Are Elderly Cancer Patients Wrongly Labelled as Palliative_Dr Lesley Young

Dr Lesley Young FRCP

Senior Clinical Lecturer, NUMed Malaysia

and

Consultant Geriatrician, City Hospitals Sunderland

Outline Changing demographics

Life expectancy

Prognostic indicators

Cancer and ageing Most cancers occur in older people

Individuals aged 65+ account for:

60% cancer incidence

70% cancer-related mortality (Pal et al Cancer J Clin 2010:60:120-132)

Cancer is the leading cause of death in 60-79 yr olds

Diagnosed with prostate cancer 1997,

aged 66

Diagnosed with bowel cancer 1985, aged 74

Demographics Developed countries have an aging population

Currently around 10% Malaysians >65yrs:

2050: 18-27% >60yrs

There will be an increase in older people, especially in the oldest old

In the UK by 2031

2/3 increase in 65+ (=22% population)

77% increase in 75+

131% increase in 85+

But ....

Life expectancy increases > health expectancy

Source: UK Government Actuary's Dept for Expectation of Life Data. ONS for health life expectancy data

Life expectancy increases > health expectancy

Healthy ageing Many older people are now as fit

as younger people

Is this lady elderly?

What do we mean by “elderly”?

Over 50?

..... 60?....

.......70?....

63

67

74

..........Or even older???

82

81

86

86

94

Life expectancy

country birth 70yrs 80yrs 90 yrs At 100yrs

Malaysia 73.3 81.4 86.7 93.7 102

Singapore 82 86.1 89.7 95.2 102.4

UK 79 85.5 88.9 94.5 102.2

USA 78.1 85.6 89.3 94.9 102.4 0

20

40

60

80

100

120

birth age70

age80

age90

age100

age

life expectancy

Source: world life expectancy.com

In Malaysia the average 80yr old has a life expectancy of 6.7 years

Change with ageing Reduced

Physiological reserve (renal, hepatic, respiratory etc) Functional status Cognition

Increased Co-morbidity Geriatric syndromes

Falls, delirium, frailty etc

Changes affect life expectancy

But: Rate and degree varies hugely between individuals

Life expectancy for US women in years by health status and age (after Walter& Covinsky JAMA 2001)

0

5

10

15

20

25

70 75 80 85 90 95

top quarter middle lower quarter

i.e. 85 yr old in average health can be expected to live a further 6 yrs

Cancer and older people Older cancer patients tend to have worse

survival (EUROCARE 4)

Increasing age gradient for worse survival for all cancers (Quaglia, Eur J Cancer 2009) ..........

Confounding factors Older patients.....

Present later (Busch, Cancer 1996; Bergman, Eur J Cancer 1992,EUROCARE-4 E J

Cancer 2009)

Have increased co-morbidity Co-morbidity, but not age is associated with poorer survival

in NSCLC (Asmis, J Clin Oncol 2008)

Co-morbidity (rather than age) influences the risk of death without recurrence in breast cancer (Ring, J Clin Oncol 2011)

Older cancer patients tend to.... Be under represented in trials

22% trial enrollees vs. 58% cancer patients aged >65yrs (Lee, J Clin

Oncol 2003)

25% enrollees vs. 63% cancer patients aged >65yrs (Hutchins, NEJM

1999)

0102030405060708090

100

lee 2003 hutchins 1999

% cancer patients aged >65 all trial

Older cancer patients tend to be....

Undertreated (Van Leeuwen, Crit Rev Oncol Hematol 2011, Bouchardy, J Clin Oncol 2003, Hanke, Ann Oncol

2010, Chambers, Interact Cardiovasc Thorac Surg 2010)

In breast cancer: 57% under treated according to national guidelines (Van Leeuwen, Crit Rev Oncol Hematol

2011)

47% >80yr old had standard treatment v 91% <80yr (Bouchardy, J Clin Oncol 2003)

Women >75yrs receive less aggressive therapy (JNCCN 2012)

Less likely to be offered surgery (Stapelkamp, BMJ 2010), radiotherapy or chemotherapy (Ring, J Clin Oncol 2011)

AND..........

Under-treatment is associated with worse survival (Van Leeuwen, Crit

Rev Oncol Hematol 2011, JNCCN 2012, Bouchardy, J Clin Oncol 2003)

Factors in under treatment Lack of trial based evidence

Physician perceptions of age

Patient related factors

Low expectations

Difficulty accessing treatment

Lack of information

What is the evidence for treating cancer in the elderly? Few evidenced based trials.......

Older patient derive the same benefit from treatment with Chemotherapy for colorectal cancer (Power, Cancer J 2010)

“Majority of published data does not support a negative correlation between poor outcome and age”

Older patients with good health status tolerate commonly used chemotherapy as well as younger patients (JNCCN 2012)

Breast, Colorectal, NCSLC

However may be more prone to side effects from aggressive treatment

In elderly patients following surgery for early stage lung cancer, no significant difference in 5 yr survival rates or other outcomes (Chambers,

Interact Cardiovasc Thorac Surg 2010)

but older patients more likely to treated palliatively (up to 47% vs. 8% in<65yrs)

Thoracic Radiotherapy is as effective and well tolerated in older as in younger patients (Redmond, Thorac Surg Clin 2009)

Treatment is effective in older patients with NSLC (pallis Ann Oncol 2010)

Determinants of outcome So, if older cancer patients have worse survival, but

evidence suggests cancer treatment is effective in older people.....

What is causing worse outcomes if not age?

Independent Determinants of worse outcome

Significant Not significant Liver metastases (vigano Arch Int med 2000)

Moderate-severe comorbidity (vigano Arch Int med 2000, Pallis Ann Oncol 2010)

Functional impairment (Pallis Ann

Oncol 2010)

Weight loss (vigano Arch Int med 2000)

Low albumen (vigano Arch Int med 2000)

Raised LDH (vigano Arch Int med 2000)

Clinicians estimate of survival <2 months (vigano Arch Int med 2000)

Non-curative resection in bowel cancer (Maeda, Am Surg 2011)

Lymph node metastases in bowel cancer (Maeda, Am Surg 2011)

Age (vigano Arch Int med 2000, Ramos-barcelo Crit Rev

Oncol Hematol 2009, Maeda, Am Surg 2009, Pallis Ann Oncol 2010)

Pain (vigano Arch Int med 2000)

Depression (vigano Arch Int med 2000)

On-going treatment (vigano Arch

Int med 2000)

Performance status (vigano Arch

Int med 2000)

Life expectancy for women in years by health status and age (after Walter& Covinsky JAMA 2001)

0

5

10

15

20

25

70 75 80 85 90 95

top quarter middle lower quarter

The life expectancy of a fit 90 yr old is the same as that of a low health

status 75yr old

Age is not the important factor.. Cancer stage

Co-morbidity

Frailty

Functional impairment

Performance status

Comprehensive Geriatric Assessment

What is CGA? More than just performance status

In patient with good performance status (Repetto, J Clin Oncol

2002), CGA identified... 13% 2+ co-morbidities

9.3% limitations of ADL, 37.7% limitations of IADL

“A multi-dimensional, inter-disciplinary diagnostic process focussed on determining a frail older persons medical, psychological and functional ability, in order to develop a co-ordinated and integrated plan for treatment and long term follow up” (BGS 2005)

CGA can.... Identify potentially treatable problems that would

otherwise adversely affect treatment or outcome ( e.g. depression, malnutrition)

Allow intervention and rehabilitation

Predict outcome (Pal, Ca Cancer J Clin 2010)

In geriatric medicine functional status is a strong predictor of morbidity and mortality

Predict toxicity from therapy (Wymenga, proc am soc clin oncol 2007, Palis, Ann Oncol 2010)

Guide decision making (Tucci, Cancer 2009)

CGA “unfit” lymphoma patients did as well with palliative treatment as with chemotherapy with curative intent

CGA includes.... Functional status

Co-morbid conditions

Cognition

Nutritional status

Psychological state

Social support

Medication review

CGA in practice Medical assessment:

Problem list

Co-morbid conditions and disease severity

Medication review

Nutritional status – MUST, SNAQ

Assessment of functioning ADL – Barthel Index

IADL -

Activity / exercise status

Gait/ balance – TUG

Psychological assessment Cognitive testing – MMSE

/ AMTS

Mood / depression - GDS / HADS

Social assessment Formal and informal

Financial

Environmental assessment Home safety

Aids and appliances

Transport

Assessment

Plan

Treatment Rehabilitation

Follow up

CGA

Does patient have sufficient life expectancy to be at moderate /high risk of dying or suffering form cancer in that lifetime?

Symptom management/ supportive care

Does the patient want cancer treatment?

Symptom management/ supportive care

Assess risk factors (CGA)

Treat according to best practise

Are risk factors modifiable?

Consider alternate treatment options to reduce toxicity

Treat risk factors

Consider alternate treatment options to reduce toxicity

Treat according to best practise

After NCCN senior adult oncology guidelines, JNCCN 2012

Are elderly cancer patients wrongly labelled as palliative?

If judged by chronological age alone? YES

Look at the bigger picture

Thank you