Cancer in the elderly
Cancer in the elderly
There is no official age at which people are deemed “elderly,” but the boundary is often set at the age of 70-75 in oncology. Contrary to popular belief, the incidence of cancer is generally higher in the elderly, sometimes with a significant risk of progression. Increasing life expectancies give more time for cancer to appear, while aging weakens the defences against tumour development.
With age, other health problems arise. These “co-morbidities” can complicate the management of cancer: the application of standard treatments is not always possible and requires numerous adjustments. We must therefore be armed with a more comprehensive assessment of the patient’s health status, carried out in close collaboration with a geriatrician, to approach the physiological reserves needed to tolerate the envisaged cancer treatments, whatever they may be: surgery, radiation therapy or medical treatments. This is what is known as a “comprehensive geriatric assessment”, which is just as important as an accurate analysis of the tumour, including its genome analysis, to arrive at a personalised comprehensive care-management strategy.
This is not always necessary, but is normally conducted if the patient is fragile, particularly when the proposed treatments present a risk of significant side effects (e.g. chemotherapy or major surgery). It identifies health problems that must be taken into account prior to treatment. This is the rationale for geriatric oncology.
Care management at Institut Curie
At Institut Curie, persons over the age of 70 (60% of whom are over 75) account for 25% to 30% of active patient files.
Institut Curie is co-responsible, with the Georges Pompidou European hospital, for one of the five coordination units in geriatric oncology (UCOG) in the Paris region. It participated in the deployment of the G8 fragility screening tool, validated by the INCa’s Oncodage programme, which it recommends at the beginning of treatment for anyone over age 75. The questionnaire can be filled in by the oncologist or the consultant nurse. A more detailed geriatric opinion is required through a special geriatric oncology consultation if the result is lower than or equal to 14, to detect potential fragility related to aging.
Depending on the degree of fragility detected, various geriatric procedures are implemented, including physical therapy, nutritional support, psychosocial measures and so on. The goal is to anticipate potential difficulties or risks of deterioration via selected support measures to ensure smooth implementation of the cancer treatment.
The G8 is considered at a multidisciplinary consultation meeting. If it is absent from the file, an additional accelerated opinion is requested before finalising the strategy.
After the cancer treatment has started, the geriatric procedures put in place are monitored by the geriatrician and dedicated nursing staff, in coordination with the referring oncologist. The desired benefit is reassessed on a regular basis.
Adjustments are common and include hypofractionated radiotherapy, reducing the number of sessions and the amount of travel, chemotherapy at lower doses, for less time or with different drugs and prevention of the most common haematological toxicities.
At Institut Curie, this multidisciplinary “geriatric” expertise supplementing the “oncology” strategy is integrated into the interdisciplinary department responsible for supportive patient care. It is exercised by a geriatrician at each hospital site, with geriatric assessment consultations, specific-day hospital visits, hospitalisation opinions (acute medicine questions, postoperative follow-up etc.), and via participation in multidisciplinary consultation meetings to facilitate the day-to-day awareness of oncologists.
Clinical research in geriatric oncology is not only different from research conducted in younger subjects, it is also indispensable. It is aimed at compensating for the ongoing deficit of research programmes accessible to the elderly population. It is widely supported by INCa, the plan to fight cancer and, at international level, by the International Society of Geriatric Oncology (SIOG).
At Institut Curie, it relies heavily on participation in the Unicancer group for clinical research in geriatric oncology, GERICO, and the GERICO/UCOG intergroup, and received approval from INCa in 2014. GERICO develops age-appropriate research methods, primarily focussed on the protection of functional capital, autonomy, and quality of life, as well as access to innovation and less-toxic modern treatments and de-escalation. For example, Institut Curie was the first centre to recruit for the ASTER 70s programme (GERICO 11) exploring the benefits of postoperative chemotherapy for breast cancer in patients over 70, based on a more detailed analysis of genes linked to tumour grade.