Geriatrics in Oncology: Lessons From a Fellow’s Perspective

Aug 24, 2016

By Rawad Elias, MD

"Doctor, my husband does not have the energy to do much. He used to take care of everything for us, and now it’s all on me—the house, the bills, his food, and his medications.”

During my first year of training in geriatric oncology, I learned about conditions such as functional dependence, cognitive impairment, comorbidity, polypharmacy, and falls. These “geriatric syndromes” are multifactorial health conditions with substantial impacts on health status and quality of life of older adults.1 However, when I started seeing patients in my oncology clinic, I found that although these syndromes are more common in those who are older than age 65, they are not specific to this age group. In fact, the patient mentioned above was a 57-year-old man.

Age as a chronologic value is no longer a reliable indicator of health. Instead, a patient’s well-being is a reflection of interactions between age and medical, functional, social, and psychological factors. Geriatric medicine pioneered the study of these interactions and established geriatric assessment as a comprehensive method to evaluate geriatric conditions.2

In the oncology world, many of these disorders have been demonstrated to have implications on the treatment tolerance and prognosis of older adults with cancer.3 Hurria et al. demonstrated that hearing deficit, falls, functional limitations, and depression were predictive of chemotherapy toxicity, and they included these factors in the Cancer and Aging Research Group (CARG) Chemo-Toxicity Calculator.4,5

The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score is another toxicity prediction tool, which includes factors such as functional limitations, cognitive deficit, and malnutrition.6 Geriatric conditions such as depression, polypharmacy, functional dependence, impaired cognition, and malnutrition can also have negative effects on patients’ prognosis and survival.7-10 It is important to note that some of these “geriatric” conditions such as cognitive dysfunction, functional limitations, and falls are already a concern in younger patients undergoing chemotherapy and in cancer survivors.11-15

In our aging population, it is critical to emphasize the role of geriatric assessment in the treatment choice, supportive measures, and prognosis of older patients with cancer. The study of geriatric oncology offers an invaluable opportunity to improve the care of older patients and has the potential to help us improve the care of all patients with cancer, but unfortunately it is still not getting the attention it deserves.

Older adults continue to be underrepresented in clinical trials, and studies designed specifically for this age group are rare.16 Talarico et al. showed that although 60% of the U.S. cancer population was older than age 65, only 36% of patients in this age group were included in the U.S. Food and Drug Administration registration trials between 1995 and 2002.17 The percentage of patients older than age 65 enrolled in National Cancer Institute (NCI) cooperative group trials remained a little more than 30% between 2001 and 2011.18

These disparities are not limited only to research; they are also present in hematology-oncology fellowship training. It has been more than 3 decades since the NCI and the National Institute of Aging recognized the need for education and training in aging and cancer.19 In 2007, the Accreditation Council for Graduate Medical Education underscored the importance of including geriatric oncology in the training of hematology-oncology fellows, but this recommendation has yet to be formally implemented.20 Only a few fellowship programs offer a combined training in hematology-oncology and geriatrics, and just a handful of fellows are enrolled in training each year. A survey of hematology-oncology program directors from 2008 showed that among responders, only 32% had a formal curriculum for geriatric oncology, although 88% agreed that it is an important component of fellows’ training.21 Another survey conducted in 2013 among fellows showed that 84% of responders thought that geriatric curriculum was very important but less than 50% had some training in geriatric oncology, only 25% had access to a geriatric oncology clinic, and only 23% were able to identify predictors of chemotherapy toxicity in older adults.22

ASCO has been leading efforts to change this. Geriatric oncology is becoming more prominent every year at the ASCO Annual Meeting, in ASCO’s publications, on ASCO University®, and through activities supported by the Conquer Cancer Foundation of ASCO.

Individuals with an interest in improving the care of older adults with cancer are getting together to help advance the field of geriatric oncology. CARG is a collaborative network of researchers devoted to this field, and Junior CARG is a chapter within the group that aims to connect trainees at different levels to one another and to senior researchers. Since it was established about 2 years ago, Junior CARG fills an essential missing link in the development and education of trainees in geriatic oncology. Through this platform, trainees help one another to overcome challenges they face in taking care of older patients with cancer, share tips on career advancement, and promote the field of geriatric oncology among their peers. Every year, Junior CARG sends a letter calling for trainees in either hematology-oncology or geriatrics to join their effort.

Much progress has been achieved since the first call to improve the care of older adults with cancer in 1983, but there is more to accomplish. Together, we will work on making geriatric oncology an essential skill set in the care of older—and maybe all—adults with cancer.


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