Does chemotherapy, with side effects like fatigue, skin sores, diarrhea, loss of appetite, nausea and “chemo brain” make sense for older patients?
Recently, our Senior Adult Oncology Center team evaluated two cancer patients. Both had colorectal cancer that had spread to the lymph nodes and both had undergone surgery to remove the cancer. When cancer is detected in the lymph nodes following surgery, the standard of care guidelines say to administer chemotherapy, but these guidelines were based on clinical studies performed in younger adults.
One patient was in her 90s and the other was in his early 70s. If we went simply by their chronological age, one might guess that the 70 year old was a better candidate for chemotherapy. However, in older adults, perhaps in all adults, age matters less than a multitude of other factors.
This wasn’t always the case.
About 70 years ago, Marjory Warren, a physician in the United Kingdom developed a checklist to assess geriatric patients who had been neglected or ignored in her hospital. Her assessment helped make the case for treating patients who had otherwise been considered “too old” to receive medical interventions.
Over the years that assessment was developed further and is now called the comprehensive geriatric assessment (CGA). It determines a patient’s “functional” age, which helps to better estimate his or her true functional and cognitive status. It examines the patient’s nutritional health, their social support and mental wellbeing, and any other illnesses they may have, including geriatric syndromes such as incontinence, dementia, depression, and likelihood of falling. It also takes into account functional measures such as activities of daily living, as well as medication risks.
Although the CGA is an excellent tool, it is not widely used today because of the expertise required to administer it.
Over the years, however, others built on this work and added tools to help specifically address cancer treatment. Questionnaires that assess the risk of chemotherapy toxicity include the Cancer and Aging Research Group’s Chemotherapy Toxicity Calculator and the Moffitt Cancer Center CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) score.
Also, the American Society for Clinical Oncology (ASCO) has created an online resource page [http://www.asco.org/practice-guidelines/cancer-care-initiatives/geriatric-oncology] to help physicians make these assessments and includes links to several online assessment calculators. These tools can add additional information to help predict the risk of chemotherapy toxicity associated with specific regimens.
Through these assessments and through discussions with the 70- and 90-year old patients about their preferences, health, and support network, it became clear that one patient could withstand the rigors of chemotherapy, while the other was likely to be better off taking a chance that the cancer might not recur on its own during the lifetime of that patient, without additional chemo.
Interestingly, it was our 90-year old who was more likely to benefit. She was active, continued to hold a job, had a great support network and her only additional condition was elevated blood pressure. The cancer treatment would most likely help extend her life.
Our 70-year patient had additional diseases, came to us in a wheelchair and hadn’t recovered well from his initial surgery. Through discussions with this patient, we decided that the risks associated with chemotherapy far outweighed the benefits, with the added possibility of making the patient more debilitated and potentially shortening his life rather than extending it.
When we define treatment for cancer, it is not limited to medical interventions – the chemotherapy, biologics, immunotherapy, radiation therapy or surgery. Rather, treatment encompasses all aspects of the geriatric oncology patient’s care, focusing particularly on elements that matter most to the patient. Care should address physical, psychological, social or spiritual issues.
For this reason, a patient’s chronological age should not be the first thing we consider. It should be the last.
Andrew Chapman, DO, is the co-director of the Center for Senior Adult Oncology and researcher at the Sidney Kimmel Cancer Center at Thomas Jefferson University.
Article Lick (Click Here)