European Journal of Cancer

Issue16, 2007

By Helen Saul, News Editor

PODIUM - Dr. Riccardo Audisio

Elderly patients: the forgotten majority

Riccardo Audisio is a consultant surgical oncologist and honorary reader (University of Liverpool, UK), and editor-in-chief of Surgical Oncology. His clinical research focuses on geriatric oncology and he chairs SIOG’s surgical task force. He is a guest editor of the EJC Special Issue ‘Cancer Management in the Elderly: A Progress Report’

Do elderly patients have special requirements?

Different approaches are needed from standard care; this is a key message. Geriatric oncology needs to attract interest, money and enthusiasm in a way similar to – but on a much larger scale than – paediatric oncology. Paediatric oncology represents a minute percentage of cancer; geriatric patients account for 60% of all cancer deaths. It is an epidemiological time bomb, an emergency, and people should be aware of it.

What do elderly patients need?

Technically speaking, there is no data on how best to manage the elderly. In the 1980s, epidemiologists started observed increasing numbers of elderly patients; they also noted that diagnoses were inadequate, staging substandard, and treatment far from optimal. Medical oncologists did not enter elderly patients into trials, so we don’t have hard knowledge on the best treatment. This is also true in surgery: the original Veronesi/Fisher study comparing lumpectomy with mastectomy had a cut off point at 70 years. There is confusion. We don’t want to over-treat frail patients, but, equally, we don’t want to under-treat just because someone is elderly.

How do elderly patients differ?

In medical oncology, the pharmacokinetics and pharmacodynamics are different. Patients are often taking multi-drugs, so drug interference is possible; oncologists do not want to induce toxicity. Similarly, elderly patients react to surgery in a different way. And they occasionally can’t comply with radiotherapy: either they can’t squeeze into the machine or they have no transport to get to the radiotherapy unit. Given that 2/3 of cancer affects elderly people, it is surprising that we don’t know how best to handle them surgically or medically. We assume that what is delivered to younger patients will be appropriate. It is shameful that we don’t put the effort into providing the care we try to give younger cancer patients. Is there ongoing research? We have come a long way in the last 10 to 15 years. Since then, the Comprehensive Geriatric Assessment (CGA) has been suggested and there are trials which will allow us to offer the best treatment according to patient’s sickness.

How well known is the CGA?

Not sufficiently, and hardly at all in surgery. Without it, someone with cancer who could withstand surgery may not be offered it; someone else may be judged fit enough, where the CGA would have revealed comorbidities such as depression or malnutrition. The CGA is derived from a more detailed geriatric tool. It is pragmatic, easy, and sufficiently reliable.

Do we need to increase the age limit in general clinical trials, or set up trials specifically for elderly patients?

Both. There is increasing evidence that medical or surgical treatment should be delivered to elderly patients who are fit enough; hence the value of the CGA. But where a frail subset of patients requires drugs which do not induce toxicity, we should develop age-specific investigation. Because 78% of elderly people take multiple medicines, drug interactions are a problem. But we can’t avoid involving these patients in trials. There is no point discovering that a drug works beautifully alone when in clinical practice, it is to be taken with several other drugs.

Is best clinical care more important than novel agents in this group?

Quality of life has to be a priority. You can’t always increase life expectancy in this older group. Life comes to an end, and you must be sure that you are not imposing an unacceptable treatment which extends survival by a few months but results in an intolerable quality of life.

Has the notion of QALYs led to discrimination against elderly patients?

Yes! I’ve even heard talk of active life expectancy, implying that those who are not active don’t deserve survival benefit. Society thinks that the rich, beautiful and young warrant care; and the ugly, poor and elderly, probably don’t. I don’t subscribe to this. These people have been paying taxes all their lives and are entitled to the best treatment. You see old people sailing through treatment and 3, 5 or 10 years later, are still happily dealing with their grandchildren. Society benefits from this.

Are there differences across Europe in how we treat older patients?

There are differences in cancer management, but not strikingly according to country. The elderly are similarly mistreated across Europe, the US and Japan. We are all making the same mistake.

What do you hope the Special Issue will achieve?

We want to raise awareness among the public, health care providers and politicians. The only way forward is to create geriatric oncology units which will optimise the management of cancer in the elderly. Only 3 currently exist in the world.