Cancer Treatment in Elderly Patients. Greg Hart Clinical Oncologist GVI Oncology

Transcription

1 Cancer Treatment in Elderly Patients Greg Hart Clinical Oncologist GVI Oncology

2

3

4

5

6 Ovarian Cancer

7 Cervical Cancer

8 Uterine Cancer

9 Cancer in the Elderly 59% of all cancers occur in over 65 s, 30% in over 75 s , 24 Oncology Drugs were registered by FDA Only 33% of the patients in these trials were >65 (10%>75)

10 Typical Clinical Trial Candidate

11 When the elderly were well represented in studies (>40%), they benefitted to a similar degree (with a similar degree of toxicity)

12 Challenges Specific to Elderly Patients Age-related organ function decline Liver Kidney Bone Marrow Heart Comorbid conditions HT Heart disease Anaemia etc

13 Age-related Organ function decline- Liver Aging is associated with a decline in hepatic volume and bloodflow Metabolism and elimination of active agents may be slowed Liver metastases may further exacerbate Careful monitoring of LFT s, especially in drugs metabolised by the liver

14 Age-related Organ function decline- Liver

15 Age-related Organ function decline- Kidney GFR decreases with age Age-related loss of muscle mass makes Creatinine less reliable GFR calculations are a more reliable guide CreatClear = Sex * ((140 - Age) / (SerumCreat)) * (Weight / 72) Volume depletion/overload are less efficiently handled Impaired renal function can result in prolonged peak drug levels

16 Age-related Organ function decline- Bone Marrow Stem Cell reserve decreases with age The incidence of Neutropenia increases with age Anaemia- cancer or chemo related Early and judicious use of growth factors Consider primary prophylaxis ASCO recommendations specify age >65 as a risk factor

17 Co-Morbid Conditions-Cardiac Pre-existing occult heart disease is more common in the elderly Cardiotoxic drugs are more likely to induce heart failure in the elderly (up to 29% in NHL pts on CHOP) Exacerbated by underlying hypertension LVEF assessment mandatory before considering anthracyclnes

18 Polypharmacy 90% of elderly patients use at least one drug Western populations- average 4 drugs

19

20 Assessment of Physical function and Reserve

21 Assessment of Physical function and Reserve- Comprehensive Geriatric Assessment Multi-disciplinary Functional status Comorbidity Cognitive function Nutrition Psychological state and social support Medication review

22 Functional Status Performance status- WHO/Karnofsky etc tend to underrepresent degree of impairment Activities of daily living- ADL s Instrumental activities- IADL s PS2 or greater, Dependence- have both been prospectively associated with increased chemo-related toxicity

23 Cognitive assessment Mini-mental assessment Dementia associated with late presentation Compliance Ability to seek assistance Associated with poor survival

24 Nutrition General geriatric population weight loss of 5% associated with an increased risk of mortality (HR 1.67) Prognostic indicator in all ages Studies needed to assess whether nutritional intervention can reduce these risks

25 Psychological State Depression is prevalent in the elderly population in general Up to 25% of elderly cancer patients More likely to have problems with independence and require formal/informal caregiving Social isolation is an independent predictor of mortality in the elderly

26 In Conclusion Cancer is an important and disproportionate cause of morbidity and mortality in the elderly population. These patients are underrepresented in clinical trials The pharmacokinetics of chemotherapy agents may be affected by age-related decline in liver/kidney/bone marrow function

27 In Conclusion A thorough assessment of functional status, comorbidity, cognition, nutrition, psychological state, social support and medication is mandatory. Patients with poor functional status and multiple comorbidities are not likely to benefit from active anti-cancer therapy

28 In Conclusion Patients with good functional status and minimal co-morbidity are likely to benefit as much from active intervention as their younger counterparts. These patients should be treated with appropriate doses, with growth factor support if indicated

29 In Conclusion The in-betweeners should be assessed in a multidisciplinary setting If active treatment is undertaken, they should be meticulously monitored for signs of renal/liver/bm compromise Further studies are needed

30 Thank You