CHAPEL HILL, N.C. – Hy Muss, MD, and Laura Hanson, MD, co-authored an editorial in the April 22, 2010 issue of the Journal of Clinical Oncology titled “Cancer in the Oldest: Making Better Treatment Decisions.” Muss, professor of medicine, is director of the UNC Geriatric Oncology Program, of which Hanson is a faculty member. Hanson, associate professor of medicine, is co-director of the UNC Palliative Care Program. They reviewed two studies in the journal that focused on issues in elders and offer their suggestions for next steps in developing best practices.
Because cancer incidence and mortality risk increase dramatically with advancing age, geriatric oncology is becoming an even more important field. For example, at present, approximately 25 percent of new cancer diagnoses are in patients 65 to 74 years old, approximately 22 percent in patients 75 to 84, and about 7.5 percent in those 85 years or older. But as more people are living longer and are diagnosed with cancer, Muss and Hanson stated that “little descriptive research and fewer therapeutic trials provide the evidence needed to guide screening and treatment decisions.”
One paper in the journal reported on breast cancer among the oldest of the old, describing a significantly higher risk of dying of breast cancer after 80 and offering evidence that treatment was significantly related to age and other medical conditions with age as the strongest predictor – or as Muss and Hanson put it: “the older you are the less treatment you get.” However, older patients were also more likely to die from diseases other than cancer, raising (as yet) unanswered questions about optimal cancer treatment for these patients. A second group reported on detecting disabilities in older patients with cancer. In comparing a comprehensive geriatric assessment to a vulnerable elders survey, they found that while the vulnerable elders survey was helpful, the comprehensive assessment is still needed for the most complete information. Such assessments may help physicians predict outcomes and treatment toxicities.
Muss and Hanson call for “elegant trials to define the benefits and risks of three major treatment options for older patients: (1) therapies proven optimal for younger patients; (2) defined dose or treatment modifications to reduce toxicity; or (3) palliative and supportive care without disease-specific treatment.” They state that “geriatric oncology trials should generate evidence for benefits beyond survival” and conclude that “geriatric patients may value and select treatments which would maintain or improve quality of life, control symptoms, and maximize the time outside of hospital care.”
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