“ Handle with Care” A GP guide to cancer care for elderly patients

Median age of diagnosis of cancer in 2007 was 67 for males and 64 for females Improvements in mortality for younger age groups has not been matched in a more elderly population…. WHY?

What are some of the reasons why elderly people may not be offered treatment? Doctors assumptions that patients won’t want treatment or will not be able to tolerate treatment Evidence about efficacy and side effects is lacking due to exclusion of elderly patients from clinical trials Doctors may feel less confident about managing the more complex elderly patient Gaps in appropriate community support may lead to doctors offering less intensive treatment

Beliefs about cancer in the elderly Elderly patients should not be treated as they are going to die anyway Elderly patients will not respond to treatment Elderly patients do not want treatment and they are not as concerned about life prolongation Elderly patients will experience more toxicity so the risks outweigh the benefits Treatments are worse than the disease and impair quality of life

Life expectancy is heterogenous, and clinicians often underestimate it

Patient preferences Assessment of patients preferences are often overlooked All reasonable treatment options should be discussed with patients Understanding is paramount Goals of care are different in older patients

“Chemotherapy, like illness, is essentially a test of physiological reserve” Ferruci et al Crit Rev Oncol Haematol 46: , 2003

Challenges of cancer treatment in the elderly Age-related organ function decline Decrease in hepatic volume and hepatic blood flow Decrease in GFR Decline in muscle mass may lead to overestimation of GFR using serum creatinine concentration Diminished bone marrow reserve Preexisting cardiac damage Comorbid conditions Polypharmacy

Approach to the patient What am I treating? Importance of biopsy Who am I treating? “Fitness” and comorbidities Social situation Patients attitudes What are the treatment aims? ie cure vs palliation

What are the important factors to consider?

Geriatric syndromes Sensory impairment Incontinencedementia Falls and immobility MalnutritionDeliriumPolypharmacy

“fit” vs “vulnerable” vs “frail”

Role of the GP Primary care physician Knows their patients well (usually) Patient advocate Patient may be more willing to express wishes to doctor they have known for a long time eg advanced care planning Polypharmacy – rationalising medications Managing common side effects and associated symptoms eg pain, hypertension, depression/anxiety There is never an inappropriate referral – benefits from a specialist review may include discussions around prognosis, advanced care planning, optimisation of pain medications, referral for palliative radiotherapy, linked in with specialist should unforeseen hospital admission be needed in future