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Geriatric Oncology: A Field Coming Of Age.
Published 2007 · Medicine
A saying within oncology is: If you’re not a pediatric oncologist, you’re a geriatric oncologist. Maybe while not literally true, this phrase is recognition that all of the subspecialties of oncology are rapidly becoming a field that will be primarily concerned with the care of older patients. While there is not one precise definition of the age of geriatric patients, it is clear that the aging of our society has necessitated a focus on this segment of the population. It has long been recognized that the most significant risk factor for the development of cancer is increasing age. This, together with epidemiologic shifts, has resulted in a marked increase in the number of older patients with cancer, which will markedly increase the cancer burden to the world. It may also compromise the life expectancy, as well as the active life expectancy, of older individuals. Cancer and cancer treatment may appear as several of the prime causes, not only of mortality, but also of disability, in older individuals. The traditional ways in which cancer is studied—by clinical trials focusing on younger, healthier patients—has left us devoid of useful data with which to treat older patients in an evidenced-based fashion. Not only have these earlier trials failed to establish the relative efficacy of cancer treatment in the elderly, but they also were unable to provide information related to the shortand long-term complications of treatment including decline in function. Among the first to recognize this issue was Dr Rosemary Yancik, who in 1983 organized a symposium sponsored by the National Cancer Institute and the National Institute on Aging, which resulted in a monograph, “Perspectives on Prevention and Treatment of Cancer in the Elderly.” The conference reached a number of conclusions and set a research agenda (Tables 1 and 2). In the 1988 American Society of Clinical Oncology (ASCO) Presidential Address, Dr B.J. Kennedy encouraged the study of aging and cancer. He stated “ . . .our society need not ration how we will treat our disadvantaged members, but should continue to seek those preventive and positive measures that can shorten our later period of morbidity. A very major cancer load will persist well into the 21st century, even if the attempts at prevention are eventually a total success. There is a developing knowledge on aging. Care of the older person needs to be part of medical education and oncology education. Research will help attain a desirable quality of life with aging and a reduced morbidity.” Since that time, studies of older cancer patients have revealed a significant amount of important clinical information. This has included the degree and severity of comorbidity and its effect on treatment, the role of polypharmacy, and the various social and financial problems facing older patients with cancer. The relative and absolute under-representation of older patients in clinical trials has been amply documented. The adverse outcomes of inadequate dosing and supportive care in both curative and palliative treatments have been demonstrated in a number of treatment settings. Even when clinical trials are available, barriers to participation of older patients have been shown to be primarily due to physician reluctance due to fear of toxicity, limited expectation of benefit, or ageism. A number of important strides have been made in the evaluation of older patients through various methodologies of geriatric assessment. The Comprehensive Geriatric Assessment developed by geriatricians is a multidisciplinary evaluation of the older patient encompassing a number of important clinical domains. Researchers in this area have shown that traditional oncology measures of performance are not adequate in older patients and that geriatric specific measures, such as activities of daily living and instrumental activities of daily living, have a much greater predictive value. Table 1. Prospects for Cancer Control in the Elderly