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
Diagnosed with Individuals aged 65+ account for: prostate cancer 1997, 60% cancer incidence aged 66 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 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

Life expectancy increases > health expectancy

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

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?....
63

67

74

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

81

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

86

82 86 94

120

age life expectancy

Life expectancy
country Malaysia Singapore UK USA
birth 70yrs 80yrs 90 yrs At 100yrs

100 80 60 40 20 0

73.3 82 79 78.1

81.4 86.1 85.5 85.6

86.7 89.7 88.9 89.3

93.7 95.2 94.5 94.9

102 102.4 102.2 102.4

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

birth age age age age 70 80 90 100

Source: world life expectancy.com

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

25 top quarter 20 15 10 5 0 70 75 80 85 90 95 i.e. 85 yr old in average health can be expected to live a further 6 yrs middle lower quarter

(after Walter& Covinsky JAMA 2001)

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)

100 90 80 70 60 50 40 30 20 10 0

% cancer patients aged >65

all trial

lee 2003

hutchins 1999

Older cancer patients tend to be....

Undertreated
2011)

(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

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
Rev Oncol Hematol 2011, JNCCN 2012, Bouchardy, J Clin Oncol 2003) (Van Leeuwen, Crit

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

Not significant

Age

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

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

Functional impairment (Pallis Ann

Oncol 2010)

Pain (vigano Arch Int med 2000)

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

Depression (vigano Arch Int med 2000)

On-going treatment (vigano Arch
Int med 2000)

Performance status (vigano Arch

Int med 2000)

<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)

Life expectancy for women in years by health status and age (after Walter& Covinsky JAMA 2001)
25 top quarter 20 15 10 5 0 70 75 80 85 90 95 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

Follow up

Plan

CGA

Rehabilitation

Treatment

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