Introduction
Cancer is mainly a disease of the elderly, particularly because other life-threatening diseases have been better managed, allowing people to reach older age. As a result, over 60% of new cancer cases and over 70% of cancer deaths occur in people aged 65 years and older in Europe and the US. Unfortunately, standard cancer strategies have been mostly validated in younger adults. Moreover, elderly patients are currently under-represented in clinical trials – only 8% to 13% of patients are aged 70 years and over.
Introduction
Cancer is mainly a disease of the elderly, particularly because other life-threatening diseases have been better managed, allowing people to reach older age. As a result, over 60% of new cancer cases and over 70% of cancer deaths occur in people aged 65 years and older in Europe and the US. Unfortunately, standard cancer strategies have been mostly validated in younger adults. Moreover, elderly patients are currently under-represented in clinical trials – only 8% to 13% of patients are aged 70 years and over.
Ageing is coupled to progressive but extremely uneven decline of functional reserves and reduction of adaptability. Because geriatricians commonly cope with the highly heterogeneous process of ageing, they have elaborated a comprehensive multidisciplinary assessment tool, called Comprehensive Geriatric Assessment (CGA), in which all aspects of older individuals are considered and resources and abilities are listed. Based on this appraisal, geriatricians can draw and co-ordinate an effective care programme, providing interventions tailored to each individual’s problems.
Health authorities and professionals are faced with the expanding challenge of the management of elderly cancer patients. Nevertheless, this evolution has not been anticipated and the increasing number of elderly patients suffering from cancer will result in rising costs of medical and social care. The costeffectiveness of the management of cancer in the elderly needs to be evaluated in terms of benefits, and cost-effective strategies for preventing and detecting cancer early should be considered.
The demographic trend has led to the emergence of a new medical discipline, geriatric oncology, and to the development worldwide of geriatric oncology programmes dedicated to the management of elderly cancer patients.
Geriatric Oncology Programmes
Geriatric oncology may be defined as a multidimensional and multidisciplinary approach of elderly cancer patients. This innovative discipline represents a way of taking care of individuals that is very different from conventional oncology daily practice. Older patients cannot be managed in the same way as their younger counterparts due to concomitant and possibly multiple medical problems. The management of elderly cancer patients requires multidisciplinary skills; notably, close relationships between oncologists and geriatrics. Oncologists must assess patients’ malignant disease and establish the diagnosis, staging and prognostic classification of tumours (comprehensive oncology assessment (COA)). Geriatricians must assess patients’ other health problems, including social and economical aspects, cognitive and psychological domains, medical conditions, nutrition and functional status of the patient (comprehensive geriatric assessment (CGA)). This comprehensive and multi-step management is depicted in the diagram shown in Figure 1.
Geriatric Oncology Programme– The Experience of the Léon Bérard Cancer Center
Over the past 10 years, a geriatric oncology programme has been developed based on an interactive collaboration between the Regional Comprehensive Cancer Centre and a Geriatrics Department at the University Hospitals of Lyon, more particularly a geriatric evaluation and management unit (GEMU). The programme displays innovative solutions due to the constant balance between geriatrics and oncology and includes different activities ‘from the bedside to the bench’.
Geriatric Oncology in Daily Practice
A geriatric assessment procedure has been initiated called ‘oncogeriatric screening’ to be performed at the out-patient department of the Léon Bérard Cancer Center, Lyon. This procedure has been adapted from the principles of the CGA enacted by the Consensus Conference in 1988. Oncogeriatric screening involves a trained interdisciplinary team including a geriatrician, a medical oncologist (geriatrics-certified), a social worker, a dietician, a physiotherapist, a pharmacist and a research nurse. Unsuspected health problems can be detected by a screening procedure in elderly cancer patients. This 90- to 120-minute procedure focuses on the major domains usually assessed in the CGA and results in an individualised care plan including cancer management.
Conversely, to respect the balance between oncology and geriatrics, the oncologist provides weekly assistance to the geriatricians to manage elderly cancer in-patients at the geriatric hospital. Since this inter-relationship has been developed, more and more cancers have been diagnosed in the geriatrics setting, allowing improvements in cancer care for this particularly disabled population. Furthermore, geriatricians seem to have become less uncomfortable when seeing elderly patients with cancer because they have learned that cancer patients can benefit from treatment, even in a palliative approach.
Finally, monthly interdisciplinary counselling meetings have also been implemented involving geriatricians, oncologists and all physicians and auxiliary nursing people caring for elderly cancer patients. Patients’ files are exhaustively reviewed and physicians jointly define individualised care programmes and initiate the comanagement of elderly cancer patients.
Clinical Research
Data collected from patients included in this oncogeriatric screening programme are recorded in a specific database, based on results of validated geriatric screening tools, tumour parameters and patients’ survival data.
The clinical research programme involves two methodological aspects – the validation of a specific tool for screening older patients requiring a CGA and the appraisal of the real impact of geriatric intervention programme in oncology.
CGA is a complex and sustained multi-step procedure and cannot be realistically implemented in the oncology practice setting. Aside from this outstanding approach, a screening tool is currently being developed that is aimed at recommending CGA only to patients who should benefit from it. Therefore, only patients with a positive screening result will be assessed by means of the CGA. The feasibility and reliability of the physical performance test (PPT) has already been tested. Preliminary results tend to show that PPT could be more relevant for screening this population of patients than the widely used performance status scale.
The CGA process has previously demonstrated its ability to improve survival and quality of life and reduce costs in the elderly community. However, previous studies have also emphasised the role of the implementation of interventions and comprehensive follow-up. Furthermore, the possible impact of geriatric intervention on cancer is not yet known. Further studies are in progress to explore the impact of CGA or CGA-related procedures in cancer patients.
Geriatric Oncology Teaching Programme
Teaching geriatric oncology is essential because the elderly cancer population keeps increasing. Teaching will deal with the basic knowledge necessary for daily practice, the right public health approach and the aim to deliver consistent care by health professionals. A specific training programme is presently on-going at Lyon University with the objective to spread a common language among the health community and to develop a multidisciplinary approach within a continuous, coherent network. Students take part in individualised training programmes consisting of both theoretical and practical education in geriatrics and oncology. Practical training aims to improve skills in geriatric and oncology clinics and in the co-management of elderly cancer patients by multidisciplinary teams.
Geriatric Oncology International Network
Since the healthcare community has become aware of the magnitude of the problem of cancer in the elderly, worldwide efforts have been made to approach this issue. The International Society of Geriatric Oncology (SIOG) was founded at the beginning of the 21st century, with an annual meeting held alternately in Europe and the US. ■
