Age Biases and Lack of Appropriate Studies Leave Elderly Cancer Patients Undertreated

WASHINGTON, DC-Despitewider interest in geriatric oncology,there remains a "clear pattern of undertreatment"of elderly cancer patientsin the US, manifested in dosereductions and delays that may compromisepatient outcomes, accordingto William B. Ershler, MD."Undertreatment must be avoidedif the best possible outcomes are to beachieved," said Dr. Ershler, Directorof the Institute for Advanced Studiesin Aging and Geriatric Medicine, GeriatricOncology Consortium (GOC),Washington, DC.Speaking at an Amgen-sponsoredsatellite symposium held in conjunctionwith the GOC first annual multidisciplinaryconference, AdvancingCancer Care in the Elderly, Dr. Ershlersaid undertreatment of elderly cancerpatients appears to be independent ofpatient health status. A major factordriving this bias is the fear that olderpatients, because of decreased hematopoieticreserves, are somehow less ableto tolerate standard chemotherapy.However, as described by other presentersat the satellite symposium, correctingmyelosuppression can makestandard-dose chemotherapy possiblein older patients, potentially leadingto better outcomes (see the report onthe presentation by Stuart Lichtman,MD, on page 8 of this issue).To illustrate the negative impact ofundertreatment bias, Dr. Ershler describedthe actual case of a 74-yearoldwoman with cough and weightloss of 3 months' duration. Physicalexamination showed remarkablecachexia, mild dementia, and dehydration.Bronchoscopy revealed smallcelllung cancer.After receiving combined chemoradiationtherapy, the woman gainedweight and her mental status improved.Three years after therapy, therewas no evidence of disease."The point is that this woman'sillness was producing cachexia," Dr.Ershler said. "It wasn't the fact that shewas 74 years old. The tumor somehowmetabolically was influencing her performance."The elderly woman's case underscoresthat clinicians "have to...resistthe temptation to take an ageist perspective,"he added. "The case actuallysupports the notion of geriatric oncology.This would be the person youwould want to treat."Part of the problem may be theperception that older cancer patientshave poorer survival because of theircancer. It may be hard for oncologiststo reconcile perception with reality,given certain statistics, for example,breast cancer registry data showingthat survival is greatest in women upto the age of 50 years, with a distinctdrop-off thereafter.In fact, "tumors are not a priorimore aggressive in older people," Dr.Ershler said. He explained that overthe years, clinicians have claimed thatobserved functional problems have lessto do with the tumor as much as withcomorbidities or all the other problemsolder people may have, whichdiminish their chances of getting theoptimal chemotherapy dose andschedule.Research has shown an overt biasagainst the administration of cancerdrugs to older people. Published datasupport the notion that there is understagingin older patients, particularlythose with lung cancer and lymphoma.In addition, older patients may receiveless informational support andrelevant communication regarding thedisease. In a recent study of older patientswith breast cancer (Cancer97:1517-1527, 2003), researchersfound a negative association betweenthe patient's age and physician provisionof interactive informational support(eg, whether a physician discussedrecurrence risk or treatment options).One barrier to the appropriatetreatment of elderly cancer patients isthe lack of studies specific to that population.A PubMed search for articleson breast cancer, encompassing thelast 20 years, yielded more than 20,000results, Dr. Ershler said. By contrast, asimilar search for aging and canceryielded only 1,707 entries; of those,less than 10% were primary clinicalresearch and only 14 were randomizedclinical trials."This tells me that as the field isevolving, we are writing a lot of reviewpapers and extracting from studieswithout an aging perspective," he said."What we really need is primary research."Data on elderly cancer patients willbecome more important as the populationages. Sometime within the nextfew decades, the portion of the populationin the geriatric age group willclimb to 20%, according to Dr. Ershler.By the year 2020, individuals aged65 years and older will comprise onequarterof the US electorate. "Thisage group has the highest turnout atthe polls," Dr. Ershler said. "If youcould mobilize this 25% to start addressingissues related to health care,they might be able to get some politicalclout."