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Journal of Clinical Oncology, Vol 25, No 14 (May 10), 2007: pp. 1821-1823 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.10.6567
Geriatric Oncology: A Field Coming of AgeMemorial Sloan-Kettering Cancer Center, Commack, NY, and New York, NY
H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL
Multidisciplinary Oncology Institute, Clinique de Genolier, Genolier, Switzerland A saying within oncology is: If you're not a pediatric oncologist, you're a geriatric oncologist. Maybe while not literally true, this phrase is recognition that all of the subspecialties of oncology are rapidly becoming a field that will be primarily concerned with the care of older patients. While there is not one precise definition of the age of geriatric patients, it is clear that the aging of our society has necessitated a focus on this segment of the population. It has long been recognized that the most significant risk factor for the development of cancer is increasing age. This, together with epidemiologic shifts, has resulted in a marked increase in the number of older patients with cancer, which will markedly increase the cancer burden to the world.1,2 It may also compromise the life expectancy, as well as the active life expectancy, of older individuals. Cancer and cancer treatment may appear as several of the prime causes, not only of mortality, but also of disability, in older individuals. The traditional ways in which cancer is studied—by clinical trials focusing on younger, healthier patients—has left us devoid of useful data with which to treat older patients in an evidenced-based fashion. Not only have these earlier trials failed to establish the relative efficacy of cancer treatment in the elderly, but they also were unable to provide information related to the short- and long-term complications of treatment including decline in function.3 Among the first to recognize this issue was Dr Rosemary Yancik, who in 1983 organized a symposium sponsored by the National Cancer Institute and the National Institute on Aging, which resulted in a monograph, "Perspectives on Prevention and Treatment of Cancer in the Elderly."4 The conference reached a number of conclusions and set a research agenda (Tables 1 and 2). In the 1988 American Society of Clinical Oncology (ASCO) Presidential Address, Dr B.J. Kennedy encouraged the study of aging and cancer.5 He stated " ...our society need not ration how we will treat our disadvantaged members, but should continue to seek those preventive and positive measures that can shorten our later period of morbidity. A very major cancer load will persist well into the 21st century, even if the attempts at prevention are eventually a total success. There is a developing knowledge on aging. Care of the older person needs to be part of medical education and oncology education. Research will help attain a desirable quality of life with aging and a reduced morbidity."5
Since that time, studies of older cancer patients have revealed a significant amount of important clinical information. This has included the degree and severity of comorbidity and its effect on treatment, the role of polypharmacy, and the various social and financial problems facing older patients with cancer. The relative and absolute under-representation of older patients in clinical trials has been amply documented.6 The adverse outcomes of inadequate dosing and supportive care in both curative and palliative treatments have been demonstrated in a number of treatment settings.7 Even when clinical trials are available, barriers to participation of older patients have been shown to be primarily due to physician reluctance due to fear of toxicity, limited expectation of benefit, or ageism.8 A number of important strides have been made in the evaluation of older patients through various methodologies of geriatric assessment. The Comprehensive Geriatric Assessment developed by geriatricians is a multidisciplinary evaluation of the older patient encompassing a number of important clinical domains.9,10 Researchers in this area have shown that traditional oncology measures of performance are not adequate in older patients and that geriatric specific measures, such as activities of daily living and instrumental activities of daily living, have a much greater predictive value.11 There has been major interest in this area by a number of professional oncology societies and organizations. In 1995, the Cancer and Leukemia Group B (CALGB) organized a Cancer in the Elderly Committee.12 The charge of the Committee was to provide a forum for CALGB members interested in cancer in the elderly to share ideas; to transform the most promising and innovative ideas into concepts and, ultimately, protocols; and to provide input to other CALGB committees about opportunities for developing clinical trials focused on cancer in the elderly. Committee members were selected based on their interest in cancer in older individuals. This has led to a number of completed and published studies in barriers to participation in clinical trials, supportive care, and cancer therapeutics.3,8,13-16 Other national cooperative groups have also developed geriatric oncology interest groups. ASCO sponsored a clinical practice forum in 2000, a symposium at its Annual Meeting in 2002, and a publication entitled, "Cancer Care in the Older Patient" as part of their Curriculum series. The Annual Meeting has included a number of education sessions and oral presentations emphasizing geriatric oncology. The 2006 update on the use of WBC growth factors has recognized older individuals as a group at high risk13 confirming the discussion within a position article by the EORTC.17 Indeed, our European colleagues have been among the first to bring the needs of the elderly to the attention of the medical community.18,19 A significant proportion, possibly the majority of clinically significant prospective trials in older cancer patients, have originated in Europe.14,15,20 The International Society of Geriatric Oncology,21 with its headquarters in Switzerland, has implemented a number of taskforces to evaluate the current literature and make treatment recommendations.10,22-27 In the United States, the National Comprehensive Cancer Network has published practice guidelines for senior adult oncology28 and the Geriatric Oncology Consortium29 has been founded to initiate clinical trials and raise awareness of problems of elderly patients. This special issue of the Journal of Clinical Oncology highlights the achievements of researchers in the field, brings clinical oncologists up to date on available data, and—more importantly—stimulates ideas for future work. The special edition is broadly divided into three sections. The first section is a general background, which provides a framework of basic knowledge in the overall problem facing oncology and our society.30-37 The current state of geriatric assessment as it applies to the oncology patient is then presented. 30 An article on clinical pharmacology of chemotherapy follows. 31 In describing various agents, it is clear that there is a paucity of prospective information available. The current state of the art in regards to the science of aging is discussed.32,36 A series of clinical articles follows. The undertreatment of older patients is discussed with an emphasis on elderly women. 37 The prevention of recurrence after primary treatment is critically important. Making the appropriate decisions regarding the proper therapy, taking into account risk of recurrence and geriatric assessment, is one of the more truly difficult clinical issues.33 Finally, a way to integrate these concepts concludes the first section. The second section focuses on a few specific disorders: breast,38 colon,39 and lung cancers,40 acute myelogenous leukemia/myelodysplastic syndrome,41 and lymphoma,42 as well as the therapeutic modalities of surgery and radiation.43,44 Surgical issues are described with emphasis on prediction of morbidity and mortality. The last section concludes with an article assessing our current state of knowledge from the geriatrician's perspective.45,46 This is particularly important as we need to ally ourselves with those in medicine dedicated to the elderly, who may have a different perspective from those of us trained in traditional oncology.46 Lastly, as Rosemary Yancik did in 1983, we need a research agenda to stimulate future endeavors and to capitalize on the strides we have made since that seminal meeting. Dr Harvey Cohen leads that effort.45 This issue strives to make the oncology audience aware of the great strides have been made in the evaluation and treatment of elderly patients. It should also be obvious that much work is to be done, as older patients have not been systematically evaluated to the degree necessary to make evidence-based decisions. In addition, issues in the basic sciences, including the biology of aging, need to be further evaluated. As older patients will become the majority of the patients that we evaluate and treat, they need to become the focus of our endeavors. They deserve nothing less. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. Author Contributions Manuscript writing: Stuart M. Lichtman, Lodovico Balducci, Matti Aapro
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J Clin Oncol 25:1898-1907, 2007 41. Estey E: Acute myeloid leukemia and myelodysplastic syndromes in older patients. J Clin Oncol 25:1908-1915, 2007 42. Thieblemont C, Coiffier B: Lymphoma in older patients. J Clin Oncol 25:1916-1923, 2007 43. Audisio RA, Zbar AP, Jaklitsch MT: Surgical management of oncogeriatric patients. J Clin Oncol 25:1924-1929, 2007 44. Horiot J-C: Radiation therapy and the geriatric oncology patient. J Clin Oncol 25:1930-1935, 2007 45. Cohen HJ: The cancer aging interface: A research agenda. J Clin Oncol 25:1945-1948, 2007 46. Rodin MB, Mohile SG: A practical approach to geriatric assessment in oncology. J Clin Oncol 25:1936-1944, 2007
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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