Cancer is largely a disease of ageing but usual considerations such as performance status and tumour characteristics may not be the most important factors in older patients.
According to Professor Hyman B Muss, director of the geriatric oncology program at the University of Northern Carolina’s Lineberger Comprehensive Cancer Centre, treatment decisions in older cancer patients were more likely to be influenced by other variables.
In his keynote address to the MOGA ASM, he said polypharmacy, comorbidities, falls, psychosocial function, social support, cognitive impairment and functional deficits should all be considered.
“A baseline geriatric assessment will uncover problems you don’t find routinely.
With falls for example, there are useful interventions such as referral to a physiotherapist that can improve quality of life and survival.”
He recommended the Cancer and Ageing Research Group (CARG) brief geriatric assessment and online tools such as the Schonberg Index for predicting life expectancy or chemotoxicity in older patients.
Professor Muss said treatment decisions cannot be based on chronological age alone.
He noted that the number of hospitalisations in the previous 12 months was one variable indicative of a poorer trajectory for older patients.
Breast cancer in older women
Professor Muss told the meeting that while breast cancer death rates had fallen in the US, older patients hadn’t enjoyed the benefits that younger patients had.
He said the most likely reason was they were not receiving the best available treatment.
Before making any treatment decisions, it was important to estimate life expectancy and define the goals of treatment.
“It’s not always longevity in older patients. Younger women will want to see their children grow up while older patients may be more concerned about being a burden.”
“For example, for a 2% improvement in survival, you don’t want a grade 3 neuropathy and the patient on a cane. We have to make sure the treatment is not worse than the problem and work to maintain the patient’s quality of life.”
He said a 2014 study showed ageing was associated with more luminal breast cancers, which had better outcomes than basal-like tumours and HER2-enriched subtypes.
After controlling for subtype, treatment, tumour size, nodal status and grade, increasing age of the patient had no impact on recurrence free survival or disease specific survival, the study found.
Professor Muss also recommended the predict online treatment decision tool and said ‘at least in the US, many people overestimate the benefit of chemotherapy’.
He also said recurrence scores based on genetic assays were useful.
“I feel that these assays are very helpful for making decisions in older patients.”