NcXHF

TREATING OLDER ADULTS WITH CANCER
Although polypharmacy may be a surrogate marker for unmeasured
vulnerability, it also increases the risk for drug interactions
during treatment. One study of older patients with
cancer identifıed potential drug problems in 62% of patients
with 50% of these rated as moderate or severe. 41 Another
study of older adults receiving chemotherapy identifıed a potential
drug interaction among 75% of patients (244 patients)
and found an association between potential drug interaction
and nonhematologic toxicity. 44 Although much more research
needs to be done on this topic, proactive management
strategies can be advocated to minimize risks for patients.
Careful review of medications, including consideration of
discontinuation of any medications without clear indication,
may benefıt many older adults. This is frequently an overlooked
opportunity in oncology practice and may be facilitated
by communication with a primary care physician or
geriatrician. Use of available drug interaction software can
help avoid initiation of new high-risk medications.
COLLABORATION WITH GERIATRIC MEDICINE
Who
There is a referral bias for the healthiest older adults to be
referred for cancer treatment. Few clinical trials enroll older
adults and those that do preselect for the fıttest patients. 45
Until there is suffıcient observational experience with a protocol
or there are trials specifıcally designed for older adults,
clinical oncologists will have to base judgments on individualized
assessments. 46 Most physicians will be able to recognize
the frailest patients without special tools. At fırst
presentation these patients may report feeling weak, having
little physical activity, and tiring easily. They may report poor
appetite and some weight loss that cannot be attributed to the
cancer or the cancer treatment. 47-49 The frail phenotype portends
loss of organ reserve and loss of homeostatic capacity
because of multiple accumulated defıcits in many organ systems.
In other words, it is not one organ, it is the integration
of the systems of organs. Frailty manifests itself, therefore, in
syndromes such as delirium, falls, and incontinence. 50
Under the rubric of patient safety and quality improvement
many U.S. hospitals and clinics now use rapid screens
built into their electronic health records intake forms that ask
straight forward functional questions to identify patients at
risk for adverse hospital events, notably falls, delirium, early
readmission and functional decline. Questions include: Do
you have any visual or hearing problems? Have you fallen?
Do you need help getting dressed, bathing, or getting your
meals? Do you need help making decisions about your health
care or fınances? There are several population-validated
short geriatric screening tools that have been piloted in geriatric
patients with cancer with good predictive value when
compared with a GA. 51-53 A screening questionnaire such as
the VES-13 or G8 is usually self-administered in 5 minutes.
These standardized questionnaires accurately identify older
adults who would benefıt from a more thorough assessment,
coupled with targeted interventions, as part of treatment
planning.
The GA has been shown repeatedly to identify older adults
at high risk for unexpected treatment toxicity. 20,54,55 By and
large, however, it turns out that all of the screening questions
are not necessary to identify those at risk. Certain items seem
to carry more weight, specifıcally those focusing on functional
limitations in performing higher order activities.
These include IADLs, which are those that are required to
live alone. 20 In part, this is evidence for the referral bias that
prevents the oldest, sickest, frailest patients from presenting
to oncology practice. Many of the geriatric tools are designed
to make fıne distinctions among very frail older adults who
may never be referred for cancer treatment. Therefore, the
tools that work the best are those that can identify older
adults who are functioning well at baseline, but they are doing
so by compensating for an underlying defıcit, the socalled
vulnerable elderly. One study found that only 20% of
older adults with a Karnofsky Performance Score (KPS) of 80
or higher performed perfectly on a 3- to 4-minute directly
observed test of gait and balance. 56 A similar short observational
tool predicted falls in older men attending a prostate
cancer clinic. 57 Directly observed performance predicted disability
and survival among older adults living in the community
with a cancer diagnosis. 58 GA accurately predicted
which of 68 older adults enrolled in a dose-escalation study
were able to complete the regimen (fıt), did not tolerate fulldose
therapy (vulnerable), or were unable to complete the
study because of excess toxicity (frail.) As expected GA did
not predict which specifıc toxicity was limiting treatment,
only that patients had predictable intolerance of symptoms. 59
When
At present, most studies report on GA or other assessments
shortly after diagnosis to predict how older patients will tolerate
fırst-line therapy. However, we would argue that some
aspects of the GA should be repeated at each visit. Toxicity is
cumulative, and patients often minimize discomfort unless
they are directly asked. This is a major part of the rationale for
having supportive and palliative care for symptom control
and for help in disclosing bad news. 60 Some toxicities, however,
may be less obvious, such as delirium, neuropathy affecting
gait and balance, drug interactions, depression, and
bowel or bladder dysfunction. Very little has been published
about the functional trajectory of older adults with cancer
even though KPS or Eastern Cooperative Oncology Group
(ECOG) Performance Status scores are routinely recorded.
As demonstrated in several studies, these scales are global,
impressionistic assessments that may miss key items of relevance
to the geriatric population.
Where
Several research reports now show that gathering GA data on
all older adults and following it with a routine or unsolicited
consultation has an effect on cancer treatment decisions;
however, several questions remain regarding how to best integrate
GA and consultation into oncology care. In a recent
systematic review summarizing the effect of geriatric evaluations
on treatment decisions, a modifıcation in treatment
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
e547