Cancer in the Elderly

Question 1

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

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

Answer 1

1. 60

2. 70

Question 2

1. Senescence of the immune system with aging results in what? 2
2. Cancer growth factors differ with age
   - What increased?
   - What is altered?
   - What may promote tumor growth?

Answer 2

1. • in less surveillance for abnormal cells
   • Blunted T-cell and NK cell activity
2. • IL-6 increases
   • Angiogenesis is altered
   • Chronic inflammation may promote tumor growth

Question 3

Some cancers have a more indolent course in the elderly

Examples? 3

Answer 3

1. Some non-small cell lung adenocarcinomas
2. Estrogen/progesterone responsive positive breast cancers
3. Prostate cancer

Question 4

Some cancers are more aggressive in the elderly

3

Answer 4

1. AML
2. Large cell non-Hodgkin lymphoma
3. Celomic ovarian cancer

Question 5

Most common cancer types overall

4

Answer 5

1. Breast
2. Prostate
3. Lung/bronchus
4. Colon and rectum

Question 6

Cancer in the Elderly-
Why are cancer death rates so high?
6

Answer 6

1. Organ vulnerability (reduced physiologic reserves)
2. Co-existing illnesses
3. More aggressive tumors
4. More likely to have advance disease at presentation
5. Age bias
6. Health care access issues

Question 7

Describe why age bias is a contributer to high death rates in the elderly?
3

Answer 7

1. Under treatment (“this treatment is too dangerous for elderly patients”)
2. Reduced participation in cancer screening programs (resulting in delayed diagnosis)
3. Under-representation in clinical trials (Exclusion of subjects > 70 years and Elderly patients make up only 10% of patients in some clinical trials)

Question 8

Cancer in the Elderly-
Treatment Issues: Surgical risk factors for elderly?
4

Answer 8

1. Emergency surgery or prolonged surgery
2. Co-existing disease (especially CVD, COPD, DM)
3. Poor nutritional status (wound healing, infections)
4. Poor functional status

Question 9

Radiation therapy major risks? 2

Answer 9

1. Mucositis (dehydration, malnourishment, sepsis)

2. Radiation pneumonitis

Question 10

What tx has the most SE?

Answer 10

Chemo

Question 11

Down sides to Chemotherapy?

6

Answer 11

1. Increased susceptibility to toxicity (oral chemotherapy better tolerated than IV treatment)
2. Decreased functional reserves
3. Co-existing disease
4. Altered metabolism and distribution of drugs
5. Poor stem cell recovery
6. Dose adjustments for reduced GFR or anemia leads to decreased treatment effectiveness

Question 12

Chemotherapy

Major risks for elderly

Answer 12

1. Myelosuppression-cumulative, more severe
2. Mucositis
3. Drug specific toxicities

Question 13

What are the complications that are associated with the following risks:

1. Myelosuppression-cumulative, more severe? 3
2. Mucositis? 3
3. Drug specific toxicities?

Answer 13

1. Myelosuppression-cumulative, more severe
   - Anemia (reduced oxygen carrying capacity)
   - Neutropenia (sepsis)
   - Thrombocytopenia (bleeding)
2. Mucositis
   - Dehydration
   - Malnutrition
   - Sepsis
3. Drug specific toxicities
   - Renal insufficiency (platinum containing drugs)
   - Cardiotoxicity (anthracyclines)
   - Neurotoxicity (platinum, taxanes, vincristine)

Question 14

Cancer treatment decisions in older adults

What should be assessed? 6

Answer 14

1. Should be based on the tumor characteristics not age
2. Need an assessment of the patient’s functional status
3. Include risk of treatment vs. benefit and effects on quality vs. quantity of life
4. Guided by the patient’s treatment goals
5. Avoid undertreatment of curable disease
6. Avoid overtreatment of indolent cancers or cancers with poor prognosis

Question 15

1. Good estimate of quality of life, life expectancy, and ability to tolerate cancer treatment) is what?
2. Components of this? 4

Answer 15

1. Physiologic Age
2. Components
   - Co-morbidities
   - Functional status
   - Nutritional status
   - Geriatric syndromes

Question 16

Cancer in the Elderly-
Treatment planning: Comorbidities?
7

Answer 16

1. CVD
2. Respiratory disease
3. Thromboembolic disease
4. DM
5. Renal insufficiency
6. Neurologic disease
7. Anemia

Question 17

What is Functional status and what is involved?

Answer 17

1. Functional status: self care and the ability to maintain an independent life
   - Activities of daily living (bathing, dressing, eating, toileting, continence, and transferring)
   - Instrumental activities of daily living (use of transportation, shopping, ability to take medications, provide one’s own meals, manage finances, do laundry and housekeeping)

Question 18

What is nutritonal status?

What red flags are we looking at? 4

Answer 18

Nutritional status: protein/calorie malnutrition, weight loss, loss of muscle mass

1. Weight loss > 10lbs over 6 months
2. Loss of muscle mass
3. BMI less than 20
4. Serum albumin less than 3.2 g/dl

Question 19

Cancer in the Elderly-
Treatment planning: What are some geriatric syndromes that should be assessed with cancer?
8

Answer 19

1. Dementia
2. Delirium
3. Depression
4. Falls
5. Spontaneous fractures
6. Neglect and abuse
7. Incontinence
8. Nutritional problems

Question 20

Cancer in the Elderly: Supportive care treatment includes?

11

Answer 20

1. Nutritional support-dietary counseling, dietary supplements, enteral feeding (G/J tube)
2. Anemia-epoetin alpha
3. Neutropenia-filgastrim (Epogen) or sargramostim (Leukine)
4. Thrombocytopenia-platelet transfusion
5. Mucositis-supportive care (hydration, “magic mouth wash,” diet modification, anti-diarrheals)
6. Nausea and vomiting-serotonin receptor antagonists (ondansetron)…limit use of anti-emetics with anticholinergic side effects
7. Pain control…often undertreated in the elderly
8. Patient reluctance to report pain
9. Atypical pain presentation (confusion, fatigue, withdrawal, depression)
10. Providers fear older patients won’t tolerate opiates
11. Communication problems (eg., cognitive impairment, language and cultural factors)