ANZIANI E CANCRO
CHE E COME FARE
Prof. Roberto Bernabei
Università
Università Cattolica del Sacro Cuore
Roma
ANZIANI E CANCRO
Future of Cancer Incidence in the United States:
Burdens Upon an Aging, Changing Nation
Smith B D et al. JCO 2009;27:2758-2765
©2009 by American Society of Clinical Oncology
Projected cases of all invasive cancers in the United States by age and sex.
Smith B D et al. JCO 2009;27:2758-2765
©2009 by American Society of Clinical Oncology
Providing Cancer Care to a Graying and
Diverse Cancer Population in the 21st Century:
Are We Prepared?
2010
2030
By 2030 elderly 70% all cancer diagnosis
+45%
1.600.000
cancer patients
2.300.000
cancer patients
Influence treatment effectiveness
Cancer Demographics
Genetic
Age
Molecular
Race
Cellular
Ethnicity
Physiologic effects
J. McKoy, A. Samara, C.Bennett; J Clin Oncol 27:1-2, 2009
Gemcitabine and
Bevacizumab resulted
in a superior response
rate, time to
progression, and
survival than expected
with gemcitabine
alone.
2 WEEKS
2,020 €/SD
Kaplan-Meier Curve of Overall Survival by VEGF
Myths & misconceptions
• The elderly do not want to be treated (“leave me alone”)
• The elderly are not able to cope with chemotherapy
– They are too frail to cope with treatment
– They would find side‐effects too burdensome
– Their QoL would suffer
• They may find discussions about treatment options too stressful and
want less information
• Geriatric assessment...too long!
The elderly do not want to be treated
(“leave me alone”
alone”)
The Reality
„ Patient preferences in the elderly are different from those of
physicians, nurses, and caregivers
French
Cancer
patients
US
Non-cancer Cancer
patients
patients
Non-cancer
patients
Percentage willing to
accept strong
chemotherapy
77.8
34.0
70.5
73.8
Percentage willing to
accept mild
chemotherapy
100
67.9
88.5
95.2
Age range: 70–95 years; 29% aged >80 years
1. Extermann et al. J Clin Oncol 2003;21:3214–3219.
2. Slevin M et al. Br Med J 1990;300:1458–1460.
3. Bremnes RM et al. Eur J Cancer 1995;31:1955–1959.
Myths & misconceptions
• The elderly do not want to be treated (“leave me alone”)
• The elderly are not able to cope with chemotherapy
– They are too frail to cope with treatment
– They would find side‐effects too burdensome
– Their QoL would suffer
• They may find discussions about treatment options too stressful and
want less information
• Geriatric assessment...too long!
The elderly are not able to cope with chemotherapy
• Age is not a contraindication to full‐dose chemotherapy
– Chronological age does not reflect functional reserve or frailty of patient
• Side‐effect management should be tailored to the individual and
based on treatment‐related toxicities and the results of complete
geriatric assessment
The elderly are not able to cope with chemotherapy
`
407 women > 80 years old
`
50% undertreated
– No surgery! or tumourectomy without radiation
`
Reasons
– Refusal (patients) : 14%
– Physician or family decided…
`
5 year survival
– « State of the art » : 90%
– Lesser therapy : 46%
Bouchardy et al. J Clin Oncol 2003;21;3580–3587.
Chemotherapy and the elderly
`
What are the true limitations?
– Renal function
– Liver function
– Drug distribution and absorption
– Drug interactions
– Marrow reserves
– Neurologic
– Multimorbidity (malfunctioning)
Multimorbidity
Effect of diabetes on disease free-survival
in an intergroup adjuvant trial in colon cancer.
Meyerhardt JA et col,J Clin Oncol. 2003;21:433-440.
Hyperinsulinemia is associated with a worse disease-specific survival
in prostate cancer, colon cancer and breast cancer.
Meyerhardt JA et col,J Clin Oncol 21:433-440,2003
Hammarsten J, Eur. J Cancer 41:2887-2895, 2005.
Goodwin PJ et col., J Clin Oncol 20:42-51, 2002
Obesity is associated with a worse progression-free survival (PFS) in
patients with ovarian cancer.
Pavelka JC et al, Cancer 107:1520-1524, 2006
Chemotherapy and the elderly
Conclusions Standard adjuvant chemotherapy is superior to capecitabine
in patients with early-stage breast cancer who are 65 years of age or
older. (ClinicalTrials.gov number, NCT00024102 [ClinicalTrials.gov]
H.Muss, E.Winer et coll, CALGB investigators; NEJM 360:2055-65 2009
Baseline Characteristics of
the Patients
Kaplan–Meier Estimates of Relapse-free and Overall Survival According to Treatment Group.
H.Muss, E.Winer et coll, CALGB investigators; NEJM 360:2055-65 2009
Kaplan–Meier Estimates of Relapse-free and
Overall Survival According to Treatment Group.
Outcomes at a Median Follow-up of 2.4 Years.
Adverse Event
H.Muss, E.Winer et coll, CALGB investigators; NEJM 360:2055-65 2009
Myths & misconceptions
• The elderly do not want to be treated (“leave me alone”)
• The elderly are not able to cope with chemotherapy
– They are too frail to cope with treatment
– They would find side‐effects too burdensome
– Their QoL would suffer
• They may find discussions about treatment options too stressful and
want less information
• Geriatric assessment...too long!
They may find discussions about treatment options
too stressful and want less information
„ Jenkins et al examined the information needs of 2,331 cancer
patients, 585 (25%) with breast cancer, 145 (6%) with urological
cancer
Jenkins V et al. B J Cancer 2001;84:48–51.
Myths & misconceptions
• The elderly do not want to be treated (“leave me alone”)
• The elderly are not able to cope with chemotherapy
– They are too frail to cope with treatment
– They would find side‐effects too burdensome
– Their QoL would suffer
• They may find discussions about treatment options too stressful and
want less information
• Geriatric assessment...too long!
What does a CGA bring?
Setting
Intervention
Risk reduction for
mortality
Elderly
Comprehensive
geriatric assessment
14%
Breast cancer
Adjuvant chemotherapy
15.3%
Myocardial infarction
Beta-blocker
22%
Extermann M, Aapro M. Hematol/Oncol Clins North Am 2000;14:63–77.
CGA profiles of oncogeriatric population in
various settings
Assessments
Oncogeriatric
Outpatient US
Oncogeritatric
Out/inpatient
Itay
VA Oncogeriatric
Outpatient US
IM/Ger Inpatient
Canada
OACE US
Age, years
75
72
68
79
74
ECOG 0-1
83
74
ADL independent,%
79
86
31
44
55
IADL independent,%
44
52
42
34
26
26 (GDS)
40 (GDS)
14 – 26 (HADS)
25 (MMSE<26)
37.8 (MMSE<24)
Depression, %
Cognitive impairment,%
Comorbidity, %
Polypharmacy
94 (CIRS)
24 (GDS)
Mean MMSE 22
51 (Clock)
5 (OARS)
6 (mean) meds
6 (mean)
meds
Geriatric syndromes, %
Disability, %
Extermann M, Hurria A, J Clin Oncol 25:1824-1831, 2007
Elderly patients with cancer:
cancer summary
• Optimal therapy has the same efficacy in older and younger patients
• Treatment tolerance is similar in older and younger patients
- exception of haematotoxicity (G-CSF)
• Assess first, treat later
• Chronological age not have to guide treatment decisions for elderly
cancer patients. Tumour biology, patient’s wishes and physical
condition should.
ANZIANI E CANCRO
COME FARE
GERIATRIC ONCOLOGY
….IS GERIATRIC?
A short history of cancer treatment in the elderly
NCCN
guidelines
US Geriatric
Oncology
Consortium
National Cancer
Institute &
National Institute
in Ageing sponsor
a symposium
Perspectives on
prevention and
treatment of
cancer in the
elderly
1983
1983
International
The Venice
statement. 1
Cancer in
the elderly:
why treated
so badly?
1988
1988
Dr BJ Kennedy
encouraged the
study of ageing
and cancer
during the
Presidential
Address at
1990
1990
Society of
Geriatric
Oncology
(SIOG)
formed
1998
1998
First edition of
2000
2000
Comprehensive
Geriatric
Oncology
released
published
practice
guidelines for
senior adult
oncology4
founded to
initiate trials
and raise
awareness of
problems of
elderly patients
2002
2002
2003
2003
First oncogeriatric
guidelines
published on
the use of
haematopoietic
growth factors in
elderly patients
receiving
cytotoxic
chemotherapy2
ASCO 1988
1. Fentiman IS et al. Lancet 1990;335:1020-1022, 2. Bokemeyer C et al. Onkologie 2002; 25: 32–39,
3. Extermann M et al. Crit Rev Oncol Hematol 2005; 55: 241–252, 4. Balducci L. NCCN clinical practice
guidelines in oncology. Senior Adult Oncology November 1, 2006, 5. J Clin Oncol 2007;25:1821–1944, 6. Eur J
Cancer 2007;15:2141–2306.
2005
2005
CGA
guidelines
assessed by
the SIOG.3
2006
2006
2007
2007
Special
supplements
in geriatric
oncology
published in
JCO and EJC5,6
The Geriatric evaluation of elderly patients
with cancer
`
`
`
Is this patient going to die of cancer or with cancer ?
Is this patient going to live long enough to suffer the consequences
of cancer ?
Is my patient able to tolerate the treatment ?
`
Are some complications of cancer treatment more common in
older individuals?
`
Is the social network of my patient adequate to support him or her
during the treatment ?
How is my patient “functioning”
`
Multidisciplinary team
All older cancer patients
Community
Long Term Care
Hospital
Facility Hospice
SCREENING (oncologist or geriatrician)
FIT
FRAIL
FRAIL
GERIATRICIAN (CGA)
Oncologist
Interdisciplinary Team:
Oncologist, Geriatrician, Physical therapist,
Usual Care
Geriatric palliative care
Professional Nurse, Psycho‐oncologist,
Social Worker……….
Modified approach
Palliative Oncology
Piano Oncologico Nazionale 2010/12
Integrazione/coordinamento dell’assistenza
intra ed extraospedaliera al paziente anziano.
E’ necessario garantire una presa in carico
globale del paziente anziano con cancro dall’inizio
del percorso diagnostico e terapeutico, attraverso
un approccio multidisciplinare e multidimensionale
sostenuto da un’organizzazione dipartimentale
che garantisca il coordinamento dell’assistenza e
delle cure oncologiche e geriatriche sia
ospedaliere sia territoriali, Unità di
Coordinamento di Onco-Geriatria. Tali Unità,
da istituirsi presso le Aziende Ospedaliere e
IRCCS di riferimento regionale, devono avere al
loro interno le competenze oncologiche e
geriatriche e devono essere in grado di gestire
direttamente le prestazioni sanitarie erogate al
paziente anziano.
2010
Workgroup oncologia geriatrica
InterRAI-cancer unica VMD per il paziente anziano
oncologico
Survey per gli oncologi
Survey per i geriatri
SURVEY 2010
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Quanti pazienti di eta’ >80 anni affetti da neoplasia sono stati visti
presso la tua struttura nell’ultimo anno?
Quale percentuale rappresentano?
Ritieni che un paziente neoplastico di eta’ >70 anni vada trattato,
se le sue condizioni generali lo consentano, con gli stessi protocolli
terapeutici utilizzati per gli adulti di eta’ inferiore a 70 anni?
Ritieni utile la creazione di protocolli terapeutici dedicati ai
pazienti con neoplasia di eta’ > 70 anni?
E’ necessaria una sezione di oncologia che si interessi dei pazienti
con eta’ superiore ai 70 anni?
SURVEY 2010
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Quante consulenze geriatriche ti sono state richieste dagli oncologi
in quest’ultimo mese?
Ritieni utile frequentare programmi formativi aventi per argomento
la gestione del paziente oncologico anziano?
L’assistenza del paziente oncologico anziano rappresenta per te
un problema?
Ritieni utile uno strumento di screening per il paziente oncologico
anziano?
INTERRAI-CANCER
Journal of Clinical Oncology Vol 21,April 2003: 1383-1389
Participation of Patients 65 Years of Age or Older in Cancer Clinical Trials
Joy H. Lewis, Meredith L. Kilgore, Dana P. Goldman, Edward L. Trimble, Richard Kaplan, Michael J. Montello, Michael
G. Housman, José J. Escarce
From RAND Health, Santa Monica; the University of California Los Angeles and the West Los Angeles Veterans Affairs Medical
Center, Los Angeles, CA; and the National Institutes of Health, National Cancer Institute, Bethesda, MD.
Purpose: Although 61% of new cases of cancer occur among the elderly, recent studies indicate that the elderly comprise only
25% of participants in cancer clinical trials. Further investigation into the reasons for low elderly participation is warranted. Our
objective was to evaluate the participation of the elderly in clinical trials sponsored by the National Cancer Institute (NCI) and
assess the impact of protocol exclusion criteria on elderly participation.
Patients and Methods: We conducted a retrospective analysis using NCI data, analyzing patient and trial characteristics for
59,300 patients enrolled onto 495 NCI-sponsored, cooperative group trials, active from 1997 through 2000. Our main outcome
measure was the proportion of elderly patients enrolled onto cancer clinical trials compared with the proportion of incident
cancer patients who are elderly.
Results: Overall, 32% of participants in phase II and III clinical trials were elderly, compared with 61% of patients with incident
cancers in the United States who are elderly. The degree of underrepresentation was more pronounced in trials for early-stage
cancers than in trials for late-stage cancers (P < .001). Furthermore, protocol exclusion criteria on the basis of organ-system
abnormalities and functional status limitations were associated with lower elderly participation. We estimate that if protocol
exclusions were relaxed, elderly participation in cancer trials would be 60%.
Conclusion: The elderly are underrepresented in cancer clinical trials relative to their disease burden. Older patients are more
likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions. Insurance coverage
for clinical trials is one step toward improvement of elderly access to clinical trials. Without a change in study design or
requirements, this step may not be sufficient.