Geriatric Oncology: why older patients need a special approach
Anthea Cree is a clinical oncologist currently undertaking an MD in advanced radiotherapy at The Christie NHS Foundation Trust. She co-founded a group within the hospital to work towards better outcomes and experience for older patients.
I recently did a clinic during which the average age of the patients was over 80 and the oldest nearer to 100. This is probably not unusual for the readers of this blog but I’m an oncologist, not a geriatrician.
I’ve been an oncology registrar for six years and even over this short period of time, it seems like encountering octogenarians in clinic has changed from unusual to routine. This is a positive step as a third of cancer patients are over 75 years old and in the past many did not get a chance to see a specialist as they were automatically deemed to be too old for treatment.
Some of my colleagues feel that they have become geriatric oncologists by default. However, when I see a patient taking 15 different medications or struggling with incontinence I feel like I’m out of my comfort zone and I often find it hard to assess if a patient will cope with a difficult but potentially curative treatment. As a clinical oncologist (who treat people with radiotherapy), our patients include those who are not suitable for surgery or chemotherapy. We have no specific training in the management of older patients and they are underrepresented in clinical trials leaving us without the evidence that we usually rely on (or think we do).
We spend a lot investigating and staging patient’s cancer, as well as the treatments themselves but currently rarely invest in fully assessing and optimising a patient’s health.
For non-oncologists, unless you are working directly with a cancer MDT, it is difficult to keep up with all the changes that are taking place within the field. Not only are the primary treatments improving but also the preventative management of side effects such as peripheral neuropathy and vomiting. Targeted therapy and immunotherapy are also becoming more common, and although generally well tolerated can have potentially life threatening side effects.
Advances in radiotherapy have also been significant, with more precise treatments reducing the dose to normal tissues and therefore reducing side effects. An example of this is stereotactic ablative body radiotherapy (SABR), which is used to treat patients with early stage lung cancer and has reduced toxicity and improved cure rates compared to standard radiotherapy.
The majority of patients with cancer are treated as outpatients and it is usually only those who are having problems who are admitted to general hospitals. This may skew perception of benefits and toxicities associated with treatment. An over optimistic view can also be problematic, leading to unnecessary investigations and false expectations.
Outcomes for older people with cancer are worse than their younger counterparts and they are less likely to receive treatment with surgery, chemotherapy or radiotherapy. In some cases this may be explained by increasing comorbidities or frailty but this is unlikely to represent the whole picture. In order to improve the situation we need both the skills of the geriatrics and oncology workforce, as well as primary care teams.
Working in a tertiary centre, there feels like there is quite a gulf between oncologists and other specialities. Nurses and allied health professionals are also becoming increasingly specialised. Although some pioneering services have been developed, it is unlikely that the current workforce will be able to support a specialist onco-geriatrics service for all patients.
We therefore do not just need to train experts but also to raise awareness and increase communication between anyone who treats older patients with cancer.
We are running an oncogeriatrics study day at the Christie Hospital in Manchester on 19 July 2019 aimed at all health professionals from both an oncology and geriatrics background. There will be lectures in the morning, with more targeted workshops in the afternoon and above all an opportunity to meet colleagues interested in this area. The event will also be live streamed.
Magnuson, A., Allore, H., Cohen, H. J., Mohile, S. G., Williams, G. R., Chapman, A., … Hurria, A. (2016). Geriatric assessment with management in cancer care: Current evidence and potential mechanisms for future research. Journal of Geriatric Oncology, 7(4), 242–248. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969156/
Hamaker ME, Wildes TM, Rostoft S. Time to Stop Saying Geriatric Assessment Is Too Time Consuming. J Clin Oncol 2017;35:2871–4. doi:10.1200/JCO.2017.72.8170.