The emerging field of oncogeriatrics, or geriatric oncology, deals with management of cancer in older people. This presentation introduces the area and reviews the evidence base. It also explains how cancer presents and behaves differently in older people.

1. Geriatric Oncology
Dr Shane O’Hanlon
Consultant in Elderly Care
Surgical Liaison and Oncogeriatrics
Royal Berkshire NHS Foundation Trust

2. Content
 Incidence, mortality
 Age and cancer progression
 Prevention
 Clinical Profile of older cancer patients
 Presentation and management of cancer
 Oncogeriatric assessment
 Long-term outcomes

3. Incidence
 People >65 years are 11 times more likely to
develop cancer than those 25-44
 Incidence of all cancer combined has been
increasing since 1970s – but biggest
increase has been in 75 and over group
 Incidence increases with age until 80-84 then
begins to decline 85+!

4. Age-specific incidence rates for all cancers
Thakkar et al 2014

5. Why drop in >85?
Theories!
 Increasing arteriosclerosis limits local
angiogenesis
 Age-dependent remodelling of immune
system
 Strongly varying exposures to carcinogens
with age
 Decreased proliferation rate of cells

6. Incidence by cancer
 Melanoma peaks in 50s then plateaus
 Breast cancer plateaus in 80s
 Colorectal, pancreatic, stomach and
myelodysplastic syndromes all continue to
increase…

7. Mortality
 Overall mortality started to drop in the 1990s
 Mortality rates rise with advancing age, and
continue to rise in oldest group
 Overall survival rates improving but at slower
rate in older people -> so widening gap
 UK worse outcomes than other Europe/US

8. Age-specific mortality rates by all cancers
Thakkar et al 2014

9. Age & Cancer Progression
 Breast cancers more likely to be ER/PR+ve
and HER-2 –ve (good prognosis)
 NSCLC mets have a longer doubling time
 Prognosis worse for:
 Acute leukaemia
 Lymphoma
 Malignant brain tumours
 Ovarian cancer

10. Cancer prevention
 Smoking remains leading cause for lung
cancer + also implicated in at least 14 others
 Older adults lowest rates of smoking now but
accumulated risk from previous smoking
 Smoking cessation does confer benefit (Peto
et al 2000), even in middle age – avoids
much of lung cancer risk
 Diet, obesity, inactivity

11. Screening
 Has helped to reduce cancer-related mortality
from breast and colon cancer in older adults
 Not suitable for others, e.g. prostate – risk
greater than benefit over age 69 (Moyer
2012) and no effect on life expectancy

12. Chemoprevention
 Administering drugs to prevent cancer
 Aspirin, NSAIDs, finasteride, Vitamin D tried
 Finasteride showed 26% reduction in
prostate cancer compared to placebo
(Thompson 2003)
 Aspirin 15% reduction in cancer deaths but
effect seems to take >3 yrs

13. Clinical profile of older cancer pt
 More likely to require assistance with ADLs
 Up to 70% functional dependence, 90%
comorbidity, 40% polypharmacy (Extermann
1998, Repetto 2002, Ingram 2002)
 Severe comorbidity associated with higher
mortality in lung, colorectal and prostate ca
(Jorgensen 2012)
 Common: DM, IHD, high chol

14. Presentation of cancers in old age
 Most present at later stage in older people
(Goodwin 2004) which has negative effect on
survival
 Common symptoms of cancer may be
ascribed to old age
 Pain, fatigue, weight loss
 In large French survey of GPs increasing age
highly assoc with decision not to refer (Delva
2011)

15. Management of cancer in old age
 Well recognised that older people with cancer
are under-treated compared to younger
 ?Because of … Comorbidity
 ?...Shorter life expectancy
 ?...Patient choice
 Or could it also be due to poor communication of
risks/benefits of treatment or not treating?
 Study of oncologists: given cases, placed too
much emphasis on chronological age

16. The case for oncogeriatric care
 Geriatricians and MDT involved in the
decision making process for cancer treatment
 Only one reasonable quality study! Van de
Water 2014
 42 pts oncogeriatric vs 104 standard care
 Oncogeriatric care group -> more intensive
treatment and trend towards increased
survival

17. CGA
 CGA affected treatment decisions in up to
82% (Chaibi 2011)
 Identified geriatric problems in over 50% of
pts (Kenis 2013)
 ADL, IADL, performance status, depression
and frailty assoc with poor health outcomes
such as treatment toxicity and mortality

18. Short screening then CGA?
 Time consuming!
 But no screening tool has been found to have
acceptable sensitivity or specificity for
identification of frailty in older people with
cancer (Smets 2014)
 CGA remains gold standard

19. Frailty in cancer
 One review of data from 20 studies, 2,916
older people with cancer, median prevalence
was 42% (Handforth 2014)
 More common in frailty:
 Treatment complications
 Post-operative complications
 Death

20. Treatment: Radiotherapy
 Mainstay of treatment for some cancers
 Less likely to be used in older people
 ?dementia, movement disorders, difficulty
tolerating or accessing
 Newer therapies such as intensity modulated
radiotherapy and stereotactic irradiation
might help to reduce toxicity

21. Treatment: Chemo
 Underused
 One cohort – 94% of <50s had it but 42% of
those >80
 Concerns that won’t be tolerated
 Fisher (2012): of pts recommended chemo, 81%
began; 52% of those completed all cycles, 34% of
treatment group received reduced dose
 Sig better survival if completed chemo

22. Chemo cont’d
 Risk assessment tools
 CRASH (Extermann)
 Greater use of oral instead of IV
 Dose reductions don’t seem to affect survival,
from preliminary evidence (O’Connor 2010)
 But well powered studies lacking

23. Surgery
 Mainstay for many, and confers best
outcomes
 Those not undergoing surgery more likely to
die within 30 days (Sheridan 2014)
 Proportion drops off for many types of
surgery in older age groups
 Recent study looked at endometrial cancer
surgery: older people less likely to undergo
laparoscopic but did not have higher rates of
morbidity or mortality (Mahdi 2015)

24. Surgery (cont’d)
 Minimally invasive, local/regional anaesthesia
and pre-op optimisation may help
 Pre-operative Assessment of Cancer in
Elderly (PACE) tool combines part of CGA
with surgery-specific metrics
 Dependence for ADL/IADL and PS >2
associated with longer stay

25. Long-term health outcomes
 Cancer survivors more likely to report
comorbidity, limited mobility, dependence for
ADLs than controls
 Sequelae from chemo
 Cardiotoxocity
 Myelodysplasia & acute leukaemia
 Peripheral neuropathy
 Dementia (Heck 2008)

26. Research
 Only 25-33% of eligible older pts enrolled to
trials; barriers:
 Physicians perceptions
 Protocol criteria, esp comorbidity
 Functional status
 Lack of social support
 Need no upper age limit, and flexible trial
design

27. Conclusions
 Cancer incidence increasing
 Mortality gap widening bt young/old group
 Older people undertreated
 Presentation can be different
 CGA helps identify areas to optimise
 Early days for the evidence base

28. Thanks!
Shane.ohanlon@royalberkshire.nhs.uk