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Geriatrics Exam Prep > 3 - Cancer in the Elderly > Flashcards

3 - Cancer in the Elderly Flashcards

1
Q

____% of all cancers occur in those age 65 or older.

A

60%

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2
Q

____% of all cancer deaths occur in those age 65 or older.

A

70%

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3
Q

Why is cancer more common in the elderly?

A
  1. Aging

2. Carcinogenesis

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4
Q

How does normal aging increase the frequency of cancer in the elderly?

A 
Immunosenescence
DNA repair mechanisms
Telomere shortening , ↓ control of cell proliferation
↑ resistance to apoptosis
Age-related physiologic changes
↓ tissue integrity
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5
Q

How does carcinogenesis increase the frequency of cancer in the elderly?

A 
Carcinogenesis takes time!
Immune surveillance
Susceptibility to carcinogens
Genetic instability
Oncogene activation
Tumor suppressor gene mutation
↓clearance of damaged cells
Altered tissue micro-environment
↓ barriers to tumor invasion
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6
Q

Describe the phases of carcinogenesis.

A
  1. Initiation - Accumulatedgenetic alterations
  2. Promotion - Clonal expansion, Pre-malignant lesion
  3. Malignant Transformation (Tumor)
  4. Progression - Clinical cancer: Tissue invasion Metastases
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7
Q

What are some factors that play into the initiation and promotion stages of carcinogenesis?

A

Carcinogens
Ionizing radiation
Infection
Spontaneous mutations

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8
Q

Why are Cancer Death Rates High in the Elderly?

A
  1. Medical issues limiting standard treatment options
    - > Age-related changes in physiology
    - > Co-existing chronic medical conditions
  2. Age bias within the health care system
    - > Under-treatment (“Cancer therapy too dangerous for older patients.”)
    - > Reduced participation in cancer screening programs (Delayed diagnosis)
    - > Under-representation in clinical trials (Efficacy of treatment)
  3. Health care access issues
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9
Q

Younger versus Older Cancer Patients:

review

A

Age-related changes in physiology complicate treatment
Cancer occurs in the setting of multiple chronic conditions in older patients.
Medical decision-making styles differ between young and old.
Preferences for treatment outcomes change with age.
Physical and cognitive function are major concerns in maintaining independence.
Competing risks may obviate treatment

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10
Q

Age-related Physiologic Changes: Renal

A

Age related loss of nephrons
↓ GFR about 1ml/min/year after age 40
Tubular and interstitial and changes

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11
Q

Age-related Physiologic Changes: Gastric

A

↓ acid, digestive enzymes

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12
Q

Age-related Physiologic Changes: Hepatic

A

↓ Liver volume and blood flow about 1% per year

↓ hepatic metabolism and clearance of drugs

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13
Q

Age-related Physiologic Changes: Immune System

A

↓ bone marrow reserve
Macrophages:↓phagocytic activity, oxidative burst and MHC classII expression
NK cells: ↓cytotoxicity, cytokine /chemokine production, and proliferative response to IL-2
↑serum levels of IL-6,IL-1β, TNF-α

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14
Q

Describe differences in treatment preferences for elderly patients.

A
  1. In general, preferences of older patients depend on
    - Burden of treatment
    - Possible outcomes
    - Likelihood of outcomes
  2. Many older patients would choose against survival for outcomes of physical or cognitive impairment
  3. Preferences for outcomes change with age and progression of disease
  4. Older persons with multiple morbidities can understand concept of competing outcomes and prioritize outcomes to guide decisions
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15
Q

Describe the challenges in providing effective cancer treatment for older patients.

A

Common comorbidities may limit therapeutic options
Age-related physiologic changes may impact toxicities
↓ reserve may delay recovery of functional status
Prognostic indices not validated in older patients
Optimal treatment for elders often not known (clinical trial exclusions)

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16
Q

Describe the approach for providing effective cancer treatment for older patients.

A

Careful medical evaluation of comorbidities and physiologic status
Proactive approach to prevent potential complications
Early involvement of cancer rehabilitation team
Cautious prognostication
Clinical research protocols designed for older patients

17
Q

Cancer treatments:

A

Surgery
Chemotherapy (includes hormonal therapy and biological agents)
Radiation Therapy

18
Q

What is the best initial treatment for elderly cancer patients?

A

Surgery

*Use radiotherapy or chemotherapy for spread to adjacent/regional lymph nodes

19
Q

True/False

Initial chemotherapy cycle often more difficult than later cycles

A

True

20
Q

True/False

Chronologic age is a reliable guide for planning treatment or predicting outcome.

A

False

Physiologic age and functional status = a better estimate of quality of life, life expectancy, and ability to tolerate cancer treatment

21
Q

True/False

Most elective surgeries are associated with relatively low mortality risk.

A

True

22
Q

What are some new less invasive procedures with less morbidity? (2)

A

Laparoscopic procedures

Robotic technology

23
Q

What are some surgical risk factors for elderly patients?

A
  1. Emergency surgery or prolonged surgery
  2. Co-existing disease (especially atherosclerosis, COPD, and diabetes mellitus)
  3. Poor nutritional status (wound healing, infections)Poor functional status
24
Q

True/False

Short course radiation therapy is very safe and convenient.

A

True!

*Relatively little functional impairment compared to surgery and chemotherapy

25
Q

What are the major risks of radiation therapy?

A
  1. Mucositis (dehydration, malnourishment, sepsis)

2. Radiation pneumonitis

26
Q

What is especially problematic about using chemotherapy in elderly patients?

A

Increased susceptibility to drug toxicity

  • Decreased functional reserves
  • Co-existing disease
  • Altered metabolism and distribution of drugs

Decreased treatment effectiveness due to dose reductions related to drug toxicities

27
Q

What are some common drug toxicities related to chemotherapy?

A

Neutopenia and sepsis
Thrombocytopenia and bleeding
Anemia → fatigue, cardiopulmonary decompensation
Vomiting/diarrhea → dehydration, anorexia and malnutrition
Renal impairment
Neurotoxicity
Cardiotoxicity

28
Q

True/False

Frailty can be used as an indicator of poor outcomes.

A

True

29
Q 
What can frailty tell you about:
Morbidity?
Mortality?
Surgical outcomes?
Chemotherapy problems?
A

Morbidity (↑ falls, ADL disability, hospitalizations)

Mortality (5-year mortality)

Surgical Outcomes
Independent predictor of postoperative complications, LOS, and discharge to skilled nursing or assisted living facilities
Improved predictive power of anesthesia risk indices

Chemotherapy
↑ probability of not completing treatment
↑mortality with chemotherapy

30
Q

What are the components of the “frailty index”?

A 
Age > 85
ADL dependence > 1
Co-morbid conditions > 3
Geriatric syndromes > 1
Unintentional weight loss
Significant muscular weakness and fatigue
--------------------------------------------------------
Unintentional weight loss
Slow walking speed
Subjective exhaustion
Low grip strength
Low levels of physical activity
31
Q

How is frailty used to determine tx planning?

A

Frailty:
Yes -> palliative treatment
No -> life-prolonging treatment
Don’t know -> individualized treatment

32
Q

What are the components of the supportive care program for elderly cancer patients?

A
  1. Nutritional support
  2. Medical support
  3. Psychosocial support
    (for patient and caregivers)
  4. Physical/occupational therapy
33
Q

Who are the major players in the patient care team for elderly cancer patients?

A

Primary care provider
Oncology specialists (surgical, medical, radiation oncologists)
Cancer rehabilitation and supportive care providers
Family and other caregivers

34
Q

What are some things to remember when treating elderly cancer patients?

(review)

A

Do not abandon your patient with cancer
Consider the entire patient in your management decisions
Focus on preserving physical and cognitive function
Respect your older patient’s values and preferences
Treat pain! Pain is often undertreated in the elderly.

35
Q

How should you treat patients without cancer (in terms of prevention)?

A 
Cancer risk assessment as part of geriatric assessment
Cancer prevention (screening) as part of routine care

Geriatrics Exam Prep (5 decks)

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