Cancer in the Elderly Flashcards
What percent of cancer patients are geriatric patients?
60% of all cancers occur in those age 65 or older.
What percent of cancer deaths occur in the geriatric population?
70% of all cancer deaths occur in those age 65 or older.
What portion of the population are considered geriatric?
Persons older than 65 account for 13% of U.S. population.
What are the factors of aging that aid cancer growth in the elderly?
Immunosenescence DNA repair mechanisms Telomere shortening , decreased control of cell proliferation increased resistance to apoptosis Age-related physiologic changes decreased tissue integrity
What factors of carcinogenesis allow cancer to more readily infect the elderly?
Immune surveillance Susceptibility to carcinogens Genetic instability Oncogene activation Tumor suppressor gene mutation decreased clearance of damaged cells Altered tissue micro-environment decreased barriers to tumor invasion
Why is Cancer More Common in the Elderly?
Cancer takes time!
What are the stages of cancer growth?
Initiation
Promotion
Malignant Transformation (Tumor)
Progression
What happens during the initiation phase?
Accumulatedgenetic alterations
What happens during the promotion phase?
Clonal expansion
Pre-malignant lesion
What happens during the Malignant Transformation phase?
The tumor develops
What happens during the Progression phase?
Clinical cancer: Tissue invasion Metastases
What factors promote tumor growth in the initiation and promotion phases?
Carcinogens
Ionizing radiation
Infection
Spontaneous mutations
Why are Cancer Death Rates High in the Elderly?
Medical issues limiting standard treatment options
Age bias within the health care system
Health care access issues
What are types of medical issues, related to the elderly, that limit standard tx options?
Age-related changes in physiology
Co-existing chronic medical conditions
What are types of age biases, related to the elderly, that limit standard tx options?
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)
What are types of health care access issues, related to the elderly, that limit standard tx options?
Transportation
Finances
T/F: Age-related changes in physiology complicate treatment.
True
T/F: Cancer occurs in the setting of multiple chronic conditions in older patients.
True
T/F: Medical decision-making styles do not differ between young and old.
False
T/F: Preferences for treatment outcomes doesn’t change with age.
False
T/F: Physical and cognitive function are major concerns in maintaining independence.
True
T/F: Competing risks may obviate treatment.
True
What are Age-related Physiologic Changes in the renal system?
Age related loss of nephrons
decreased GFR about 1ml/min/year after age 40
Tubular and interstitial and changes
What are Age-related Physiologic Changes in the GI system?
decreased acid, digestive enzymes
What are Age-related Physiologic Changes in the hepatic system?
decreased Liver volume and blood flow about 1% per year
decreased hepatic metabolism and clearance of drugs
What are Age-related Physiologic Changes in the immune system?
decreased bone marrow reserve
Macrophages:↓phagocytic activity, oxidative burst and MHC classII expression
NK cells: decreased cytotoxicity, cytokine /chemokine production, and proliferative response to IL-2
increased serum levels of IL-6,IL-1β, TNF-α
Why does GFR ↑ or remain stable in about 1/3 of adults after age 40 years?
idk
Does age-related ↓ GFR progress to ESRD?
idk
Is age-related decrease in GFR independently associated with morbidity, mortality, or disability?
idk
What do the treatment preferences in a geriatric patient depend on?
Burden of treatment
Possible outcomes
Likelihood of outcomes
What to geriatric patients more likely to choose when deciding between survival and a treatment that causes physical/cognitive impairment?
Many older patients would choose against survival for outcomes of physical or cognitive impairment
T/F: Preferences for outcomes don’t change with age but do with the progression of disease
False, Preferences for outcomes change with age and progression of disease
T/F: Older persons with multiple morbidities can understand concept of competing outcomes and prioritize outcomes to guide decisions
True
What are challenges for effective treatment of cancer in elderly adults?
- Common comorbidities limit therapeutic options
- Age-related physiologic changes may impact toxicities
- Decrease in reserve may delay recovery of functional status
- Prognostic indices not validated in older patients
- Optimal treatment for elders often not known (clinical trial exclusions)
What are the guidelines for how we should approach effective treatment in older adults?
- 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
What are general approaches for cancer treatment?
Primary treatment modalities
Surgery
Chemotherapy
Radiation Therapy
Initial therapy
Surgery or radiation therapy for control of primary tumor
Radiotherapy or chemotherapy
Chemotherapy for systemic (metastatic) disease
Focal radiation therapy for symptomatic lesions
Tolerability
Initial chemotherapy cycle often more difficult than later cycles
Cumulative toxicity with chemotherapy and radiation therapy
What does chemotherapy treatment for cancer in the elderly include?
includes hormonal therapy and biological agents
What is the best opportunity for cure or control with cancer in the elderly?
Initial therapy
What has to be examined before surgery or radiation in attempting to control a primary tumor?
Histological assessment of adjacent/regional lymph nodes
When do we use radiotherapy or chemotherapy?
For spread to adjacent/regional lymph nodes
What type of therapy do we used for symptomatic lesions?
Focal radiation therapy for symptomatic lesions
What is significant about the initial treatment of chemotherapy?
Initial chemotherapy cycle often more difficult than later cycles
How do we assess and deduce what the treatment goals will be for a geriatric patient?
Treatment goals – ASK!
What are the types of treatment goals?
- Cure
- Long-term disease control & prolongation of life
- Palliative/supportive care
- Hospice/end-of-life care (comfort)
What does palliative/supportive care include as a treatment goal for geriatric cancers?
Control symptoms, optimize function
T/F: Chronologic age alone (<85) is a reliable guide for planning treatment or predicting outcome.
FALSE, it is not a reliable guide
What do we have to consider about aging and treatment options for each individual geriatric patient?
Effects of aging vary among individual patients
Rates of loss of functional reserves vary from organ to organ in any single individual
What is a good estimate of quality of life, life expectancy, and ability to tolerate cancer treatment in geriatric patients? How do we find this out?
Physiologic age and functional status – ASSESS!
What components can affect the treatment options of a geriatric patient?
Co-morbidity, physiologic function, and functional status
What is the most effective therapy for local control of many malignancies?
Surgery
What are most elective surgeries associated with in geriatric patients?
relatively low mortality risk
What are new less invasive procedures with less morbidity?
Laparoscopic procedures
Robotic technology
What are surgical risk factors for the elderly?
Emergency surgery or prolonged surgery
Co-existing disease
Poor nutritional status
Poor functional status
What are examples of co-existing diseases that can cause surgical risk factors for the elderly?
atherosclerosis, COPD, and diabetes mellitus
Why is poor nutritional status a risk factor for surgery?
decreased wound healing
increased infections
Describe radiation treatment and its use in the elderly?
Its a safe and effective curative and palliative therapy for localized cancer in the elderly
What is the risk of functional impairment for the elderly in regards to surgery or chemotherapy?
Relatively little functional impairment compared to surgery and chemotherapy
What are the major risks associated with radiation therapy?
Mucositis (dehydration, malnourishment, sepsis)
Radiation pneumonitis
Is short course RT very safe for elderly patients?
Yes, short course RT is very safe AND convenient (especially for sick patients)
What is a common chemotherapy treatment issue with geriatric patients ?
Decreased treatment effectiveness due to dose reductions related to drug toxicities
Why are elderly patients on chemotherapy more susceptible to drug toxicity?
- Decreased functional reserves
- Co-existing disease
- Altered metabolism and distribution of drugs
What are common drug toxicities in the elderly on chemotherapy?
Neutopenia and sepsis
Thrombocytopenia and bleeding
Anemia leading to fatigue and cardiopulmonary decompensation
V/D causing dehydration, anorexia and malnutrition
Renal impairment
Neurotoxicity
Cardiotoxicity
Frailty as a predictor of poor outcomes
Morbidity
Mortality (5-year mortality)
Surgical Outcomes
Chemotherapy
What is frailty a predictor of poor outcomes for?
Morbidity
Mortality
Surgery
Chemotherapy
How does frailty lead to an increase in morbidity?
Increases falls, ADL disability and hospitalizations
How is frailty a good predictor of poor out comes for surgery?
Independent predictor of postoperative complications, LOS, and discharge to skilled nursing or assisted living facilities
Improved predictive power of anesthesia risk indices
What effect does frailty have on geriatric patients receiving chemotherapy?
increases the probability of not completing treatment
increases mortality with chemotherapy
What is conceptualized as a global phenotype of physiologic reserves and resistance to stressors?
Frailty
In surgery, what has frailty been associated with?
In nonsurgical populations, this phenotype has been associated with adverse health outcomes.
What is frailty?
physical weakness : the quality or state of being frail
What is the “frailty index”?
Age > 85 ADL dependence > 1 Co-morbid conditions > 3 Geriatric syndromes > 1 Unintentional weight loss Significant muscular weakness and fatigue
What is the frailty index fried?
Unintentional weight loss Slow walking speed Subjective exhaustion Low grip strength Low levels of physical activity
When assessing frailty you find them to not be deemed “frail”, what does this mean? What is their treatment strategy?
They are independent, mobile, have good nutrition and limited co-morbidity
Life-Prolonging treatment
When assessing frailty you find them to be deemed “intermediate”, what does this mean? What is their treatment strategy?
They are borderline
Individualize Treatment
When assessing frailty you find them to be deemed “frail”, what does this mean? What is their treatment strategy?
They have poor ADL functions, poor nutrition and/or significant co-morbidities
Palliative Treatment
What is the Supportive Care Program for elderly patients with cancer?
Nutritional support
Medical support
Psychosocial support
Physical/occupational therapy
What is involved in nutritional support for elderly patients with cancer?
Dietary counseling, dietary supplements, enteral feeding (G/J tube)
What is involved in medical support for elderly patients with cancer?
Anemia
Neutropenia
Thrombocytopenia (Platelet transfusion)
Mucositis (Hydration, “magic mouthwash”, diet modification, anti-diarrheals)
N/V (Serotonin receptor (5-HT3) antagonists (limit use of antiemetics with anticholinergic side effects))
Who is given psychosocial support?
Patient AND caregiver
What is incorporated into the physical and occupational therapy for elderly patients with cancer?
Assistance in physical and cognitive function
What do we give in medical support for anemia?
(Transfusion Epoetin alpha)
What do we give in medical support for neutropenia?
(G-CSF, GM-CSF)
What do we give in medical support for thrombocytopenia?
Platelet transfusion
What do we give in medical support for Mucositis?
(Hydration, “magic mouthwash”, diet modification, anti-diarrheals)
What do we give in medical support for N/V?
Serotonin receptor (5-HT3) antagonists (limit use of antiemetics with anticholinergic side effects)
What goes into a care plan for a geriatric patient that does not have cancer?
Still incorporate cancer risk assessment as part of geriatric assessment AND cancer prevention (screening) as part of routine care
You are an Integral part of a patient care team,
Who else is involved in the care of a geriatric patient with cancer?
Primary care provider
Oncology specialists (surgical, medical, radiation oncologists)
Cancer rehabilitation and supportive care providers
Family and other caregivers
What are key things to remember when dealing with a geriatric cancer patient?
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 under-treated in the elderly.
