When Age Is Only a Number

IN JUNE 2013, Laura Jensen found herself sitting at the cancer center at the University of North Carolina in Chapel Hill filling out a geriatric assessment, a health survey for older cancer patients. The questions were easy: Was she able to do her own housework and prepare meals? Yes. Did she exercise? Yes—she rarely missed a water aerobics class. Was her appetite normal? Yes. Lastly, Jensen, then 71, completed a series of simple exercises, including walking down a hallway.

The 30-minute assessment showed that Jensen was in excellent health. Except for one thing: A few weeks earlier, she had been diagnosed with stage I breast cancer following a routine mammogram.

Jensen’s oncologist, Hyman Muss, the director of the Geriatric Oncology Program at the University of North Carolina Lineberger Comprehensive Cancer Center, had ordered the assessment to determine if she was healthy enough to withstand aggressive treatment. And the results were clear. “We found that she had excellent function,” says Muss, “so we treated her as we would a younger patient.”

A Disease of Aging

Adults over age 65 like Jensen represent an increasing number of cancer patients, and the number is expected to grow as baby boomers age. Fifty-three percent of cancer diagnoses occurred in individuals over 65 in 2012; experts predict that the number will rise to 70 percent by 2030. This is primarily because the risk of developing cancer increases with age.

Yet physicians are still determining how best to care for these patients—what regimens are most effective, how to reduce side effects, and how other age-related health conditions and the medications they require can affect treatment choices. The geriatric assessment Jensen received is one approach that doctors can use to determine which older patients can withstand, and are most likely to benefit from, more aggressive cancer treatments.

Jensen was particularly fortunate that her oncologist is one of the leaders in the small but growing field of geriatric oncology. Doctors with expertise in this area, like Muss, recognize that for otherwise healthy patients, age is just a number. But they are also familiar with the host of other health problems—chronic conditions such as heart disease and diabetes, functional issues such as a loss of physical strength and balance, and dwindling social support systems—that many older patients diagnosed with cancer are already facing.

Meeting a Need

The first U.S. geriatric oncology clinic was established in 1993 at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, by oncologist Lodovico Balducci. Today, about 20 programs focused on geriatric oncology exist nationwide. In some of them, the emphasis is on integrating palliative and support services for elderly patients and their caregivers into oncology care. Others provide multidisciplinary teams, extensive geriatric assessments or opportunities to enroll in clinical trials designed for older adults.

A traditional oncology approach focuses on how to eradicate cancer using surgery, chemotherapy and radiation,” says Martine Extermann, a geriatric oncologist at the Moffitt Cancer Center. “Geriatric oncology goes beyond that to put the cancer in the context of all the other issues the patient might have.”

Geriatric assessments, which can be 30-minute questionnaires or more-comprehensive evaluations lasting up to two hours, can be vital in establishing that context. They are used to determine a patient’s physiological age—a number that takes into account frailty, cognitive function, nutritional and psychological status, social support and other health issues.

Physicians also may use geriatric assessments to customize treatments. At the Geriatric Oncology Clinic at the University of Rochester Medical Center Wilmot Cancer Institute in New York, for example, the assessment includes a question about whether the patient is prone to falling, as well as physical tests of balance. “We might subsequently determine that [such a] problem is due to peripheral neuropathy in the feet,” says Allison Magnuson, a geriatric oncologist at the institute. “We’d then be able to help tailor the patient’s chemotherapy. For example, we might advise against treatment with a [chemotherapy] drug in the taxane group,” because one of their side effects is neuropathy, and the patient is already dealing with this problem. She says they’d also offer other support, including physical therapy as well as education on how to prevent falls and what to do should a fall occur.

Patients may find the geriatric assessments useful as well. As Jensen went through her treatment, which included surgeries—a mastectomy following two lumpectomies—and chemotherapy, she took the same assessment three more times. By the third assessment, which took place partway through her chemotherapy treatments, Jensen says, “my mobility became more restricted, my eating habits changed and I realized that I wasn’t able to do as much.” The changes were both frustrating and galvanizing, she says, motivating her to get back to where she was before.

From Research to Practice

Although Muss and other geriatric oncologists routinely refer patients for geriatric assessments, they know few oncologists who are currently doing the same. “Most oncologists aren’t really aware of these tools, and they may feel as though they don’t have time to use them,” he says.

Supriya Mohile, a geriatric oncologist at the Wilmot Cancer Institute, is working to change that. She is currently leading a study funded by the Patient-Centered Outcomes Research Institute, a nonprofit organization that funds research about issues important to patients and their caregivers. In the study, 500 patients will undergo geriatric assessments, but only half, along with their physicians, will receive the results.

“We hope to determine if knowing the assessment results improves communication between patients and their physicians about age-related concerns” that may interfere with or affect the patient’s treatment, she says. It’s possible, she adds, that increased communication may “lead to better quality of life and patient satisfaction, which could affect treatment outcomes.” If that’s the case, geriatric oncologists say they will have more evidence to help encourage oncologists who treat older patients to use these assessments.

To date, members of the Cancer and Aging Research Group (CARG) have spearheaded much of the research on geriatric assessments and other geriatric oncology topics in the U.S. Their work is filling a huge gap that has existed for decades: a vast under-representation of older adults in clinical trials. For instance, a study published in 2012 in the Journal of Clinical Oncology found that only about one-third of patients enrolled in clinical trials for cancer drugs that went on to receive approval from the U.S. Food and Drug Administration between March 2007 and June 2010 were 65 or older—even though nearly 60 percent of all cancer patients are in that age group.

As a result, treatment protocols have largely been determined by data from clinical trials that enrolled younger patients. But older patients often cannot tolerate the toxicity of the standard dose, says breast cancer survivor and CARG patient advocate Beverly Canin, 80. Conversely, some doctors, assuming or fearing their older patients won’t tolerate standard doses routinely prescribe less effective doses.

It is “both a social justice and equality issue” as well as “vital for effective treatment” that older adults be enrolled in clinical trials, Canin says.

Experts cite a number of reasons for low clinical trial enrollment of older adults, from health conditions that make them ineligible to inadequate outreach and education about available trials. But CARG researchers have demonstrated that there are ways to increase enrollment, such as training patient advocates to educate older patients about clinical trials. Many of these efforts are described in the Aug. 20, 2014, Journal of Clinical Oncology, the second special issue of the journal dedicated to geriatric oncology (the first was in 2007), which includes articles on topics such as the integration of older patients into clinical trials, supportive care considerations and heart problems associated with anticancer drugs.

An Array of Approaches

Some geriatric oncology programs also bring in palliative care services for patients and caregivers, focusing on addressing patients’ practical concerns and providing social support.

In early 2012, Peggy Anderson turned to the Joan Karnell Supportive Care Services at Pennsylvania Hospital in Philadelphia (now part of the University of Pennsylvania Abramson Cancer Center) to help her manage late-stage lung cancer. Anderson, now 76, met with a geriatric oncology social worker, a palliative care physician and a palliative care nurse practitioner to discuss risks and benefits of different treatment options.

“I went in expecting advice, but that’s not what I got,” Anderson says. “Instead, here were three people asking me questions, helping me figure out my priorities and drawing out of me, in almost a Socratic method kind of way, what I truly wanted. It was such a help to have this sounding board of experts to help me manage my fears about surgery, chemotherapy, sadness, pain and many other aspects of my care and well-being.”

Other programs, like the one at the Wilmot Cancer Institute, have an even broader multidisciplinary approach. Valerie Aarne Grossman, a registered nurse, will forever be grateful for the way the institute’s geriatric oncology team cared for her father, John Aarne, who lives in Macedon, New York, after he was diagnosed in 2010 with colon cancer at age 80. The team’s geriatric assessment showed that apart from some balance issues Aarne was very fit, and “Dr. Mohile told us that there was no reason [my father] shouldn’t get aggressive treatment, despite his age,” Grossman says.

The geriatric oncology team consulted with Aarne’s other doctors and saw him nearly every week throughout his treatment, which included chemotherapy and radiation, followed by surgery. “We showed him exercises to maintain his strength, made sure he was eating properly and generally tried to head off problems before they got worse,” Mohile says.

Aarne’s goal throughout treatment was to get back his independence—which included being able to use his snow blower and mow his lawn. “When Dr. Mohile heard that,” recalls Grossman, “she said, ‘We’re going to make that happen’ ”—and she did. “My father bought his first John Deere mower at age 82.”

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