- Email: [email protected]
Keynote comment: Cancer survivorship and ageing—a double whammy
Reflection and Reaction
Keynote comment: Cancer survivorship and ageing—a double whammy With improvements in cancer treatment over the past few decades the number of cancer survivors has been increasing. Of the almost 10 million cancer survivors in the USA (and almost 24 million worldwide), more than 60% are older than 65 years.1 Issues associated with this age-group have, until the past few years, been almost unaddressed. Calls for action about cancer survival care were issued in 2004 by the report of the US President’s Council1 and in 2006 by the US Institute of Medicine.2 Neither report addressed some serious issues specific to elderly cancer survivors. With the increasing age of the population in most developed nations, the number of elderly adult cancer survivors has, and will continue to, increase, resulting in the need to focus on the interface between this survival state and the consequences of ageing. Older people (especially those older than 75 years) and, thus, older cancer survivors, differ from younger adults in several important ways, including: heterogeneity of health status; multiple, often interacting, diseases; changed physiology; atypical presentations of disease; heightened importance of social support (often widowed or with a frail spouse); increased adverse effects of treatments; and differing goals of treatment. Ageing can be viewed as the changes in structure and function of the body that occur during adult life,
Social support is especially important in elderly people
882
which result in decreased reserve capacity and increased vulnerability to stressors, including disease and other causes of mortality, which ultimately lead to death. This ageing process is mediated by dysregulation and decline of physiological function, and the effect of genetics, environment, and disease. People often move from full independence to partial dependency, frailty, functional decline, substantial dependency, disability, and death, although the pace is highly variable and can be discontinuous or even partly reversible. The late effects of cancer and its treatment, such as reproductive issues, premature menopause, endocrine changes including thyroid and vasomotor alterations, osteoporosis, sexual dysfunction, reduced energy, cognitive complaints, and pain,3 could easily be attributed to advancing age, and potentially dismissed as such in an elderly survivor. Moreover, in elderly patients, concerns arising after cancer become just one of a myriad of issues that contribute to the individual’s overall functional status, quality of life, and health, and are often not even the most prominent or important issue for the patient. Conversely, in view of the similarity of the changes noted above associated with both the late effects of cancer and of ageing, cancer survivorship might enhance or accelerate the ageing phenotype towards greater frailty. In older cancer survivors, the burden of both cancerrelated and non-cancer-related illness is heightened, and patients have increased comorbidity, decreased functional status, and a reduced physical, but not cognitive, health status.4–6 However, adjusted analyses7,8 seem to show that non-cancer comorbidities—eg, cardiovascular disease, diabetes, and arthritis—rather than the cancer-survivorship state per se, affect functional status, quality of life, healthcare costs, and even survival in elderly cancer survivors more than any other problems. This trend is especially important because studies have shown that cancer survivors often do not receive the necessary care or attention to these important non-cancer issues, possibly because the focus is on cancer-related issues, or because the roles of oncologists and primary-care providers are unclear.9 What then is to be done about this? The 2006 report by the US Institute of Medicine suggested several http://oncology.thelancet.com Vol 7 November 2006
Reflection and Reaction
approaches, most of which centre around the creation of a survivorship plan—an explicit document that details the follow-up assessments necessary for a cancer survivor.2 However, the proposal does not address many important issues for survivors who are elderly. For example, what plan should older adults follow? The report suggests use of evidence-based guidelines, but guidelines are generally designed to address individual conditions—eg, hypertension—and might not be equally applicable in the setting of the multiple morbidities and physiological changes seen in elderly adults. Moreover, the guidelines rarely accommodate interaction of any two or more diseases. The proposed survivorship plan does not take into account changes in health status, or any new issues that will arise as patients age. Perhaps more importantly, however, is the question of who will provide this care, as it is likely to be time intensive and require substantial communication. The creation of new health-care delivery systems has been suggested2, but these proposed systems seem to focus mainly on the management of cancer-related issues—eg, screening for recurrence, which, as noted previously, may be the least problematic issue in elderly patients. Furthermore, although the report suggests that healthcare personnel should be trained, further discussion is needed about primary-care personnel, in particular of the potential role of geriatricians in the care of elderly cancer survivors. I suggest that this interface between survival and the consequences of age would present an excellent opportunity for geriatricians to work together with oncologists to develop and implement approaches to the care of elderly cancer survivors. Perhaps of even greater potential is the small but increasing cadre of geriatric
oncologists—individuals jointly trained in geriatrics and oncology. Such physicians could certainly fill a substantial niche in leading the charge for developing a research agenda and promoting interdisciplinary collaboration to achieve the goal of better care for elderly cancer survivors. Although further research is needed, the time to act is now. As we seek improved approaches to future care, more and more elderly cancer survivors are seeking an answer. We must respond to this challenge.
The 7th annual meeting of the International Society of Geriatric Oncology will be held in The Hague, Netherlands (Nov 2–4, 2006).
Harvey Jay Cohen Center for the Study of Aging and Human Development, Box 3003, Duke University and Veterans Administration Medical Centers, Durham, NC 27710, USA [email protected] I declare no conflicts of interest. 1
2
3
4
5 6 7
8
9
The President’s Cancer Panel. Living beyond cancer: finding a new balance, (prepared by Reuben SH). National Cancer Institute, National Institutes of Health. US Dept of Health and Human Services, 2004. Hewitt M, Greenfield S, Stovall E, eds. From cancer patient to cancer survivor: lost in translation. Committee on Cancer Survivorship: improving care and quality of life, Institute of Medicine and National Research Council. Washington, DC: National Academies Press, 2006. Rao AV, Demark-Wahnefried W. The older cancer survivor. Crit Rev Oncol Hematol; published online Sept 9, 2006. DOI:10.1016/j.critrevonc.2006.06.003. Yabroff KR, Lawrence WF, Clauser S, et al. Burden of illness in cancer survivors: findings from a population-based national sample. J Natl Cancer Inst 2004; 96: 1322–30. Keating NL, Norredam M, Landrum MB, et al. Physical and mental health of older long-term cancer survivors. J Am Geriatr Soc 2005; 53: 2145–52. Sweeney C, Schmitz KH, Lasovich D, et al. Functional limitations in elderly female cancer survivors. J Natl Cancer Inst 2006; 98: 521–29. Garman KS, Pieper CF, Seo P, Cohen HJ. Function in elderly cancer survivors depends on comorbidities. J Gerontol A Biol Sci Med Sci 2003; 58A: 1119–24. Seo PH, Pieper CF, Cohen HJ. Effects of cancer history and comorbid conditions on mortality and healthcare utilization among older cancer survivors. Cancer 2004; 101: 2276–84. Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer 2004; 101: 1712–19.
Rising importance of patient-reported outcomes The Article by Basch and colleagues1 in this month’s The Lancet Oncology takes another step in the growing movement in clinical trial research in oncology towards the incorporation of patient-reported outcomes (PROs). Basch and co-workers adapt the US National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) for use by patients rather than by clinicians. The aim of the researchers was to describe the commonalities and discrepancies between adverse event grading by patients and by clinicians. http://oncology.thelancet.com Vol 7 November 2006
Scientific evidence for the reliability of PROs was first reported in the 1970s with pain reporting—which is now collected routinely in clinical trials when patients are enrolled on a clinical trial and at all evaluations during treatment—and continued with studies that showed that patient-reported versions of performance status and symptom distress were prognostic for survival.2–4 The findings of Basch and colleagues are consistent with those of published studies that indicate that patients can indeed understand and report the severity of their
See Articles page 903
883
Keynote comment: Cancer survivorship and ageing—a double whammy With improvements in cancer treatment over the past few decades the number of cancer survivors has been increasing. Of the almost 10 million cancer survivors in the USA (and almost 24 million worldwide), more than 60% are older than 65 years.1 Issues associated with this age-group have, until the past few years, been almost unaddressed. Calls for action about cancer survival care were issued in 2004 by the report of the US President’s Council1 and in 2006 by the US Institute of Medicine.2 Neither report addressed some serious issues specific to elderly cancer survivors. With the increasing age of the population in most developed nations, the number of elderly adult cancer survivors has, and will continue to, increase, resulting in the need to focus on the interface between this survival state and the consequences of ageing. Older people (especially those older than 75 years) and, thus, older cancer survivors, differ from younger adults in several important ways, including: heterogeneity of health status; multiple, often interacting, diseases; changed physiology; atypical presentations of disease; heightened importance of social support (often widowed or with a frail spouse); increased adverse effects of treatments; and differing goals of treatment. Ageing can be viewed as the changes in structure and function of the body that occur during adult life,
Social support is especially important in elderly people
882
which result in decreased reserve capacity and increased vulnerability to stressors, including disease and other causes of mortality, which ultimately lead to death. This ageing process is mediated by dysregulation and decline of physiological function, and the effect of genetics, environment, and disease. People often move from full independence to partial dependency, frailty, functional decline, substantial dependency, disability, and death, although the pace is highly variable and can be discontinuous or even partly reversible. The late effects of cancer and its treatment, such as reproductive issues, premature menopause, endocrine changes including thyroid and vasomotor alterations, osteoporosis, sexual dysfunction, reduced energy, cognitive complaints, and pain,3 could easily be attributed to advancing age, and potentially dismissed as such in an elderly survivor. Moreover, in elderly patients, concerns arising after cancer become just one of a myriad of issues that contribute to the individual’s overall functional status, quality of life, and health, and are often not even the most prominent or important issue for the patient. Conversely, in view of the similarity of the changes noted above associated with both the late effects of cancer and of ageing, cancer survivorship might enhance or accelerate the ageing phenotype towards greater frailty. In older cancer survivors, the burden of both cancerrelated and non-cancer-related illness is heightened, and patients have increased comorbidity, decreased functional status, and a reduced physical, but not cognitive, health status.4–6 However, adjusted analyses7,8 seem to show that non-cancer comorbidities—eg, cardiovascular disease, diabetes, and arthritis—rather than the cancer-survivorship state per se, affect functional status, quality of life, healthcare costs, and even survival in elderly cancer survivors more than any other problems. This trend is especially important because studies have shown that cancer survivors often do not receive the necessary care or attention to these important non-cancer issues, possibly because the focus is on cancer-related issues, or because the roles of oncologists and primary-care providers are unclear.9 What then is to be done about this? The 2006 report by the US Institute of Medicine suggested several http://oncology.thelancet.com Vol 7 November 2006
Reflection and Reaction
approaches, most of which centre around the creation of a survivorship plan—an explicit document that details the follow-up assessments necessary for a cancer survivor.2 However, the proposal does not address many important issues for survivors who are elderly. For example, what plan should older adults follow? The report suggests use of evidence-based guidelines, but guidelines are generally designed to address individual conditions—eg, hypertension—and might not be equally applicable in the setting of the multiple morbidities and physiological changes seen in elderly adults. Moreover, the guidelines rarely accommodate interaction of any two or more diseases. The proposed survivorship plan does not take into account changes in health status, or any new issues that will arise as patients age. Perhaps more importantly, however, is the question of who will provide this care, as it is likely to be time intensive and require substantial communication. The creation of new health-care delivery systems has been suggested2, but these proposed systems seem to focus mainly on the management of cancer-related issues—eg, screening for recurrence, which, as noted previously, may be the least problematic issue in elderly patients. Furthermore, although the report suggests that healthcare personnel should be trained, further discussion is needed about primary-care personnel, in particular of the potential role of geriatricians in the care of elderly cancer survivors. I suggest that this interface between survival and the consequences of age would present an excellent opportunity for geriatricians to work together with oncologists to develop and implement approaches to the care of elderly cancer survivors. Perhaps of even greater potential is the small but increasing cadre of geriatric
oncologists—individuals jointly trained in geriatrics and oncology. Such physicians could certainly fill a substantial niche in leading the charge for developing a research agenda and promoting interdisciplinary collaboration to achieve the goal of better care for elderly cancer survivors. Although further research is needed, the time to act is now. As we seek improved approaches to future care, more and more elderly cancer survivors are seeking an answer. We must respond to this challenge.
The 7th annual meeting of the International Society of Geriatric Oncology will be held in The Hague, Netherlands (Nov 2–4, 2006).
Harvey Jay Cohen Center for the Study of Aging and Human Development, Box 3003, Duke University and Veterans Administration Medical Centers, Durham, NC 27710, USA [email protected] I declare no conflicts of interest. 1
2
3
4
5 6 7
8
9
The President’s Cancer Panel. Living beyond cancer: finding a new balance, (prepared by Reuben SH). National Cancer Institute, National Institutes of Health. US Dept of Health and Human Services, 2004. Hewitt M, Greenfield S, Stovall E, eds. From cancer patient to cancer survivor: lost in translation. Committee on Cancer Survivorship: improving care and quality of life, Institute of Medicine and National Research Council. Washington, DC: National Academies Press, 2006. Rao AV, Demark-Wahnefried W. The older cancer survivor. Crit Rev Oncol Hematol; published online Sept 9, 2006. DOI:10.1016/j.critrevonc.2006.06.003. Yabroff KR, Lawrence WF, Clauser S, et al. Burden of illness in cancer survivors: findings from a population-based national sample. J Natl Cancer Inst 2004; 96: 1322–30. Keating NL, Norredam M, Landrum MB, et al. Physical and mental health of older long-term cancer survivors. J Am Geriatr Soc 2005; 53: 2145–52. Sweeney C, Schmitz KH, Lasovich D, et al. Functional limitations in elderly female cancer survivors. J Natl Cancer Inst 2006; 98: 521–29. Garman KS, Pieper CF, Seo P, Cohen HJ. Function in elderly cancer survivors depends on comorbidities. J Gerontol A Biol Sci Med Sci 2003; 58A: 1119–24. Seo PH, Pieper CF, Cohen HJ. Effects of cancer history and comorbid conditions on mortality and healthcare utilization among older cancer survivors. Cancer 2004; 101: 2276–84. Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer 2004; 101: 1712–19.
Rising importance of patient-reported outcomes The Article by Basch and colleagues1 in this month’s The Lancet Oncology takes another step in the growing movement in clinical trial research in oncology towards the incorporation of patient-reported outcomes (PROs). Basch and co-workers adapt the US National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) for use by patients rather than by clinicians. The aim of the researchers was to describe the commonalities and discrepancies between adverse event grading by patients and by clinicians. http://oncology.thelancet.com Vol 7 November 2006
Scientific evidence for the reliability of PROs was first reported in the 1970s with pain reporting—which is now collected routinely in clinical trials when patients are enrolled on a clinical trial and at all evaluations during treatment—and continued with studies that showed that patient-reported versions of performance status and symptom distress were prognostic for survival.2–4 The findings of Basch and colleagues are consistent with those of published studies that indicate that patients can indeed understand and report the severity of their
See Articles page 903
883