Geriatric Oncology: Opportunities and challenges

1. Geriatric Oncology: Opportunities and challenges Jean-Pierre Droz, MD, PhD. Professor of Medical Oncology, Lyon-RTH Laënnec School of Medicine. Chairman department of Medical Oncology, Centre Léon-Bérard, Lyon.

2. Cancer incidence increases with age. Example of men. Cardiovascular diseases.

3. The hypothesis : There are two approaches of geriatric-oncology.

4. The characteristics of geriatrics (A medical oncologist opinion !!!) • Elderly patients have multiple problems. • Pathology is always poly-pathology. • There is time for observation, time for investigations, time for conclusion, time for intervention. • Tools are numerous and sophisticated. • The objective of patient management is to increase « health status ».

5. The characteristics of oncology. • Extensive work-up, refined staging. • Multidisciplinary approach, global treatment strategy, standard treatments and decision trees. • Interest for objective response and median survival. • Technical interest for toxicity. • Recent interest for quality of life.

6. Possible opinions on Geriatric Oncology: « popular » opinion ! • Too sick ! • Too old ! • I know how to treat this kind of cancer, even in an elderly patient. • Never chemotherapy ! • Too old for surgery ! • Good indication for palliative treatment and quality of life issues (the recently converted medical oncologist).

7. The way to find. • To learn about elderly patients. • To learn about cancer in elderly patients. • To understand what is the specific geriatric approach of patients. • To think on specific geriatric approaches of elderly patients cancer treatment.

8. Practical approach to geriatric oncology. I. The «classic oncological approach ».

9. The classical approach of medical oncology in elderly patients. • Cancer treatment is multimodal : surgery, radiotherapy, medical treatments. • The most important prognostic factor is performance status : Karnofsky Index. • Multivariate analysis is a good methodological approach in oncology. • Geriatric parameters are refined KI factors to be introduced in multivariate analysis.

10. However chemotherapy has the same effect in elderly than younger cancer patients. • Aggressive NHL : MACOP, VNCOP-B or CHOP induce 40-50% cure rate and 0-30% toxic death rate (1). • Pooled series (3351 pts) of 5-FU adjuvant chemotherapy in colo-rectal cancer : same survival benefit (2). • Zinzani & al. Blood 1999; 94 : 33-38. • Sargent & al. N Engl J Med 2001; 345 : 1091-7.

11. Practical approach to geriatric oncology. II. The «geriatric approach ».

12. Practical approach to elderly cancer patients I. • To screen cancer patients likely to receive chemotherapy : • No major organ failure (# few comorbidities). • Good performance status (# no dependency). • Able to follow experimental treatment (# no dementia). • Without drug interaction (# no polypharmacy). Consequence : Neither « frail », nor « too sick » patients

13. Senior adult patients in the SWOG studies. (Hutchins, NEJM, 1999). • 16,396 patients. • 164 SWOG trials between 1993 and 1996. • 65 years and older: 25% in the trial population vs 63% in the true life. • Breast cancer : 9% vs 49% respectively. • 70 years and older patients represent only 14% of patients who were included in clinical trials.

14. Older breast cancer patients. Trimble, 1994

15. Practical approach to elderly cancer patients II. • To build the trials on standard format : • Selection of patients. • Selection of tumor. • Introduction of selected « geriatric parameters » in the protocol. • To aim the trial to study « oncologic parameters » as objective response, survival, toxicity, EORTC QLC-30, pharmacologic parameters.

16. The problems of such an approach. • It does not consider elderly patients group as a particular entity. • It selects only a small proportion of patients in « good health ». • Results of trials may not be generalized. • Do we learn anything from such studies ? • Which geriatric parameters to select ?

17. Life expectancy and treatment. (Prostate cancer) Limit for curative Treatment. • May be important for : • High-risk disease. • Metastatic disease. 7,7 years

18. Differential life expectancy according to « percentiles » Médian. Healthy Vulnerable = reversible problem. Frail = non reversible problems. Too sick. Good health # Frailty. From IACR; Drugs & Aging 1998 ; 13 : 467-478.

19. Geriatric oncology approach in a Geriatric-Oncology Program. Exemple of Geriatric-Oncology Pilot Unit of the French National Cancer Institute in Lyon.

20. Two institutions with equal role. • Geriatrics hospital (within Lyon Hospitals network) : 400 beds, « acute care unit », long term hospitalization, CGA Unit, day hospital. • Comprehensive Cancer center with GOP (one full time Medical Oncologist, specific team) • Contract between institutions : 5 years prospective planification. Pr Ph Courpron, Dr G Albrand, Dr S Gaujard. Dr C Terret, Mrs G Moncenix RN.

21. Tools for Health status evaluation in senior adult patients. • Gold standard : Comprehensive Geriatric Assessement (CGA). • Derived products, screening tools : • Senior Adult Oncology Program (Tampa). • Multidisciplinary Assessment of Cancer in the Elderly (MACE) (Padova). • Mini geriatric evaluation (Lyon). • Simplified screening in oncology clinics : • µ-evaluation ? • PPT or Performance Status Index ?.

22. Evaluation of Elderly Cancer Patients in the program. Clinics : µ-evaluation. « Tumor specific committe » + GOP : mini-CGA. Geriatric-Oncology Committee Antoine-Charial Hospital : CGA. Decision & treatment.

23. Clinics : µ-evaluation of screening. • Clinical examination. • Co-morbidities & pharmacy. • Screening of geriatric syndroms. • Activity daily living. • Social setting. • Monopodal stay. Need for a test : PPT. Decision : - no further investigation. - mini-evaluation. -CGA in geriatric hospital.

24. Mini-evaluation : result of the work of a team in the cancer center. • Geriatrician. • Medical oncologist. • Social worker. • Dietetrician. • Physiotherapist. • Pharmacist. • Research nurse.

25. Mini-evaluation (1). • Clinical exam. • Measure of geriatric scales : ADL & IADL, MNA, GDS, MMS, Tinetti test. • Nutritionnal assessement. • Pharmaceutical assessement. • Specific questionnaire (including QoL). • Biological screening : • Hemogram, liver tests, creatinine clearance, Ca & Ph • TSH & LT4, vitamine B 12, folic acid, vitamin D3 • Albumin & pre-albumin.

26. Mini-evaluation (2). • Synthesis : clinical report, recommandation. • Clinical intervention on geriatric problems if « vulnerable ». • Decision on cancer treatment. • Information to the patient & family. • Information to the general practitioner. • Follow-up procedures : home or institution. Time : 90 + 30 mn.

27. Decision of CGA in geriatric hospital. • Patients who are « frail » or at the frontier « frail / too sick ». • Patients who require specific work-up : • Geriatric syndrom (dementia+++). • Carefull dependency evaluation. • Evolutive co-morbidity. • Complex social problems.

28. Treatment must be adapted to Health status. • Good health : same treatment as younger patients • Vulnerable : intervention then standard treatment. • Frail : intervention then adapted treatment. • Palliation. Standard treatment trials. Geriatric intervention trials. Not included in trials but demography must be known.

29. The importance to introduce both screening and CGA / Geriatric intervention planning. Screening Diagnosis Cancer treatment CGA (structure) Intervention Vulnerable. Frail. Good health. Mini-evaluation (team) Micro-evaluation (Individual) Orientation Orientation Too sick. Cancer treatment Palliative cares.

30. Examples of research programs. • Geriatrics : evaluation methodology • PPT : screening of dependence. • Nutritional aspects. • Impact of interventions. • Oncology : cancer research • Biology of aging and cancer. • Research on drug metabolism. • Decision trees applied to elderly patients. • Clinical trials on treatment strategies.

31. Teaching. • Professional education of health care workers. • Medical education : International University graduate in « Geriatric Oncology ». • Organisation of a Geriatric Oncology network and fellowship.

32. Conclusion. • Importance of an « cross-talk » between geriatricians and oncologists. • To direct research to: • develop specific tools of evaluation. • develop specific decision trees in oncology. • Increase the knowledge in cancer treatment tools. • Increase the knowledge on aging and cancer. • Requires specific teaching programs. A long term program !