Transcript 2016-cancer-in-the-elderly-bubis

Cancer Treatment in the Elderly
Jeffrey A. Bubis, DO, FACOI, FACP
Clay County, Baptist South, and Palatka
• Patients 65 and older are the fastest growing
segment of the US population
– By 2030, it will comprise 20% of the population
– There will be a disproportionate increase in
patients greater than 75 years old
Yancik R, Ries LA. Cancer in older persons: an
international issue in an aging world. Semin Oncol 2004
• There is a sharp rise in the incidence of most
cancers after age 60
• Currently…
– 50% of all cancers arise in those 65 and older
– 70% of all cancer deaths occur in those 65 and
older
Yancik R, Ries LA. Cancer in older persons: an
international issue in an aging world. Semin Oncol 2004
• This age group is underrepresented in clinical
trials
• Those that are included in trials result in data
not applicable to the entire elderly population
due to exclusions (esp over 80)
– Poor performance status
– Renal impairment
– Hepatic impairment
– Bone marrow dysfunction
Scher KS, Hurria A. Under-representation of older
adults in cancer registration trials: known problem, little
progress. J Clin Oncol 2012
“…The essential principles of treating cancer in
the elderly are the same as in younger
patients…”
NCCN Guidelines - Older Adult Oncology v. 1.2016
http://www.nccn.org/professionals/physician_gls/pdf/senior.pdf
• Chemotherapy
• Radiation
• Surgery
• Alone or in combination/sequence
Challenges
• Age related organ function decline
– Age-related loss of physiologic reserve
– Puts patients at risk for decompensation
• Liver
– Decline in hepatic volume and blood flow
• Affects drug metabolism
– Liver metastases
• Kidney Function
– GFR falls with age
– Loss of muscle mass complicates assessment
– Volume status
• Bone marrow
– Reserve diminishes with age
• Heart
– Increased risk of CAD
– Increased risk of valvular heart disease
– Decreased ventricular compliance
• Muscle
– Sarcopenia - defined by loss of skeletal muscle
mass two standard deviations below sex-specific
normal values for young adults
• Comorbdities
– DM
– Cardiac disease
– Anemia
– HTN
– GI dysfunction
• Quality of life
– Available data suggest that older patients are just
as willing to try chemotherapy as their younger
counterparts, but less willing to endure severe
treatment-related side effects
Yellen SB, Cella DF, Leslie WT. Age and clinical decision making in oncology
patients. J Natl Cancer Inst 1994
Sanoff HK, Goldberg RM, Pignone MP. A systematic review of the use of quality
of life measures in colorectal cancer research with attention to outcomes in
elderly patients. Clin Colorectal Cancer 2007
Pharmacokinetics
The aging process can significantly alter the
pharmacokinetics of chemotherapy agents.
These pharmacokinetic differences may be
caused by alterations in excretion, metabolism,
distribution and absorption.
• Impaired renal function can result in higher
peak drug levels and more prolonged
exposure to chemotherapy, causing excessive
toxicity with agents that are dependent upon
renal excretion for their clearance
– Platinum agents
– Methotrexate
Heptic metabolism and function
• Although liver size and hepatic blood flow are
decreased with aging, these changes are not of
sufficient magnitude to require routine dose
modification in elderly individuals.
• Concurrent hepatic impairment, due to the
malignancy or other comorbid conditions, may
necessitate dose adjustments.
– Adriamycin
– Gemcitabine
Functional Status
• Chronologic age does not reliably predict
physiologic decline.
• Dosing is not based on age.
• Modifications to doses or changes in therapy
need to be considered when drug toxicity
– overlaps with comorbid conditions
– Increases susceptibility to complications
Relevant Comorbid Conditions
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CKD
Hepatic disease
Ascites/pleural effusion
Decreased bone marrow reserve
Heart disease
ECOG PS > 2, KPS < 60
Performance Status
• ECOG
– Grade 0: Fully active, able to carry on all pre-disease performance without
restriction
– Grade 1 : Restricted in physically strenuous activity but ambulatory and able to
carry out work of a light or sedentary nature, e.g., light house work, office
work
– Grade 2 : Ambulatory and capable of all selfcare but unable to carry out any
work activities. Up and about more than 50% of waking hours
– Grade 3 : Capable of only limited selfcare, confined to bed or chair more than
50% of waking hours
– Grade 4 : Completely disabled. Cannot carry on any selfcare. Totally confined
to bed or chair
– Grade 5 : Dead
-Oken MM, et al. Am J Clin Oncol 1982
Performance Status
• Karnofsky
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100 - Normal; no complaints; no evidence of disease.
90 - Able to carry on normal activity; minor signs or symptoms of disease.
80 - Normal activity with effort; some signs or symptoms of disease.
70 - Cares for self; unable to carry on normal activity or to do active work.
60 - Requires occasional assistance, but is able to care for most of their personal needs.
50 - Requires considerable assistance and frequent medical care.
40 - Disabled; requires special care and assistance.
30 - Severely disabled; hospital admission is indicated although death not imminent.
20 - Very sick; hospital admission necessary; active supportive treatment necessary.
10 - Moribund; fatal processes progressing rapidly.
0 - Dead
Karnofsky DA, et al. The Use of the Nitrogen Mustards in the Palliative
Treatment of Carcinoma - with Particular Reference to Bronchogenic
Carcinoma. Cancer. 1948
What are the goals of therapy?
• Cure
– ex. Early stage lung cancer
• Consider SBRT or chemo-RT instead of surgery
• Consider no adjuvant treatment for resected breast or colon cancer
• Disease Control
– Ex. CLL
• Consider oral biologic therapy instead of infused bio-chemotherapy
• Palliation
– Metastatic pancreatic cancer
• Consider single agent chemotherapy instead of multi-agent therapy
What are the patient’s goals?
• Personal definition of quality of life
• The bucket list
– Trips
– Family events and milestones
– Etc.
Integrated Care
• In addition to multi-modality cancer therapy
– Nutrition
– Physical therapy
– Occupational therapy
– Aggressive pain management
– Psychosocial plan of care
Thank you
Jeffrey A. Bubis, DO, FACOI, FACP
Clay County, Baptist South, and Palatka
[email protected]
Cell 904-704-4170