Older Cancer Patients Benefit From Geriatric Assessment

FT. LAUDERDALE, Fla—Older cancer patients are at increased risk for complications of chemotherapy, and such risks must be weighed against the potential benefits of treatment. However, chronologic age is an imprecise gauge of physical condition. A geriatric assessment can help the physician determine the best approach to cancer treatment, Lodovico Balducci, MD, said at the fifth annual conference of the National Comprehensive Cancer Network (NCCN).

Dr. Balducci is co-chair of the NCCN Senior Adult Care Task Force, along with Jerome W. Yates, MD, MPH, of Roswell Park Cancer Institute. Dr. Balducci is professor of medicine and program leader of the Senior Adult Oncology Program, H. Lee Moffitt Cancer Center & Research Institute of the University of South Florida, Tampa.

“Age by itself is not a contraindication to cancer treatment,” Dr. Balducci said. However, in frail individuals who are already barely able to dress and bathe themselves, cancer treatment may hasten the loss of independence, he noted.

Very old patients with a limited life expectancy stand to gain less from cancer treatment than other senior adults. “This is the difficulty,” Dr. Balducci said. “As you age, the benefits do decline, and the risks do increase. Here stands the knot of our decisions.”

A geriatric age assessment can help the physician evaluate the risks of cancer treatment for a particular patient. This is important because chronologic age is a poor predictor of functionality. “The elderly are a very diverse population, and we need to have a uniform assessment to allow patients to be stratified according to risk,” Dr. Balducci said.

Not every patient will need a comprehensive geriatric assessment, but screening for such an assessment should begin at age 70. “The geriatric evaluation can provide us with some evidence about survival and also tolerance of treatment in these older people,” Dr. Balducci said.

Screening involves simply asking each patient a number of questions directed at determining emotional status, ability to perform activities of daily living, and social support. Comorbid conditions would also be evaluated at this time. The screening test proposed by the task force is modified from a screening instrument described by Lachs et al (Ann Intern Med 112:699-706, 1990).

Depending upon the results of the screening test, a more extensive geriatric assessment may be needed. “The assessment does not have to be provided by an oncologist, but if nobody else has done it, I think it behooves the oncologist to do it,” Dr. Balducci said.

The assessment will identify frail persons who have exhausted most of their functional reserves and are best served by palliative rather than curative treatment.

Frailty is said to exist when a person exhibits dependence in one or more activities of daily living, or at least three comorbid conditions, or at least one geriatric syndrome. Geriatric syndromes include spontaneous fractures, frequent falls, severe dementia, severe depression, and incontinence.

“A number of questions arise when elderly patients undergo chemotherapy,” he said. “Should hematopoietic growth factors be used? At what level should hemoglobin be maintained? Should chemotherapy doses be adjusted?”

Studies have shown that routine prophylactic use of hematopoietic growth factors (G-CSF, GM-CSF) can reduce the risk of myelodepression in patients receiving myelotoxic chemotherapy regimens, Dr. Balducci said. For this reason, the task force is proposing guidelines that recommend the use of hematopoietic growth factors in patients aged 70 and over receiving moderately toxic chemotherapy regimens.

The task force is also recommending hematopoietic growth factors for patients aged 60 and over who are receiving induction or consolidation chemotherapy for acute myelogenous leukemia (AML). Studies have shown that the use of growth factors in these patients reduces the duration of hospitalization and may increase therapeutic response, Dr. Balducci said.

Anemia-related fatigue should be prevented by maintaining hemoglobin levels at or above 12 g/dL with an erythropoietin preparation, the task force proposed. Two studies presented at the 1999 annual meeting of the American Society of Clinical Oncology support this approach.

The forthcoming NCCN’s guidelines for the management of cancer in older persons will offer a step-by-step decision tree to help physicians individualize cancer treatment for elderly patients.

The task force encouraged physicians to consider adjusting the dose of drugs excreted through the kidneys to the measured glomerular filtration rate. However, it urged clinicians to escalate dosages if no toxicity occurs at lower dosages in order to ensure the effectiveness of the therapy.

The task force also recommended the use of less toxic alternatives to doxorubicin in patients aged 70 and over.