Treating Cancers in elderly....how old is too old??

Dr. Rahul Kulkarni

As an oncologist, I come across lot of elderly patients who are diagnosed with cancers. Some are lucky enough to be diagnosed at early stages while some unfortunately get diagnosed at advanced stages. In some patients cure is possible if we treat as per the standard cancer treatment plan, whereas for some patients cure is not possible but still they can be offered treatment which can control the cancer and improve their quality of life. However, many people are skeptical while starting cancer treatment particularly only because of old age and the most important question which is asked is “Can he/she sustain cancer treatment at this age???”. Many a times only because of this mindset some patients miss out the chance of cure since they choose to opt out from desired cancer treatment. In this article we will see how we as oncologist approach while we deal with elderly cancer patients and how we can personalize treatment to derive the best care plan for them and this will help you in making treatment decisions for your near and dear ones.

Almost 60 % of cancers occur above 65 years of age. However treatment of cancer in elderly becomes challenging as older adults are more likely to have chronic illnesses like diabetes, blood pressure, heart diseases, lung disorders, joint problems or they may be frail due to age. These factors may increase the risk of complications during surgery, chemotherapy or radiotherapy. But age should not be the only factor which guides the decision; as we don’t just look at chronological age but biological age is more important in treatment decisions. In geriatric medicine or in particular geriatric oncology, we consider a constellation of factors while making treatment decisions in elderly cancer patients. We discuss following points with patients and relatives.

1) What type of cancer it is and how far it has spread?
Certain cancer types have favourable response to treatment, example- lymphomas, myeloma, breast cancer , lung cancer, prostate cancer can respond very well to simple and less toxic treatments which can give dramatic results to treatment even in advanced stages 

 2) What is going to be the treatment goal?

a)
Cure- whether being cancer free is possible and if so what modalities are required to achieve the goal. In such cases we need to be bit aggressive as it’s a question of life and death but at the same time balance the risks and benefits.
b) Control- Sometimes, even if cure is not possible, we can control cancer very well by simple treatment options. Patients can live longer even with cancer with simple and effective medications.
c) Palliation- in some cases which are very advanced and aggressive cancers, goal can be to just alleviate the symptoms and to make patient comfortable.

3) What are the treatment options and risks and benefits of each one?

Cancers can be treated using any of the following method
a) Surgery
b) Radiotherapy
c) Chemotherapy- oral/IV
d) Targeted therapy
e) Immunotherapy 

 4) How do we decide while choosing the treatment option?

While dealing with elderly patients, we do a overall evaluation of patient which is called
“Comprehensive Geriatric Assessment”.It is a multidisciplinary diagnostic and treatment process that identifies medical, psychological and functional limitations of elderly patients in order to develop a coordinated plan to maximize the cancer treatment outcome.

The questionnaire includes evaluation of following points:

a) Age
b) Medical comorbidities - Heart problems, Kidney /liver dysfunction
c) Ability to perform functional tasks and need for assistance in doing activities of daily living- whether patient can perform their activities on their own/limited/bedridden and whether the current status was prior to diagnosis of cancer or due to the cancer itself.
d) Fall history
e) Mental health
f) Social and financial support.

Various assessment scales can help us to stratify vulnerable elderly patients for whom we can choose to offer milder yet effective treatment options and reduce the chances of toxicities.

5) How can we modify treatment decisions based on Comprehensive Geriatric assessment?

a) Surgical Options-  based on the cardiac/renal/liver/lung function status some patients may be fit even for aggressive surgeries which can certainly cure cancers with minimal risks. ( eg: Breast cancer surgery can be offered relatively safely and can be curative for the patient).On the other hand some surgeries which involve higher cardiac/pulmonary risk may be better avoided if patients are vulnerable and unfit and patients can be offered alternative treatment options thus minimizing the risk. ( eg- esophageal cancer surgery may be morbid if patient has cardiopulmonary issues and can be offered chemoradiation)However this decision is personalized based on detail assessment and requires discussion with your oncosurgeon. 

b) Chemotherapy- many patients are very scared about receiving chemotherapy in old age. However after proper geriatric assessment we can choose proper chemotherapy drugs, doses and schedules which can be safely given. We as medical oncologist are trained to modify and handle the chemotherapy in such vulnerable patients as well as manage the medical problems associated with it. We have many options to modify the treatment in such patients:

  • Reduce the dose intensity- We generally start with a lower than desired doses of chemotherapy so that we can judge the effects as well as reduce the chances of sideeffects. Based on the tolerance we can either increase or decrease the doses in next cycle
  • Modify the dose frequency- We can give small doses of chemotherapy more frequently eg weekly instead of usual 3 weekly chemotherapies. By doing this we can judge the patient periodically and modify treatment as per responses and side effects. This can also help in building confidence in patient as well as relatives and acceptance of treatment can increase.
  • Choosing alternative modes of administration- We can sometimes choose oral chemotherapy drugs over Intravenous which avoids need for hospitalization if patient is not fit because of disease, but at the same time patients condition can improve slowly on oral chemotherapy and later the treatment can be intensified as per the improvement in general condition.
  • Choosing more selective treatment- with great advances in oncology, now a days we have many targeted therapies which act selectively on cancer cells without much side effects but at the same time it can give wonderful results


    So there are multiple ways to modify the treatment and make it most effective as per the condition of patient.
c) Radiotherapy- With newer and newer techniques radiation therapy can be delivered more precisely with minimal toxicities. In certain indications where aggressive surgical treatment is not possible due to fitness issues, patients can be treated with comparative results with aggressive radiation with or without chemotherapy. Also radiation can provide good symptom relief in case of pain/bleeding etc.Eg- Oral cancers, laryngeal cancers, esophageal cancers.

The most important message which needs to go out in the society is that, age is not the sole determinant for cancer treatment planning.
 Age is just a number!! Don’t deprive your near and dear elders from cancer treatment which they deserve just on the basis of age.

Together We Can make their life better!!


Dr.Rahul Kulkarni
MD,DM(MedicalOncology)
Diploma in Geriatric Medicine
European Certification in Medical Oncology
 

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