1. Cancer Treatment in the Elderly
Jeffrey A. Bubis, DO, FACOI, FACP
Clay County, Baptist South, and Palatka

2. Patients 65 and older are the fastest growing segment of the US population
By 2030, it will comprise 20% of the population
There will be a disproportionate increase in patients greater than 75 years old
Yancik R, Ries LA. Cancer in older persons: an international issue in an aging world. Semin Oncol 2004

3. There is a sharp rise in the incidence of most cancers after age 60
Currently…
50% of all cancers arise in those 65 and older
70% of all cancer deaths occur in those 65 and older
Yancik R, Ries LA. Cancer in older persons: an international issue in an aging world. Semin Oncol 2004

4. This age group is underrepresented in clinical trials
Those that are included in trials result in data not applicable to the entire elderly population due to exclusions (esp over 80)
Poor performance status
Renal impairment
Hepatic impairment
Bone marrow dysfunction
Scher KS, Hurria A. Under-representation of older adults in cancer registration trials: known problem, little progress. J Clin Oncol 2012

5. “…The essential principles of treating cancer in the elderly are the same as in younger patients…”
NCCN Guidelines - Older Adult Oncology v

6. Chemotherapy
Radiation
Surgery
Alone or in combination/sequence

7. Challenges

8. Age related organ function decline
Age-related loss of physiologic reserve
Puts patients at risk for decompensation

9. Liver Decline in hepatic volume and blood flow Liver metastases
Affects drug metabolism
Liver metastases

10. Kidney Function GFR falls with age
Loss of muscle mass complicates assessment
Volume status

11. Bone marrow
Reserve diminishes with age

12. Heart Increased risk of CAD Increased risk of valvular heart disease
Decreased ventricular compliance

13. Muscle
Sarcopenia - defined by loss of skeletal muscle mass two standard deviations below sex-specific normal values for young adults

14. Comorbdities DM
Cardiac disease
Anemia
HTN
GI dysfunction

15. Quality of life
Available data suggest that older patients are just as willing to try chemotherapy as their younger counterparts, but less willing to endure severe treatment-related side effects
Yellen SB, Cella DF, Leslie WT. Age and clinical decision making in oncology patients. J Natl Cancer Inst 1994
Sanoff HK, Goldberg RM, Pignone MP. A systematic review of the use of quality of life measures in colorectal cancer research with attention to outcomes in elderly patients. Clin Colorectal Cancer 2007

16. Pharmacokinetics

17. The aging process can significantly alter the pharmacokinetics of chemotherapy agents. These pharmacokinetic differences may be caused by alterations in excretion, metabolism, distribution and absorption.

18. Impaired renal function can result in higher peak drug levels and more prolonged exposure to chemotherapy, causing excessive toxicity with agents that are dependent upon renal excretion for their clearance
Platinum agents
Methotrexate

19. Heptic metabolism and function
Although liver size and hepatic blood flow are decreased with aging, these changes are not of sufficient magnitude to require routine dose modification in elderly individuals.
Concurrent hepatic impairment, due to the malignancy or other comorbid conditions, may necessitate dose adjustments.
Adriamycin
Gemcitabine

20. Functional Status

21. Chronologic age does not reliably predict physiologic decline.
Dosing is not based on age.
Modifications to doses or changes in therapy need to be considered when drug toxicity
overlaps with comorbid conditions
Increases susceptibility to complications

22. Relevant Comorbid Conditions
CKD
Hepatic disease
Ascites/pleural effusion
Decreased bone marrow reserve
Heart disease
ECOG PS > 2, KPS < 60

23. Performance Status ECOG
Grade 0:  Fully active, able to carry on all pre-disease performance without restriction
Grade 1 : Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
Grade 2 : Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
Grade 3 : Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
Grade 4 : Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
Grade 5 : Dead
-Oken MM, et al. Am J Clin Oncol 1982

24. Performance Status Karnofsky
100 - Normal; no complaints; no evidence of disease.
90 - Able to carry on normal activity; minor signs or symptoms of disease.
80 - Normal activity with effort; some signs or symptoms of disease.
70 - Cares for self; unable to carry on normal activity or to do active work.
60 - Requires occasional assistance, but is able to care for most of their personal needs.
50 - Requires considerable assistance and frequent medical care.
40 - Disabled; requires special care and assistance.
30 - Severely disabled; hospital admission is indicated although death not imminent.
20 - Very sick; hospital admission necessary; active supportive treatment necessary.
10 - Moribund; fatal processes progressing rapidly.
0 - Dead
Karnofsky DA, et al. The Use of the Nitrogen Mustards in the Palliative Treatment of Carcinoma - with Particular Reference to Bronchogenic Carcinoma. Cancer. 1948

25. What are the goals of therapy?
Cure
ex. Early stage lung cancer
Consider SBRT or chemo-RT instead of surgery
Consider no adjuvant treatment for resected breast or colon cancer
Disease Control
Ex. CLL
Consider oral biologic therapy instead of infused bio-chemotherapy
Palliation
Metastatic pancreatic cancer
Consider single agent chemotherapy instead of multi-agent therapy

26. What are the patient’s goals?
Personal definition of quality of life
The bucket list
Trips
Family events and milestones
Etc.

27. Integrated Care In addition to multi-modality cancer therapy Nutrition
Physical therapy
Occupational therapy
Aggressive pain management
Psychosocial plan of care

28. Thank you Jeffrey A. Bubis, DO, FACOI, FACP
Clay County, Baptist South, and Palatka
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