3 - Cancer in the Elderly Flashcards
____% of all cancers occur in those age 65 or older.
60%
____% of all cancer deaths occur in those age 65 or older.
70%
Why is cancer more common in the elderly?
- Aging
2. Carcinogenesis
How does normal aging increase the frequency of cancer in the elderly?
Immunosenescence DNA repair mechanisms Telomere shortening , ↓ control of cell proliferation ↑ resistance to apoptosis Age-related physiologic changes ↓ tissue integrity
How does carcinogenesis increase the frequency of cancer in the elderly?
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
Describe the phases of carcinogenesis.
- Initiation - Accumulatedgenetic alterations
- Promotion - Clonal expansion, Pre-malignant lesion
- Malignant Transformation (Tumor)
- Progression - Clinical cancer: Tissue invasion Metastases
What are some factors that play into the initiation and promotion stages of carcinogenesis?
Carcinogens
Ionizing radiation
Infection
Spontaneous mutations
Why are Cancer Death Rates High in the Elderly?
- Medical issues limiting standard treatment options
- > Age-related changes in physiology
- > Co-existing chronic medical conditions - 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) - Health care access issues
Younger versus Older Cancer Patients:
review
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
Age-related Physiologic Changes: Renal
Age related loss of nephrons
↓ GFR about 1ml/min/year after age 40
Tubular and interstitial and changes
Age-related Physiologic Changes: Gastric
↓ acid, digestive enzymes
Age-related Physiologic Changes: Hepatic
↓ Liver volume and blood flow about 1% per year
↓ hepatic metabolism and clearance of drugs
Age-related Physiologic Changes: Immune System
↓ 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
Describe differences in treatment preferences for elderly patients.
- In general, preferences of older patients depend on
- Burden of treatment
- Possible outcomes
- Likelihood of outcomes - Many older patients would choose against survival for outcomes of physical or cognitive impairment
- Preferences for outcomes change with age and progression of disease
- Older persons with multiple morbidities can understand concept of competing outcomes and prioritize outcomes to guide decisions
Describe the challenges in providing effective cancer treatment for older patients.
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)
Describe the approach for providing effective cancer treatment for older patients.
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
Cancer treatments:
Surgery
Chemotherapy (includes hormonal therapy and biological agents)
Radiation Therapy
What is the best initial treatment for elderly cancer patients?
Surgery
*Use radiotherapy or chemotherapy for spread to adjacent/regional lymph nodes
True/False
Initial chemotherapy cycle often more difficult than later cycles
True
True/False
Chronologic age is a reliable guide for planning treatment or predicting outcome.
False
Physiologic age and functional status = a better estimate of quality of life, life expectancy, and ability to tolerate cancer treatment
True/False
Most elective surgeries are associated with relatively low mortality risk.
True
What are some new less invasive procedures with less morbidity? (2)
Laparoscopic procedures
Robotic technology
What are some surgical risk factors for elderly patients?
- Emergency surgery or prolonged surgery
- Co-existing disease (especially atherosclerosis, COPD, and diabetes mellitus)
- Poor nutritional status (wound healing, infections)Poor functional status
True/False
Short course radiation therapy is very safe and convenient.
True!
*Relatively little functional impairment compared to surgery and chemotherapy
