Cheryl Lillegraven MSN, ARNP, ACNS-BC
Geriatric Clinical Nurse Specialist
OLDER ADULTS AND THE EFFECTS OF COMORBIDITIES ON CANCER TREATMENT
DISCLOSURE AND ACKNOWLEDGMENTS
I have nothing to disclose
 Thank you

 Patti
Berger and her ONS colleagues
 Conference Planning Committee
CURRENT STATE
Cancer is a disease associated with aging – the majority of cancer
diagnoses and deaths occur in people older than 65 years – and
the United States population is rapidly aging, with a projected
doubling in the number of individuals age ≥ 65 from the year
2000 to 2030.
A dramatic increase in the number of new cancer diagnoses is
projected for the next 20 years. It is anticipated that patients age
≥ 65 will account for 70% of all cancer diagnoses by the year
2030.
(Tinetti, 2012)
CURRENT STATE
Due to the overall increase in life expectancy coupled with
more therapeutic management, elderly cancer patients are
expected to live longer and in better conditions.
 More curative treatments
 Adjuvant chemo after surgery and age is no longer a
limiting factor
 Treatments of advanced disease, like palliative chemo, are
more frequently proposed to the elderly.
Unfortunately, older adults are poorly represented in most
oncology clinical trials and only a few studies have focused
on advanced biological age, so results are extrapolated to
the elderly.
THE FUTURE
Instead of only focusing on the cancer diagnosis, older
persons are in need of a more holistic approach that
focuses on a combination of medical, social, functional,
cognitive, mental and nutritional needs.
COMORBIDITY
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With increasing age, the number of comorbid illnesses
increases.
A study of 7,600 patients older than 55 years with
cancer, those age 55 to 64 had an average of 2.9
comorbid conditions compared with patients ≥ 75,
who had an average of 4.2 comorbid conditions.
(Tinetti, 2012)
MULTIMORBIDITY
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Patients with CAD, it is the sole condition in only 17%
cases
Almost 3 in 4 individuals aged 65 years and older
have multiple chronic conditions, as do 1 in 4 adults
younger than 65 who receive care
(Tinetti, 2012)
RISK
Important to consider the physiologic age of the patient, as
opposed to the chronologic age alone. Evaluation tools can be
helpful
Comprehensive Geriatric Assessment (CGA)
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Allows for identification of older patients with higher risk of morbidity
and mortality
Also identifies who is higher functioning and perhaps can tolerate a
more aggressive approach
Risks and benefits of anticancer therapy must be assessed
Tools to risk-stratify an older patient population for frailty has
enormous prognostic value
FRAILTY
Clinical Syndrome
Includes the presence of 3 or more of the following components
 Unintentional weight loss of 10 pounds or more in the past year
 Self-reported exhaustion (lack of vigor, or the presence of fatigue and
tiredness
 Strength – weakness (grip strength, loss of physical robustness)
 Slowness – slow walking speed, lethargic, unsteady and unbalanced
gait
 Low physical activity – inactivity or sedentariness
Scoring: 0 = robust, 1-2 = intermediate or pre-frail, 3 = frail
(consultgerirn.org)
FRAILTY
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Epigenetic phenomenon
Declining functional reserve
Unclear, controversial etiology
Functional immune alterations
Associated clinical syndromes
Potentiated normal aging changes
(Kagen, 2015)
FRAILTY
FRAILTY (CLEGG, 2011)
CGA
The CGA is an interdisciplinary patient evaluation that leads to the
identification of the general health status including medical, functional,
cognitive, social, nutritional and psychological parameters. Designed by
geriatricians as a multidimensional assessment of general health status based
on validated geriatric scales and tests that produce an inventory of health
problems, allowing for the development of an individualized geriatric
intervention program
At least 4 good reasons for an oncologist to obtain a CGA
1.
Has important prognostic information that can be helpful in estimating life
expectancy
2.
Can predict toxicity or decrease in QoL
3.
Can reveal previously unknown geriatric problems
4.
Allows targeted interventions, which can improve QoL and compliance to
therapy
It is recommended by the National Cancer Center Network (NCCN) and the
International Society of Geriatric Oncology (SIOG).
(Kenis et al., 2013 & Caillet et al., 2014)
CGA CHALLENGES
1.
2.
3.
Time consuming for busy clinicians
Lack of trained staff
Poor financial reward for performing the CGA by insurance
There are shorter screening tools to detect older persons with a geriatric
profile who would then benefit from the CGA
1.
Flemish Triage Risk Screening Tool (TRST)
2.
Vulnerable Elders Survey -13 (VES-13)
3.
Groningen Frailty Indicator (GFI)
4.
G8
(Kenis et al., 2013)
CGA
Study in Belgium (2013). Multi-center, non-interventional study
 Purpose – to evaluate the large-scale feasibility and usefulness of geriatric
screening and assessment in clinical oncology practice by assessing the impact
on the detection of unknown geriatric problems, geriatric interventions and
treatment decisions
 1,796 patients who had a malignant tumor and were ≥ 70 years old and a
treatment decision needed to be made. Limited to 6 tumor types: breast,
colorectal, ovarian, lung, prostate cancer and hematological malignancies
 The G8 risk tool was used to screen. If the G8 (range: 0-17) demonstrated a
score of ≤ 14, a CGA was carried out. 70.7% of patients had abnormal G8
scores, warranting a CGA
 The CGA detected unknown geriatric problems in 51.2% of these patients
 Geriatric interventions were planned in 286 patients (25.7%). Included referral
to a geriatrician, geriatric liaison team, SW, OT, PT, geriatric day care, fall
prevention clinic, gero-psych, dietician
(Kenis et al., 2013)
CGA
Study in France (2014). Comprehensive Review
 Medline search for articles published between January 1, 2000 and April
14, 2014
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Patients aged ≥ 65 years with solid malignancies
Looked at studies with at least 100 participants, a multivariate analysis and assessments
of at least five the following CGA domains: nutrition, cognition, mood, functional status,
mobility and falls, polypharmacy, comorbidities and social environment.
Results – All types of CGA identified a large number of unrecognized health
problems capable of interfering with cancer treatment. CGA influenced 2149% of treatment decisions. All CGA domains were associated with chemo
toxicity or survival in at least one study. The abnormalities that most often
predicted mortality and chemo toxity were functional impairment,
malnutrition and co-morbidities
(Caillet et al., 2014)
CGA
For each patient the decision whether or not to have
cytotoxic chemo and/or radiation and/or surgery for
cancer is a balance between potential benefits and
adverse effects. The CGA is useful and helpful in decision
making. The outlook of older patients may differ from that
of younger patients. Short-term QoL and the ability to
manage their daily activities may be more important than
a modest survival advantage when deciding whether or
not to accept treatment
(Chaibi, et al., 2011)
GERIATRIC SYNDROMES
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Falls
Sleep
Pain
Eating problems
Confusion (dementia/delirium/depression)
Incontinence
Anxiety
Living abilities (ADLs, IADLs)
Skin integrity issues
Elimination issues
GERIATRIC SYNDROMES – INOUYE AND COLLEAGUES (2007)
LONG WAY TO GO…..
GERIATRIC COMPETENCE
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The healthcare needs of older adults require a healthcare
workforce knowledgeable about the aging process, skilled in
assessment and management of chronic illness, and with the
ability to practice in interdisciplinary milieu
(Mezey et al., 2008)
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Reframing healthcare as age-friendly supports geriatric
competence
https://extranet.who.int/agefriendlyworld/
GERIATRIC COMPETENCY
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Hospital staff lack education in caring for older
patients
Lack of a shared philosophy of care within diverse
care settings
Health care professionals paternalistic
Little recognition of gero-oncology
Decisions made on basis of chronological age rather
than supporting patients’ unmet needs
RESOURCES
1.
2.
3.
4.
www.consultgerirn.org
www.nccn.org
www.siog.org
www.uptodate.com
Cheryl.lillegraven@unitypoint.org