Dr. Dale notes that ‘Staging the Aging’ with cancer has several important points, notably (i) balancing the risks of treating the disease versus not treating, (ii) weighing the timing of remaining life-expectancy versus cancer progression, and (iii) to consider the impact of potential treatment options on the disease versus toxicities on the aging individual.
Biochemical recurrence occurs in 25-40% of men initially treated with surgery or radiation, however Dr. Dale states that the optimal timing of starting androgen deprivation therapy (ADT) is controversial, particularly in the elderly man. ADT has a number of important toxicities, specifically fatigue, weakness, muscle loss, inactivity, slowed gait, osteoporosis, and falls. Interestingly, these points are all similar to general geriatric frailty, notes Dr. Dale.
There are three key aspects for treating older patients with cancer. First, an estimate of the remaining life expectancy is important, taking into account both the demographic profile as well as the geriatric assessment. Second, staging the aging allows for treating the cancer as aggressively as possible while minimizing toxicity to the patient. Third, decision making and communication is important, specifically framing the clinical scenario, the emotions that may be involved, and establishing trust with the patient and his family.
Age and life expectancy are sometimes difficult to ascertain and Dr. Dale cautions that we must disassociate the chronological age with life expectancy in many cases. It is important to delineate which older patients with cancer are robust, which are frail, and which are “vulnerable”. The goals of a geriatric assessment are to ascertain non-cancer realistic life expectancy, identify areas of vulnerability and target interventions appropriately. This includes an evaluation of functional status, comorbidities, cognition, geriatric syndromes, nutritional status, psychological status, and social support. In a Delphi Consensus of Geriatric Oncology experts organized by Dr. Dale, a panel of 30 participants met consensus that “all patients aged 75 years or older and those who are younger with age-related health concerns should undergo geriatric assessment, including all 7 domains”.1
Dr. Dale has lead research specific to the elderly assessing prostate cancer related stress and implications for starting ADT. Among 67 patients with biochemical recurrence of prostate cancer, 33% of patients initiated ADT at the first or second clinic visit. Elevated prostate cancer anxiety was the most robust predictor of early initiation of ADT (OR 9.19, p=0.01).2 This resulted in an additional time on ADT of 14 months, with no added survival benefit.
To conclude, Dr. Dale highlighted a 5-step process putting “the geriatric assessment process together”. First, a cancer-based prognosis with and without treatment allows for staging the cancer. Second, an aging-based prognosis separate from the cancer-based prognosis allows for staging the aging. Third, using the geriatric assessment to identify resources needed to maintain independence is important for targeting intervention and matching those needs. Fourth, we need to ascertain the patient’s preferences and values for care, and finally, we need to communicate the available options to the patient and their family.
Presented By: William Dale, MD, PhD, City of Hope, Los Angeles, CA, USA
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
at the 2017 ASCO Annual Meeting - June 2 - 6, 2017 - Chicago, Illinois, USA
1. Mohile SG, Velarde C, Hurria A, et al. Geriatric Assessment-Guided Care Processes for Older Adults: A Delphi Consensus of Geriatric Oncology Experts. J Natl Compr Canc Netw 2015 Sep;13(9):1120-1130.
2. Dale W, Hemmerich J, Bylow K, et al. Patient anxiety about prostate cancer independently predicts early initiation of androgen deprivation therapy for biochemical cancer recurrence in older men: A prospective cohort study. J Clin Oncol 2009 Apr 1;27(10):1557-1563.