Fundamentals of Geriatrics Oncology 2023
- 1. Click to edit Master title style 1 TITLE Fundamentals of Geriatric Oncology B y D r. Ay u s h G a r g
- 2. Click to edit Master title style 2 TITLE 2
- 3. Click to edit Master title style 3 TITLE INTRODUCTION 3 • Aging • 60% > 65 years • 70% by 2030 • What is the age criteria? • Young old 65-70 years • Old 70-85 years • Old adult > 85 years
- 4. Click to edit Master title style 4 TITLE INTRODUCTION 4 • WHO—which describes ageing populations as those over aged 60 years • Societal point of view- age of retirement-entitlement (usually around 65 years in many countries). • In politics- 70 or 75 years and above • Geriatric institutions- 85 years and older • Onco-geriatric sense- A threshold around 70–75 years might be appropriate
- 5. Click to edit Master title style 5 TITLE Frailty • Age=85 • 3+ comorbidity • 1+ geriatric syndromes • 1+ ADL • Primary goal of treating frail patients is palliation.
- 6. Click to edit Master title style 6 TITLE National cancer registry Program, ICMR Population based cancer registry reports In India, according to registry data about 45–50% of all the cancers in males and 35–41% of all cancer in females occur above the age of 60. 50% 38% 6.5 out of 10 males… 2.3 females… INTRODUCTION
- 7. Click to edit Master title style 7 TITLE Disadvantages in Old Age • Decreased life expectancy • Increased comorbidities • Decreased functional reserve • Decreased renal and hepatic functions • Decreased hematopoietic reserve • Altered pharmacokinetics/dynamics • Limited oncology evidence base
- 8. Click to edit Master title style 8 TITLE Age bias Numerous studies in oncology have shown that older people are • Less aggressively screened • Less systematically staged • Receive less standard surgical therapy • Receive less adjuvant radiation/chemotherapy • Receive less cosmetic surgical reconstruction consultation • Receive less dose-intense chemotherapy • Receive CSF’s less often with chemotherapy • Receive strong analgesic and anti-emetic drugs less often
- 9. Click to edit Master title style 9 TITLE CANCER TREATMENT 9 Surgery • Risk of post operative complications • Increased duration of hospital stay • Increased death in emergency surgery • Increased need of assistant post surgery • Increased 6 months post surgery morbidity
- 10. Click to edit Master title style 10 TITLE CANCER TREATMENT 10 Radiotherapy • More tolerable than surgery and chemotherapy • Concurrent chemotherapy to be used cautiously, alternatives like Gefitinib can be tried • Dose modification required • Pain management and nutritional assessment
- 11. Click to edit Master title style 11 TITLE CANCER TREATMENT 11 Chemotherapy • Decreased excretion of drug leading to more side effects • Decreased volume of distribution leading to less effective • Increased dose adjustment • Prophylactic use of GCSF/ Peg GCSF • Hb>12g/dL
- 12. Click to edit Master title style 12 TITLE CANCER TREATMENT 12 Targeted therapy • Reduced therapeutic compliance in comparison to others • More complications
- 13. Click to edit Master title style 13 TITLE CANCER TREATMENT 13 Hormone therapy • Safer than others
- 14. Click to edit Master title style 14 TITLE ASSESSMENT TOOLS • Zubrod scale • KPS/ ECOG • CGS
- 15. Click to edit Master title style 15 TITLE SCREENING TOOLS 15 • To identify patients in need of GA and multidisciplinary approach • CGA • G8 QUESTIONNAIRE
- 16. Click to edit Master title style 16 TITLE G8 • Recommended by SIOG • 8 items in 5 minutes • Developed for the cancer population • Compared with CGA in 8 studies • Sensitivity 65-92%; specificity 3-75% (>60 in 4 studies) • high sensitivity for functional decline • predictive of chemo toxicity in some • Food intake • Weight loss • Mobility • Neuropsych • BMI • Medications • Self report of health status • Age
- 17. Click to edit Master title style 17 TITLE Other screening tools • Vulnerable Elders Survey-13 (VES-13) • Groningen Frailty Indicator • Barber Questionnaire • Identification of Seniors At Risk (ISAR) • Oncogeriatric screen • Abbreviated Comprehensive Geriatric Assessment etc.
- 18. Click to edit Master title style 18 TITLE ( C G A ) 18 Comprehensive Geriatric Assessment
- 19. Click to edit Master title style 19 TITLE COMPREHENSIVE GERIATRIC ASSESSMENT • For better Quality of Life • To see estimate • Life expectancy • Functional reserve • Comorbidities • Social resource availability
- 20. Click to edit Master title style 20 TITLE ADVANTAGES OF CGA 20 • Reduces the risk of hospitalization • Nursing home placement • Improves QoL • Compliance and safety of cancer treatment • Assess outcome of treatment
- 21. Click to edit Master title style 21 TITLE MAJOR COMPONENTS OF CGA 21 Core components that should be evaluated are as follows: • Functional capacity • Fall risk • Cognition • Mood • Polypharmacy • Social support • Financial concerns • Goals of care • Advance care preferences
- 22. Click to edit Master title style 22 TITLE MAJOR COMPONENTS OF CGA 22 Additional components may also include evaluation of the following: • Nutrition/weight change • Urinary continence • Sexual function • Vision/hearing • Dentition • Living situation • Spirituality
- 23. Click to edit Master title style 23 TITLE Geriatric Syndromes • Delirium, • Incontinence, • Dementia, • Depression, • Falls, • Failure to thrive, and • Neglect and abuse.
- 24. Click to edit Master title style 24 TITLE ACTIVITIES OF DAILY LIVING 24 An older adult's functional status can be assessed at three levels: • Basic activities of daily living (BADLs) • Instrumental or intermediate activities of daily living (IADLs) • Advanced activities of daily living (AADLs)
- 25. Click to edit Master title style 25 TITLE Basic activities of daily living 25 BADLs refer to self-care tasks which include: • Bathing • Dressing • Toileting • Maintaining continence • Grooming • Feeding • Transferring
- 26. Click to edit Master title style 26 TITLE Instrumental or intermediate activities of daily living 26 • Shopping for groceries • Driving or using public transportation • Using the telephone • Performing housework • Doing home repair • Preparing meals • Doing laundry • Taking medications • Handling finances • Ability to use a cellphone or smartphone • Ability to use the internet • Ability to keep a schedule of activities IADLs refer to the ability to maintain an independent household which include:
- 27. Click to edit Master title style 27 TITLE Advanced activities of daily living 27 These advanced activities include • The ability to fulfill societal, community, and family roles • Participate in recreational or occupational tasks
- 28. Click to edit Master title style 28 TITLE 28
- 29. Click to edit Master title style 29 TITLE Impact of the CGA • Reduction in: • Adverse events • Hospitalizations • Patient stress • Mortality • May reduce relative risk of death by 15.3% (in breast cancer adjuvant therapy) Impact of a geriatric intervention (experimental arm) on the survival of older patients with early or late stage cancer. McCorkle R, et al. A specialized home care intervention improves survival among older postsurgical cancer patients(2000).
- 30. Click to edit Master title style 30 TITLE Toxicity more common & severe in the elderly • Hematologic • Cardiomyopathy • Mucositis • Delayed nausea & vomiting • Central & peripheral neuropathy
- 31. Click to edit Master title style 31 TITLE • Prophylactic use of filgrastim or pegfilgrastim for patients treated with moderately toxic regimens (CHOP, AC, FEC) and when dose intensity is required for response or cure. Hematologic toxicity & age
- 32. Click to edit Master title style 32 TITLE Cardiotoxicity • Age is risk factor due to decreased myocardial reserve • MUGA scans have limited predictive value • Myocardial damage rare <=300mg/m2
- 33. Click to edit Master title style 33 TITLE Prevention of cardiotoxicity • Caution with use of anthracyclines, trastuzumab • Alternative schedules • Continuous infusion • Weekly administration • Monitor LVEF & clinical symptoms • Alternative drugs, eg. Mitoxantrone, epirubicin, liposomal anthracyclines
- 34. Click to edit Master title style 34 TITLE Prevention & treatment of mucositis • Should be always treated aggressively in older individuals. • Early hospitalization • Provide nutritional support • Oral cryotherapy, ie. Ice • Dose & schedule selection • Rapid correction of dehydration • Treatment of secondary infection
- 35. Click to edit Master title style 35 TITLE CGA Independent Full-dose treatment Grade 3-4 toxicity Dose adjustment No toxicity Same dose Dependent IADLs Comorbidity No toxicity Escalate dose Grade 1-2 Same dose Grade 3-4 Dose adjustment
- 36. Click to edit Master title style 36 TITLE Summary • Cancer disproportionately affects older adults in terms of incidence, morbidity, and mortality • Older patients with cancer have more comorbidity, disability, polypharmacy, and altered pharmacology that impact all aspects of oncology research and practice • Age is not a contraindication to anti-cancer treatment • Older cancer patients may benefit from anti-cancer treatment irrespective of age
- 37. Click to edit Master title style 37 TITLE MULTIDISCIPLINARY TEAM 37 • Oncologist • Geriatrician • Palliative medicine specialist • Oncology nurse practitioner • Pain specialist • General practitioner • Nutritionist • Important consultants to the oncology team such as: • Dermatologist • Cardiologist • Neurologist • Pneumologist • Endocrinologist • Surgeon • Nephrologist • Psychiatrist • Ear, nose and throat specialist (ENT) • Rheumatologist • Ophthalmologist • Sexual health specialist • Psycho-oncologist • Social worker • Physiotherapist • Pharmacist • Clerics (or spiritual helper) • Volunteers • Care-home staff • Self-help and support groups
- 38. Click to edit Master title style 38 TITLE CGA CGA Independent Treatment complete Intermediate Rehabilitation Yes Treatment complete No Special precautions Dose reduction Best supportive care Frail Symptomatic management
- 39. Click to edit Master title style 39 TITLE “ “If you are not a pediatric oncologist, you are a geriatric oncologist” - Source Unknown Thank You
Editor's Notes
- #35: If the patient is fully independent, use fulldose chemotherapy, and dose adjustments [should] be done later. If the patient is frail, only palliative treatment [should] be used. Palliative treatment nowadays may include some form of chemotherapy, like vinorelbine/gemcitabine. But those patients, [who are] in between, who are dependent in some IADLs with comorbidity, are the patients in whom the renal dose adjustment may be indicated. That, I think, makes a very good, strong case for the use of the geriatric assessments.