Aging and Cancer — Does doing less make sense?

Interesting recent articles in the Journal of Clinical Oncology on treatment of cancer in those over age 80.

The crux of the debate was whether the elderly (over age 80) cancer patient is treated less aggressively and whether this adversely effects outcome.

Women age ≥ 80 years have breast cancer characteristics similar to those of younger women yet receive less aggressive treatment and experience higher mortality from early-stage breast cancer.

And on the other hand:

The authors found a trend for poorer survival in women 80 or older who received chemotherapy. This may have been due to more aggressive tumors or increased treatment toxicity in the treated group. Because of the descriptive and retrospective nature of this study, unmeasured variables, such as cognitive function, performance status, and patient preferences may confound the reported relationships.

But it needs to be fully acknowledged that elderly patients are known already to be less able to tolerate aggressive treatments as their younger comparators.

Elderly patients have more comorbidities and tend to tolerate aggressive chemotherapy and radiotherapy more poorly than their younger counterparts. Much of the data available today is based on retrospective studies of trials that included patients with good performance status and patients of all ages. However, retrospective analyses of ordinary trials without age-specific entry criteria are potentially biased by intrinsic selection that govern enrollment. Hence, it is hazardous to extrapolate results observed in these analyses to the general population of elderly lung cancer patients. Thus, specifically designed prospective studies are mandatory to provide definitive recommendations for the treatment of elderly patients with lung cancer. Relevant prospective data are available only for advanced NSCLC. Elderly patients with lung cancer are at risk for both empirical undertreatment resulting in poor survival and excessive toxicity from standard therapy. Hence, phase III randomized trials are needed to define specific standards of care for the elderly.

Medicynical Note: For someone who has lived over 80 years the promise of a 2-4 month improved outcome is not impressive. This is particularly the case with highly toxic, expensive, and not fully covered by insurance treatment options.

Interestingly the elderly, when facing the reality of the diagnosis and the limits and toxicity of therapy, most often choose treatment that maintains quality of life. The challenge for the medical oncologist is to make sure patients fully understand the risks and benefit –without bankrupting them.

Given that we are talking about applying treatments with known outcomes in younger people, I’m not sure that the elderly will go for a treat/no treat randomization in a phase III trial. The issue is more whether or not to risk the side effects and toxicity, or rediculous costs of treatments and not so much the extent to which the treatment may provide benefit–particularly if we are talking about a few months improvement in survival as is often the case.


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