Medicynic

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.

Sad but not surprising news regarding the U.S.’s child mortality being reported in Lancet (full text online May 24 and available with registration). The report notes declines in the rate of child death worldwide but our rate of decline (the U.S.’s) is significantly less than elsewhere. Currently 6.7 child deaths/1000 occur here. In most of Europe and Canada the rate is now under 5–in Singapore it’s under 3. There appears no good explanation for this discrepancy other than the unevenness and cost of our non-system.

Underscoring historic recent gains in global health, the number of children younger than 5 who die this year will fall to 7.7 million, down from 11.9 million two decades ago, according to new estimates by population health experts. But as much of the world makes strides in reducing child mortality, the U.S. is increasingly lagging and ranks 42nd globally, behind much of Europe as well as the United Arab Emirates, Cuba and Chile.

Singapore, the country with the lowest child mortality rate in the world at 2.5 deaths per 1,000 children, cut its rate by two-thirds between 1990 and 2010. Serbia and Malaysia, which were ranked behind the U.S. in 1990, cut their rates by nearly 70% and now are ranked higher.

The data instead suggest broader problems with the nation’s fragmented, poorly planned healthcare system, Murray and other healthcare experts say. Although the U.S. spends nearly twice as much per capita on healthcare as most other industrialized countries, researchers are finding substantially higher levels of preventable deaths from diseases such as diabetes and pneumonia.

Other countries with slow rates of decline include Britain, New Zealand and South Korea, which have all fallen in the international rankings since 1990. All three are still ahead of the U.S.

link: Child mortality rates dropping, study finds, but U.S. lags

Medicynical Note: The article in the LA Times puts some faith in notion that the newly enacted health care law will approach our uncoordinated non-system that costs twice as much as elsewhere. That remains to be seen as many in our culture don’t feel there is a collective responsibility to assure access to affordable health care. In this we remain a remarkable outlier in the world.