Dec 23, 2014
By Shira Klapper, Senior Medical Writer/Editor
The United States—and much of the world—is experiencing unprecedented demographic shifts in the population of older people, defined as people age 65 and over. In 2012, the population of older people in the United States reached the never before- seen heights of 43.1 million, a number that will more than double, to 83.7 million, by 2050. In terms of percentages, in 2012, 13.7% of people in the United States were age 65 and older; by 2030, that figure will reach 20.3%, with the largest increase among people 85 years and older. By comparison, the percentage of those age 18 to 64 years will decrease.1
This dramatic growth in the number of older people will impact every level of society, whether economic, social, political, or cultural. It will bring invaluable boons—more grandparents, more people with a lifetime of social and professional experience, and more people who possess that intangible good called “wisdom.” But the boom in older people will also bring significant challenges in the provision of health care.
From an oncology perspective, the aging of the population is already acutely felt. After all, people age 65 and older account for 60% of cancer diagnoses, 69% of cancer deaths, and more than 60% of all survivors.2 Combine these cancer statistics with the reality of a rapidly growing aging population and it is easy to see how the field of geriatric oncology will become a defining concern for oncologists worldwide over the next few decades.
The importance of focusing the spotlight on older people with cancer is perhaps best summed up in the words of leading geriatric oncologist Stuart M. Lichtman, MD, FACP: “All oncologists are geriatric oncologists, whether they know it or not.” Dr. Lichtman is an attending physician at Memorial Hospital for Cancer and Allied Diseases and a member of Memorial Sloan Kettering Cancer Center’s 65+ Clinical Geriatric Group, as well as the recipient of ASCO’s 2014 BJ Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology.
ASCO leads the way
ASCO is leading the way in geriatric oncology by providing oncologists with the education, research base, and professional support they will need to deliver the highest quality care to an aging population.
| Byrl James (“BJ”)
As far back as 1988, ASCO’s then-President, Byrl James (“BJ”) Kennedy, MD, emphasized the importance of focusing attention on the study of geriatric oncology. In his Presidential Address, he said, “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 reduced morbidity.”
Today, ASCO continues to place geriatric oncology at the front and center of its efforts, launching initiatives such as the Journal of Clinical Oncology (JCO) “Special Series on Geriatric Oncology,” spearheading educational efforts to integrate geriatric oncology into general sessions at the Annual Meeting and into ASCO University® modules, addressing the oncology workforce shortage, bringing awareness to research needs in geriatric oncology, and introducing early-career oncologists to research on aging through the Leadership Development Program (LDP) and the Conquer Cancer Foundation (CCF) of ASCO’s Young Investigator Award (YIA) and Career Development Award (CDA). (See the "Conquer Cancer Foundation Supports Geriatric Oncology Research" sidebar for a list of geriatric research projects that have been funded by CCF in the last decade.)
Needs of the older patient with cancer
In some ways, older patients with cancer have an advantage over younger patients, with studies showing that older age bestows upon patients a greater ability to face the psychological challenges that attend a cancer diagnosis.3 In other ways, however, older patients are at a disadvantage: as age goes up, so does the risk of developing toxicity as a result of treatment.
Dr. Lichtman explained the interaction between age and toxicity using the following example: “I had a patient who was 83 years old, she had colon cancer and comorbidities, and she had renal insufficiency. Now, when planning therapy for an 80 year old with metastatic colon cancer with multiple comorbidities, we need to balance off the potential benefit of treatment, which in terms of survival may be only a few months, versus the risk of toxicity. We know from the study of the Cancer and Aging Research Group, that if this patient has a declining functional status, renal insufficiency and poor social supports, the risk of developing grade three or greater toxicity is approximately 80%.”4
The increased risk for toxicity is not limited to patients who have complex medical histories, such as those who have multiple chronic diseases in addition to cancer. “We know from [the Hurria et al.] study that even if you are just older and have no other risk factors, your chance of getting severe toxicity is still 25% to 30%,” said Dr. Lichtman.4 “Even among the ‘well’ elderly, you still have to be really careful.” Older patients are more likely to develop numerous toxicities, including febrile neutropenia, anemia, osteoporosis, depression, and fatigue—conditions that interact with and are complicated by, the presence of age-related diseases such as diabetes and cardiac disease.
Treating older patients is also complicated by the fact that as people grow older, chronologic age is no longer a reliable indicator of overall health, said Arti Hurria, MD, another leader in the field of geriatric oncology, the recipient of the 2013 BJ Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology, and a medical oncologist and Director of the Cancer and Aging Research Program at City of Hope National Medical Center.
“At 40, we’re probably physiologically very similar, but as we age, there’s a lot more heterogeneity so that the number 70 or 80 can no longer really reflect what that individual’s physiologic reserve is,” said Dr. Hurria, who is also the Past President of the International Society of Geriatric Oncology (SIOG) and founder and current Director of the Cancer and Aging Research Group (CARG). “So it’s really about getting to know that individual patient. Of course, as doctors, we do that with every age group, but it’s even more essential in a geriatric population. You have to understand their functional status, their cognition, their social support, and other medical problems that might influence treatment recommendations.”
In addition, older patients’ goals for treatment may differ from those of patients in an earlier stage of life. For example, when deciding on a treatment plan, an older patient might place much more weight on how a specific drug is likely to affect his or her independence and/or cognitive function than on whether it can bring about cure or remission.5
Integrating geriatric oncology into ASCO programs
Caring for older patients with cancer demands that clinicians acquire a strong knowledge base and skill set in geriatric oncology. But often, the multiple demands on early-career oncologists’ time means this kind of in-depth geriatric knowledge is not provided.
| Hyman B. Muss,
“Everyone wants the time of the fellows, but given that they already have to fulfill working hours and the fact that medicine is exploding in information, geriatric training is often not provided,” said Hyman B. Muss, MD, FASCO, one of the original founders of geriatric oncology; the Director of Geriatric Oncology at the Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill; and the recipient of the 2008 BJ Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology. “The point is—we’re not giving physicians enough information about how to treat older patients and how they can bring this information into practice.”
In order to address this educational gap, ASCO has instituted a policy of integrating geriatric oncology education into all of its general educational initiatives, including the Annual Meeting, ASCO University, and JCO.
A prime example of this new educational focus is the 2015 Annual Meeting, which will be held in Chicago from May 29-June 2. New to this year’s meeting—and as a result of the efforts of the Geriatric Oncology Track of the Cancer Education Committee—topics in geriatric oncology will be integrated across many of the general oncology sessions. For example, a session on adjuvant treatment for patients with colon cancer could also include a discussion on the associations between age and toxicity. The 2015 Annual Meeting iPlanner will make it possible to search for all sessions featuring geriatrics as a primary or complementary track.
|Jamie H. Von Roenn,
According to Jamie H. Von Roenn, MD, FASCO, the Senior Director of ASCO’s Department of Education, Science, and Career Development, the decision to raise the profile of geriatric oncology at the Annual Meeting reflects ASCO’s philosophy towards the field as a whole. “An important component of our philosophy about geriatric oncology is that the majority of cancer patients are older, and so it’s important educationally for the audience to not see geriatrics as a stand-alone discipline but to have it woven in as a theme throughout the Meeting.”
The Annual Meeting will also feature three geriatric sessions that have been mainstays of the Meeting for several years. These include a three-hour Special Session focusing on integrating geriatric oncology into practice, a Clinical Science Symposium focused on geriatric issues, and the BJ Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology. The award is funded by the Conquer Cancer Foundation and recognizes members who have made outstanding contributions to the research, diagnosis, and treatment of cancer in the elderly.
Looking ahead to other ASCO educational initiatives, members can expect to see geriatric oncology education incorporated into ASCO University products, such as the Tumor Board series. Similarly, additional questions measuring the quality of care for patients 65 and older might be added to the Quality Oncology Practice Initiative (QOPI®), the Society’s physicianled quality reporting and improvement tool.
Members will also be able to learn more about geriatric oncology in the pages of The ASCO Post—beginning in 2015, the newspaper will feature a monthly column focused on older people with cancer.
In addition, JCO continues to provide a platform for geriatric education through its “Special Series on Geriatrics.” The first Special Series issue was published in 2007; the second issue was published in August 2014 and covered a broad range of topics, including assessment of the older patient with cancer, survivorship issues, and the effects of cancer therapy on cognitive function.
A gap in the research
|Click the image to enlarge|
ASCO leadership and volunteers are working to address one of the main challenges facing geriatric oncology: Older people with cancer are not enrolled onto studies in proportion to their numbers, resulting in a lack of evidence to help guide treatment decisions in the geriatric population.
A 2004 study in JCO reported that while older patients comprise 60% of patients with cancer in the United States, they represent only 36% of patients enrolled onto trials. This discrepancy between the actual number of older patients with cancer and their representation on trials only increases with age. Whereas people age 65, 70, and 75 or older account for 60%, 46%, and 31% of the population of people with cancer, respectively, they represent only 36%, 20%, and 9% of the population enrolled in trials, respectively.6 This unevenness in the age distribution of patients on trials has not improved over the years. From 2001-2011, the percentage of older patients enrolled onto National Cancer Institute (NCI) Cooperative Group Clinical Treatment Trials remained flat at a little above 20%.2
According to Dr. Hurria, fear of inducing toxicity is one of the main reasons doctors do not enroll older patients onto trials.
“It’s a barrier, but it’s also the exact reason we need to do these studies—to find out more about cancer treatment in older people,” said Dr. Hurria. “Yes, older people are at risk for toxicity. That doesn’t mean we shouldn’t treat them, but that we should do it with the right knowledge about how to moderate risk and how to best support the patient through the process. Understanding the toxicity profile and how we can build in those safety parameters to decrease the risk is really the key.”
Mobility is another factor that can explain why fewer older people enroll onto trials; as people age, they become less mobile and, therefore, less willing to travel to major research centers where the majority of clinical trials are carried out
ASCO moves forward on IOM report
The need for more research in geriatric oncology was one of the issues explored in the 2013 Institute of Medicine (IOM) report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.” The report “examine[d] the quality of cancer care in the United States and formulate[d] recommendations for improvement,” according to the IOM website.
The IOM report made two major recommendations to address the dearth of data on older people with cancer. First, increase the breadth of data on older patients by ensuring that older people are better represented on studies. Second, increase the depth of data by capturing more detailed characterizations of study populations through tools such as geriatric assessments.7
Geriatric assessments help clinicians to collect detailed information on such patient characteristics as functional status, comorbidity, cognition, mental health status, fatigue, nutrition, geriatric syndromes, and social status and support.8
Although the IOM releases reports and recommendations, it does not take steps to implement policies that will turn those recommendations into action. That’s where ASCO comes in.
After the release of the report, Dr. Hurria contacted ASCO leadership and asked for their help in forming a Geriatric Working Group with the goal of devising specific action points based on the IOM report. The working group, chaired by Dr. Hurria, met several times in 2014 and presented its recommendations at the fall 2014 meeting of the Cancer Research Committee (CRC). Throughout 2015, the working group’s recommendations will be in the discussion stage. Once finalized, the recommendations will hopefully pave the way to an era of increased breadth and depth in geriatric oncology research. (See the sidebar for a list of Geriatric Working Group members, including Harvey Cohen, MD, one of the founders of geriatric oncology and the recipient of the 2010 BJ Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology.)
Preparing future leaders
ASCO is also committed to inspiring a new generation of researchers to take up the mantle of geriatric oncology. To this end, ASCO leadership chose geriatric oncology as the focus of study for a group of doctors in the 2013 class of the Leadership Development Program (LDP). LDP is a year-long program that seeks to prepare the future leaders of ASCO through leadership classes, advocacy experience on Capitol Hill, and opportunities to network and receive mentoring from ASCO leadership.
|Beverly Moy, MD, MPH|
“LDP is a great program that provides leadership skills and practical training to early- to mid-career oncologists in the hopes of grooming future ASCO leaders,” said Beverly Moy, MD, MPH, a member of the 2012-2013 LDP and the Clinical Director of the Breast Oncology Program at Massachusetts General Hospital. “One of the most important components of this program is to assign us team-based learning to study a major issue that ASCO is grappling with. There were three teams in our group, and our team was asked to develop a strategic plan for how ASCO should prioritize its agenda in geriatric oncology.”
That strategic plan was published in the Journal of Oncology Practice (JOP) under the title, “Geriatric Oncology for the 21st Century: A Call for Action,” with Dr. Moy as its first author.9 The paper states that “geriatric oncology educational sessions should be seamlessly integrated into each disease site track at oncology meetings, such as the annual meetings of ASCO...,” an idea which is being put into practice at the 2015 Annual Meeting.
Dr. Moy said that the connections she formed with mentors through her participation in the LDP paved the way for her current research in geriatric oncology. Dr. Moy is now a member of CARG and is collaborating with Dr. Hurria on an NIH-funded grant looking at older women with breast cancer who are receiving chemotherapy.
CancerLinQ, ASCO’s cutting-edge health information technology platform— slated to roll out in the second half of 2015—will have the ability to aggregate a massive amount of data from health information systems across the country. That data will then be used to uncover patterns to improve care and provide real-time quality feedback to providers.
In addition to its direct clinical application, CancerLinQ has the potential to dramatically increase the volume of data available on older patients. Currently, records on patients not enrolled in clinical trials sit untouched in individual practices, but CancerLinQ will deidentify and aggregate those records, thus allowing research to discover patterns and insights that will answer such questions as: How do older people respond to a particular drug, what is the rate of toxicity for a particular treatment, and how does response to treatment change in the setting of chronic health conditions such as diabetes and heart disease?
Commenting on the potential of CancerLinQ to move geriatric research forward, ASCO President Peter Paul Yu, MD, FACP, FASCO, said: “One of the most exciting aspects of CancerLinQ is its potential to unlock data on populations who have historically been under-represented in clinical trials. This includes racial and ethnic minorities, but also people age 65 and over, who are the majority of patients with cancer but who are nonetheless often excluded from trials based on their comorbidities and doctors’ concerns about inducing toxicity. The catch-22 is that the only way to learn more about how comorbidities and age interact with toxicity is to collect data on older patients. This is where CancerLinQ can revolutionize care. By unlocking data on older patients who are not enrolled in trials, CancerLinQ will enable us to answer some of the more important questions we have about cancer treatment and the geriatric patient.”
Addressing the workforce shortage
ASCO leadership is working hard to address one of the most urgent challenges affecting the care of older patients with cancer: the looming oncology workforce shortage.
This shortage is one of the issues explored in the 2014 ASCO report, The State of Cancer Care in America: 2014, a comprehensive report that looked at demographic, economic, and oncology practice trends that will impact cancer care in the United States in the coming years.
Published as a 60-page report available online at asco.org/stateofcancercare, and as an article in the March 2014 issue of JOP, the report states that demand for oncologists over the next few decades will outpace supply, a trend driven in large part by the aging of the population. Indeed, demand for oncology services will grow by 42% or more by 2025, while the oncology workforce will only grow by 28%.10
According to the report, the upcoming oncologist shortage is not only due to an aging patient population, but to an aging workforce; for the first time, the proportion of oncologists age 64 and older surpasses the proportion of oncologists under age 40, and many of these older oncologists can be expected to retire soon. This wave of retirement will have a disproportionate influence on capacity since older physicians also see more patients in a given amount of time, compared to younger physicians.
| Dean F. Bajorin,
Addressing the workforce shortage— and coming up with solutions— is the work of the ASCO Workforce Advisory Group (WAG). According to Dean F. Bajorin, MD, FASCO, an oncologist at Memorial Sloan Kettering Cancer Center and Chair of the WAG, the volunteer members of the workgroup devote the majority of their time to “identifying how ASCO might be able to enhance either the retention of oncologists or potentially enhance training of oncologists.” Current efforts of the Workforce Advisory Group include identifying interventions to ameliorate burnout and improve work-life balance, examining how access to oncologists differs by geographical region, and studying how the use of advanced practice providers (APPs), such as nurse practitioners and physicians assistants, can increase workforce capacity.
For further information, visit asco.org/practice-research/workforce-initiatives.
Through its efforts to integrate geriatric oncology learning into all of its educational endeavors, form policies and actions to increase research on older people with cancer, and ensure that the oncology workforce will be able to meet the needs of a growing population, ASCO is working to fulfill its vision—that “All patients with cancer will have lifelong access to high-quality, effective, affordable, and compassionate care.”
1. United States Census Bureau. An Aging Nation: The Older Population in the United States: Population Estimates and Projections.www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed 5 Oct 2014.
2. Hurria, A. Improving the Evidence-Base for Treating Older Adults with Cancer. [PowerPoint]. Alexandria, VA: Cancer Research Committee Meeting; September 30, 2014.
3. Rowland JH, Bellizzi KM. J Clin Oncol.2014;32:2662-68.
4. Hurria A, Togawa K, Mohile SG, et al. JOncol Pract. 2011;29:3457-65.
5. Hurria A, Dale W, Mooney M, et al. J ClinOncol. 2014;32:2587-94.
6. Talarico L, Chen G, Pazdur R. J Clin Oncol.2004;22:4626-31.
7. Institute of Medicine of the National Academies. Delivering high-quality cancer care: charting a new course for a system in crisis.www.iom.edu/~/media/Files/Report%20Files/2013/Quality-Cancer-Care/qualitycancercare_rb.pdf. Published Sept 10, 2013.
8. Wildiers H, Heeren P, Puts M. J Clin Oncol.2014;32:2595-2603
9. Moy B, Flaig TW, Muss HB, et al. J OncolPract. 2014;10:241-3.
10. J Oncol Pract. 2014;10:119-42.