Geriatric Oncology
Health Status Screening in Elderly Patients – Is this the Way Forward? Joanna Kazmierska
Radiation Oncologist and Head, Radiotherapy Department II, Greater Poland Cancer Centre and Research Associate, Poznan University of Medical Sciences
Abstract
The rapid ageing of the European population poses a challenge for healthcare systems. The incidence of cancers will rise as the number of adults aged 65 years and older increases. Moreover, the health status of individuals in this age group is diverse, and thus requires modern oncology to apply an individualised approach to treatment. There is a clear need to develop and validate health assessment tools enabling the identification of specific geriatric issues which might be overlooked by standard assessment methods. The Comprehensive Geriatric Assessment (CGA) is the ‘gold standard’ for geronto-oncology assessment. However, the complexity of this test has stimulated a search for pre-screening methods able to identify individuals with the potential to gain most from full pre-treatment CGA. Such tools consist of specific tests to evaluate health status in the important functional, psychological, social and cognitive domains. The choice of which tests are best to use within the various screening tools is still a subject of debate. This paper presents a review of the most commonly used tests within various health status domains as well as of the most valuable screening tools.
Keywords Screening tools, geriatric assessment, oncogeriatrics, comprehensive geriatric assessment, elderly
Disclosure: The author has no conflicts of interest to declare. Received: 3 December 2011 Accepted: 9 January 2012 Citation: European Oncology & Haematology, 2012;8(1):63–8 Correspondence: Joanna Kazmierska, Head of Radiotherapy Department II, Greater Poland Cancer Center, Garbary St 15, Poznan, Poland. E:
joanna.kazmierska@wco.pl
Europe is undergoing considerable demographic change. It is estimated that people aged over 65 years will make up 28 % of Europe’s population in 2050.1
Many neoplasms develop and are
diagnosed in seniors; for example, 65 % of males with prostate cancer are aged over 65 years while women aged 75–79 years have the highest incidence rate of breast cancer at 441.9 cases per 100,000.2
At the same time, however, the outcomes of treatment of elderly patients suffering from cancer are far from satisfactory. This may be because patients who are over 75-years-old are underrepresented in the group of patients treated aggressively with radical intent. A good illustration of this was described in a study conducted by Aparicio, which revealed that 52 % of elderly patients diagnosed with colorectal cancer had sub-standard cancer treatment, especially with regard to adjuvant therapy.3
Bastiaannet et al. found striking
differences in the relative survival rates of elderly breast cancer patients by comparison with younger patients.4
Lunbrook oberseved
a similar situation in the treatment of small cell lung cancer: only 40 % of patients aged over 75 years were treated with radical chemoradiotherapy compared to 86 % of patients younger than 65 years.5
This situation has been confirmed in an analysis of relative risk survival in elderly cancer patients, which detected reductions in survival rates with increasing age for most cancer sites.6
Moreover,
the under-representation of older patients in clinical trials makes treatment databases incomplete and makes it impossible to assess the potential for individualised treatment of older patients. This creates a number of difficulties when using evidence-based medicine recommendations and decision-making tools such as Adjuvant! Online, which are reliant on treatment results from large groups of patients which may not include seniors.
© TOUCH BRIEFINGS 2012
The individualisation of treatment is particularly important for patients aged 70–85 years, whose state of health can be very variable. There are no precise definitions of the stages of aging, and date of birth alone clearly cannot be regarded as a sufficient criterion. Some patients may undergo radical treatment with no modifications in therapeutic protocols; however, more vulnerable patients might only tolerate individualised palliative treatment or best supportive care. For some senior patients the situation is more complicated, as despite having a good performance status before treatment, their physiological reserves may be exhausted, homeostatic balance disturbed and their health deteriorate during treatment.
This group requires an individualised approach to both radical and palliative treatment because of physiological changes due to ageing and their co-morbidities and the interactions between medications used for treating them and any oncological treatment, especially cytostatics. The average number of medications taken by seniors with co-morbidities is six, most of which may potentially interact with anticancer drugs.7
This situation poses a challenge for the multidisciplinary team charged with planning treatment. Often, for logistical reasons, it is not possible to include a geriatrician in the team. Even having a geriatrician who is familiar with oncological issues in the team does not solve the problem, however, because the comprehensive geriatric assessment (CGA) – the clinically-validated gold standard for assessment of seniors8–11
due to its complexity and multidimensionality,12 logistical and financial problems.13
– is time and manpower consuming, bringing other
It seems advisable to include a preliminary credible screening of elderly patients by an oncologist, 63
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