1. Trevor A. Jolly MBBS Cancer and Older Adults: Care and Treatment November 19, 2015 Why Worry About Cancer As We Get Older

2. The Tsunami of Cancer and Aging

3. The US Population is Aging

4. Population Age 65+ in North Carolina, 2000 Mean = 12.0%. Range = 6.3% to 23.6%

5. Population Age 65+ in North Carolina, 2030* Mean = 17.7%. Range = 10.5% to 35.2% *Based on July 2006 population projections

6. 1 2 3 4 5 1 Cellular Water 2 Kidney Blood Flow 3 Maximum Breathing Capacity 4 Nerve Conduction Velocity 5 Heart Output Age (years) Percent Reserve Capacity Remaining 100 80 60 40 20 0 0 406080 Organ Reserve and Age Baker and Martin, Geriatric Medicine, 1996

7. Comorbidity and Age Prevalence of various comorbid ailments by severity across the age spectrum. Piccirillo et al. Crit Rev Oncol Hematol. 2008 Aug;67(2):124-32. DementiaHeart Failure Prior Cancer HIV/AIDS DiabetesHypertension

8. Erikson, C. et al. J Oncol Pract; 3:79-86 20070 Age-specific cancer incidence rates/100,000 year 2000 The Median Age of a Cancer Diagnosis in US is 67 ! Cancer incidence and Age

9. Cancer Mortality and Age Smith B D et al. JCO 2011;29:4647-4653

10. Cancer Survivorship and Age 18 Million Cancer Survivors Projected in 2022

11. Projected Future Need for Geriatricians The Present: 1 Geriatrician: 2620 The Future: 1 Geriatrician: 3798 Projected future need for geriatricians in 2030: 30,623 AGS: Geriatric Workforce Policy Study Center

12. Important Points The US population is aging Cancer is associated with age The number of older cancer patients and survivors will increase The majority of cancer mortality occurs in older adults Other medical conditions increase with age There are not enough geriatricians to care for older adults with cancer.

13. Assessing Older Adults

14. Oncologist –General –Chronological age –History and Physical Examination –Functional Status –Karnofsky performance status –Eastern Cooperative Oncology (ECOG) Group performance status

15. Age

16. Tumor Characteristics Performance status Age Function deficits Comorbidities Nutritional deficits Psychosocial dysfunction Polypharmacy Falls Cognitive impairment Social Support Organ function The Geriatric Oncology Iceberg

17. Geriatric Assessment….

18. The Value of Geriatric Assessment  Uncovers problems not found routinely  Many problems have beneficial interventions –Improve function –Quality of life –Survival  Allows for accurate life-expectancy estimate  Can predict cancer related toxicity

19. Brief Geriatric Assessment DOMAINASSESSMENT MEASURE Health ProfessionalSelf Reported Functional Status Timed Up and Go KPS- Physician Rated Activities of Daily Living (ADL) Instrumental Activities of Daily Living Karnofsky Self Reported No. of Falls in the last 6 months Co-morbidity Number /Type of Comorbid Conditions No. of Medications Vision and Hearing Assessment Cognition Blessed Orientation Memory-Concentration Psychologic Mental Health Index-17 Social Social Activity Limitation Measure (MOS) Social Support Survey (MOS) NutritionBMI Unintentional Weight Loss 6 mths 10 minutes 20-30 minutes

20. Deficits in Normal PS Patients Frequency (%) Professionally-Assessed KPS Patient- Rated KPS <50 60-70 80-100 Total <50 8 (0.8%) 3 (0.3%) 8 (0.8%)19 (2%) 60-7010 (1%)38 (4%)89 (9%)137 (14%) 80-100 4 (0.4%)28 (3%)796 (81%)828 (84%) Total22 (2%)69 (7%)893 (91%)984 (100%)

21. Sarcopenia….

23. Molecular Aging….

24. p16 (CDKN2A)  Cyclin-dependent kinase inhibitor 2A –inhibits CDK4  Codes tumor suppressor protein –helps regulate the cell cycle  mutations increase risk of developing a variety of cancers  Increased expression with aging  Ned Sharpless UNC world expert

25. Interventions….

26. Walking Intervention Leigh Callahan UNC Effective in Arthritis ↓ pain and stiffness Scalable Pt sets pace Can do anywhere Goal 30 min 5 x weeks Pilot trial In AI and now R-21 randomized trial HBM/June 2014

27. 1/22/15

28. Thank You!