting we must insert geriatric assessment; it’s been documented in
literature that multidimensional geriatric evaluation has lead to significant
changes in treatment planning, in most of cases with the aim of attenuate it
[28]. At the present a multidimensional geriatric assessment is not often
performed in the process of decision making regarding oncologic treatment of
older patients. It’s been shown anyway that older cancer patients who have been
evaluated in such a way have completed their treatment in a significant higher
percentage, and with less modifications, compared to those who haven’t received
it.
Radiotherapy
radiotherapy is the clinical discipline which aims at curing cancer by means
of ionizing radiations; it could be employed as the sole therapeutic modality
or in association with surgery and \or systemic therapies. [29,30]. A geriatric
evaluation is strongly advisable for older patients who are candidates to
radiotherapy, first of all for those treatments which consider its association
with a systemic therapy, but also for the exclusive setting. Around 70% of
cancer patients will require a radiation treatment, and this is especially true
in older patients, as state of art radiotherapy techniques offer higher cure
rates with less side effects. Moreover, treatment time can be reduced, and this
can help patient with logistic difficulties (e.g. distance from radiotherapy
facility) and their family\caregivers. This is true first of all in the
palliative setting (e. g. Treatment of pain from bone metastases), but it could
be accomplished even in the non-palliative setting, with the adoption of
shortest scheduled.
Conclusion
The first dilemma of radiation and medical oncologists treating aged
patients is how to decide if a patient is suitable for a given treatment and
whether to treat patients with standard protocols or with adapted regimens. So,
it’s advisable to include a geriatrician in multidisciplinary oncological teams
(Tumour Board).
If it’s not possible, a good result can be achieved even with a conventional
geriatric evaluation and a higher cooperation among specialists. Anyway, even
after an effective evaluation has declared that an older patient is fit enough
to undergo an oncological treatment, it’s mandatory to monitor such a patient
in a closer and stricter way compared to a younger one [31].
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