Aging and cancer: the geriatrician's point of view

Impact of geriatric assessment for the therapeutic decision-making of breast cancer: results of a French survey. AFSOS and SOFOG collaborative work

BACKGROUND

Cancer management in the elderly is often considered as suboptimal, highly variable, and rarely evidence-based. Data are needed to understand decision-making processes in this population.

MATERIALS AND METHODS

A survey was performed in France to describe decision-making in gynaecologic patients over 70. It followed a three-step method: (1) 101 representative physicians questioned about treatment decision criteria; (2) simplified individual data were collected; (3) as well as detailed data patients receiving chemotherapy. This analysis refers to breast cancer subgroup of patients.

RESULTS

Main decision criteria were performance status, comorbidities, and renal function. In adjuvant setting, the main concern was life expectancy, whereas it was quality of life in metastatic setting. Of the 631 patients entered in the simplified analysis, 41% had been evaluated by a geriatrician, 67% received chemotherapy. In the detailed analysis, patients older than 75 were more likely to receive a monochemotherapy and to be treated with weekly/divided dose. In adjuvant setting, respectively, 19, 55, and 26% of the patients were treated with regimen validated in the elderly, validated in a younger population, and not validated. A G-CSF was prescribed in 48% of the patients, as primary prophylaxis in 78 and in 41% of patients with a risk of febrile neutropenia < 10%.

CONCLUSION

Geriatric covariates become an increasing concern in the decision-making process. This survey also suggests an insufficient use of validated chemotherapy regimens. To date, age remains a risk factor for heterogeneity in oncologic practice justifying a persistent effort for elaborating and disclosing specific recommendations.

Cancer, comorbidities, and health-related quality of life of older adults

This study examined the physical and mental health of 126,685 males and females age 65 or over, with and without cancer that completed a Medicare Health Outcomes Survey (MHOS) between 1998-2002. Cancer information was ascertained through the National Cancer Institute's (NCI's) Surveillance, Epidemiology and End Results (SEER) program and linked to MHOS data. Results indicated that across most cancer types, cancer patients reported significantly more comorbid conditions and poorer physical and mental health compared with patients without cancer. Negative associations were most pronounced in those with two or more comorbidities and in those diagnosed with cancer within the past year.

The meaning of having to live with cancer in old age

Little is known about how older people with cancer experience their life situation. To increase the understanding of how illness is experienced in older people with cancer, the aim of this study was to investigate the meaning of living with cancer in old age. The hermeneutic phenomenological method as described by van Manen and referred to as 'phenomenology of praxis' was used. Ten persons (seven women and three men) aged 75 and over, who had a diagnosis of cancer and who had just completed cancer treatment, were interviewed in their own homes. The analysis revealed a life world affected to varying degrees by the cancer disease. The lived experiences across the interviews were revealed in four overarching essential themes: transition into a more or less disintegrated existence, sudden awareness of the finiteness of life, redefinition of one's role in life for good and for bad, meeting disease and illness. To provide individual support and appropriate care to older people with cancer it is important for health care professionals to identify and take care of disabilities and to support the reorientation in the disintegrated life situation. It is also important to have preparedness to meet the old person's thoughts about death. Thus, it is important to encourage the old person to describe her/his illness experience to increase understanding about what is meaningful for her/him.

What are we trying to measure? Rethinking approaches to health outcome assessment for the older person with cancer

The health burden of cancer within the older population is well recognized. For many of these patients, interventions and treatments will focus predominantly on improvements in health outcomes. There has been substantial interest in the development and application of health outcome assessments for use in cancer patients, yet in comparison, there has been less focus on the older person with cancer. This paper will review current perspectives on health outcome assessment in older people with cancer; the methodological challenges associated with this work and present recommendations for future work, including the potential application of a 'user-generated' approach to health outcome assessment in the older person with cancer.

Disease-free survival advantage of weekly epirubicin plus tamoxifen versus tamoxifen alone as adjuvant treatment of operable, node-positive, elderly breast cancer patients: 6-year follow-up results of the French adjuvant study group 08 trial

PURPOSE

To assess whether an epirubicin (EPI) -based chemotherapy plus hormonal regimen improves disease-free (DFS) in women older than 65 years, with node-positive, operable breast cancer (BC), relative to tamoxifen (TAM) alone.

PATIENTS AND METHODS

A total of 338 patients were randomly assigned after surgery to receive TAM 30 mg/d for 3 years (TAM, n = 164), or EPI 30 mg on days 1, 8, and 15 every 28 days for six cycles plus TAM 30 mg/d for 3 years (EPI-TAM, n = 174). In both arms, patients received radiotherapy, delivered after chemotherapy (CT) in the EPI-TAM group.

RESULTS

The 6-year DFS rates were 69.3% with TAM and 72.6% with EPI-TAM (P = .14). The multivariate analysis shows a relative risk of relapse of 1.93 (95% CI, 1.70 to 2.17) with TAM compared with EPI-TAM (P = .005). The 6-year OS, related to disease progression, was 79.1% and 79.8%, respectively (P = .41). Compliance with CT was good: 96.9% of patients received six cycles. The acute toxicity per patient was mild: grade 2 neutropenia in 5.9%, grade 2 anemia in 2.0%, grade 3 nausea or vomiting in 4.6%, and grade 3 alopecia in 7.2%. Five cases (in five patients) of decreased left ventricular ejection fraction occurred after CT: three after adjuvant CT, and two after anthracycline-based CT for relapse. One patient died as a result of dysrhythmia related to carcinomatous lymphangitis. No secondary leukemia occurred.

CONCLUSION

This study conducted in node-positive elderly patients demonstrates a significant contribution of a weekly EPI regimen in terms of DFS. Moreover, this regimen is safe for hematologic, nonhematologic, and cardiac toxicities.

The experiences of older people living with cancer

Nursing care for older people with cancer requires an understanding of their history and current needs from both an individual and generalized view. The aim of this study was to investigate the experience of older people living with cancer and the way it affects their daily life. During the study, 41 individuals 75 years of age and older (mean age, 83 years) who had a cancer diagnosed within the past 5 years were interviewed in their homes. After verbatim transcription, the interviews were analyzed with latent content analysis. Four main categories were identified: 1) living with cancer means bodily, mental, social, and existential experiences; 2) being aware of the disease or not; 3) handling of daily life; 4) feeling affirmation or rejection from healthcare professionals. Experiences of daily life with cancer were influenced by the combination of old age, comorbidities, and the perception of current and previous life. This combination more or less affected all aspects of life. The power to choose the approach to daily life with cancer, the disease, and its treatment proved to be crucial for handling cancer and the outcome. It seems that the main role for healthcare professionals is to empower the older person to choose for himself or herself. Furthermore, it seems to be important that healthcare professionals support older persons in their choices, whether they choose to take an active part in understanding the disease and handling of daily life or whether they decide to be more passive and hand themselves over to the healthcare system.