Are Elderly Cancer Patients Wrongly Labelled as Palliative_Dr Lesley Young
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Transcript of Are Elderly Cancer Patients Wrongly Labelled as Palliative_Dr Lesley Young
Dr Lesley Young FRCP
Senior Clinical Lecturer, NUMed Malaysia
and
Consultant Geriatrician, City Hospitals Sunderland
Outline Changing demographics
Life expectancy
Prognostic indicators
Cancer and ageing Most cancers occur in older people
Individuals aged 65+ account for:
60% cancer incidence
70% cancer-related mortality (Pal et al Cancer J Clin 2010:60:120-132)
Cancer is the leading cause of death in 60-79 yr olds
Diagnosed with prostate cancer 1997,
aged 66
Diagnosed with bowel cancer 1985, aged 74
Demographics Developed countries have an aging population
Currently around 10% Malaysians >65yrs:
2050: 18-27% >60yrs
There will be an increase in older people, especially in the oldest old
In the UK by 2031
2/3 increase in 65+ (=22% population)
77% increase in 75+
131% increase in 85+
But ....
Life expectancy increases > health expectancy
Source: UK Government Actuary's Dept for Expectation of Life Data. ONS for health life expectancy data
Life expectancy increases > health expectancy
Healthy ageing Many older people are now as fit
as younger people
Is this lady elderly?
What do we mean by “elderly”?
Over 50?
..... 60?....
.......70?....
63
67
74
..........Or even older???
82
81
86
86
94
Life expectancy
country birth 70yrs 80yrs 90 yrs At 100yrs
Malaysia 73.3 81.4 86.7 93.7 102
Singapore 82 86.1 89.7 95.2 102.4
UK 79 85.5 88.9 94.5 102.2
USA 78.1 85.6 89.3 94.9 102.4 0
20
40
60
80
100
120
birth age70
age80
age90
age100
age
life expectancy
Source: world life expectancy.com
In Malaysia the average 80yr old has a life expectancy of 6.7 years
Change with ageing Reduced
Physiological reserve (renal, hepatic, respiratory etc) Functional status Cognition
Increased Co-morbidity Geriatric syndromes
Falls, delirium, frailty etc
Changes affect life expectancy
But: Rate and degree varies hugely between individuals
Life expectancy for US women in years by health status and age (after Walter& Covinsky JAMA 2001)
0
5
10
15
20
25
70 75 80 85 90 95
top quarter middle lower quarter
i.e. 85 yr old in average health can be expected to live a further 6 yrs
Cancer and older people Older cancer patients tend to have worse
survival (EUROCARE 4)
Increasing age gradient for worse survival for all cancers (Quaglia, Eur J Cancer 2009) ..........
Confounding factors Older patients.....
Present later (Busch, Cancer 1996; Bergman, Eur J Cancer 1992,EUROCARE-4 E J
Cancer 2009)
Have increased co-morbidity Co-morbidity, but not age is associated with poorer survival
in NSCLC (Asmis, J Clin Oncol 2008)
Co-morbidity (rather than age) influences the risk of death without recurrence in breast cancer (Ring, J Clin Oncol 2011)
Older cancer patients tend to.... Be under represented in trials
22% trial enrollees vs. 58% cancer patients aged >65yrs (Lee, J Clin
Oncol 2003)
25% enrollees vs. 63% cancer patients aged >65yrs (Hutchins, NEJM
1999)
0102030405060708090
100
lee 2003 hutchins 1999
% cancer patients aged >65 all trial
Older cancer patients tend to be....
Undertreated (Van Leeuwen, Crit Rev Oncol Hematol 2011, Bouchardy, J Clin Oncol 2003, Hanke, Ann Oncol
2010, Chambers, Interact Cardiovasc Thorac Surg 2010)
In breast cancer: 57% under treated according to national guidelines (Van Leeuwen, Crit Rev Oncol Hematol
2011)
47% >80yr old had standard treatment v 91% <80yr (Bouchardy, J Clin Oncol 2003)
Women >75yrs receive less aggressive therapy (JNCCN 2012)
Less likely to be offered surgery (Stapelkamp, BMJ 2010), radiotherapy or chemotherapy (Ring, J Clin Oncol 2011)
AND..........
Under-treatment is associated with worse survival (Van Leeuwen, Crit
Rev Oncol Hematol 2011, JNCCN 2012, Bouchardy, J Clin Oncol 2003)
Factors in under treatment Lack of trial based evidence
Physician perceptions of age
Patient related factors
Low expectations
Difficulty accessing treatment
Lack of information
What is the evidence for treating cancer in the elderly? Few evidenced based trials.......
Older patient derive the same benefit from treatment with Chemotherapy for colorectal cancer (Power, Cancer J 2010)
“Majority of published data does not support a negative correlation between poor outcome and age”
Older patients with good health status tolerate commonly used chemotherapy as well as younger patients (JNCCN 2012)
Breast, Colorectal, NCSLC
However may be more prone to side effects from aggressive treatment
In elderly patients following surgery for early stage lung cancer, no significant difference in 5 yr survival rates or other outcomes (Chambers,
Interact Cardiovasc Thorac Surg 2010)
but older patients more likely to treated palliatively (up to 47% vs. 8% in<65yrs)
Thoracic Radiotherapy is as effective and well tolerated in older as in younger patients (Redmond, Thorac Surg Clin 2009)
Treatment is effective in older patients with NSLC (pallis Ann Oncol 2010)
Determinants of outcome So, if older cancer patients have worse survival, but
evidence suggests cancer treatment is effective in older people.....
What is causing worse outcomes if not age?
Independent Determinants of worse outcome
Significant Not significant Liver metastases (vigano Arch Int med 2000)
Moderate-severe comorbidity (vigano Arch Int med 2000, Pallis Ann Oncol 2010)
Functional impairment (Pallis Ann
Oncol 2010)
Weight loss (vigano Arch Int med 2000)
Low albumen (vigano Arch Int med 2000)
Raised LDH (vigano Arch Int med 2000)
Clinicians estimate of survival <2 months (vigano Arch Int med 2000)
Non-curative resection in bowel cancer (Maeda, Am Surg 2011)
Lymph node metastases in bowel cancer (Maeda, Am Surg 2011)
Age (vigano Arch Int med 2000, Ramos-barcelo Crit Rev
Oncol Hematol 2009, Maeda, Am Surg 2009, Pallis Ann Oncol 2010)
Pain (vigano Arch Int med 2000)
Depression (vigano Arch Int med 2000)
On-going treatment (vigano Arch
Int med 2000)
Performance status (vigano Arch
Int med 2000)
Life expectancy for women in years by health status and age (after Walter& Covinsky JAMA 2001)
0
5
10
15
20
25
70 75 80 85 90 95
top quarter middle lower quarter
The life expectancy of a fit 90 yr old is the same as that of a low health
status 75yr old
Age is not the important factor.. Cancer stage
Co-morbidity
Frailty
Functional impairment
Performance status
Comprehensive Geriatric Assessment
What is CGA? More than just performance status
In patient with good performance status (Repetto, J Clin Oncol
2002), CGA identified... 13% 2+ co-morbidities
9.3% limitations of ADL, 37.7% limitations of IADL
“A multi-dimensional, inter-disciplinary diagnostic process focussed on determining a frail older persons medical, psychological and functional ability, in order to develop a co-ordinated and integrated plan for treatment and long term follow up” (BGS 2005)
CGA can.... Identify potentially treatable problems that would
otherwise adversely affect treatment or outcome ( e.g. depression, malnutrition)
Allow intervention and rehabilitation
Predict outcome (Pal, Ca Cancer J Clin 2010)
In geriatric medicine functional status is a strong predictor of morbidity and mortality
Predict toxicity from therapy (Wymenga, proc am soc clin oncol 2007, Palis, Ann Oncol 2010)
Guide decision making (Tucci, Cancer 2009)
CGA “unfit” lymphoma patients did as well with palliative treatment as with chemotherapy with curative intent
CGA includes.... Functional status
Co-morbid conditions
Cognition
Nutritional status
Psychological state
Social support
Medication review
CGA in practice Medical assessment:
Problem list
Co-morbid conditions and disease severity
Medication review
Nutritional status – MUST, SNAQ
Assessment of functioning ADL – Barthel Index
IADL -
Activity / exercise status
Gait/ balance – TUG
Psychological assessment Cognitive testing – MMSE
/ AMTS
Mood / depression - GDS / HADS
Social assessment Formal and informal
Financial
Environmental assessment Home safety
Aids and appliances
Transport
Assessment
Plan
Treatment Rehabilitation
Follow up
CGA
Does patient have sufficient life expectancy to be at moderate /high risk of dying or suffering form cancer in that lifetime?
Symptom management/ supportive care
Does the patient want cancer treatment?
Symptom management/ supportive care
Assess risk factors (CGA)
Treat according to best practise
Are risk factors modifiable?
Consider alternate treatment options to reduce toxicity
Treat risk factors
Consider alternate treatment options to reduce toxicity
Treat according to best practise
After NCCN senior adult oncology guidelines, JNCCN 2012
Are elderly cancer patients wrongly labelled as palliative?
If judged by chronological age alone? YES
Look at the bigger picture
Thank you