Nicolò Matteo Luca Battisti1 and Lissandra Dal Lago2
1Breast Unit – Department of Medicine, The Royal Marsden NHS Foundation Trust, Breast Cancer Research Division,
The Institute of Cancer Research, London, UK
2Medicine Department, Institut Jules Bordet, Brussels, Belgium
Corresponding author: Nicolò Battisti Email: nicolo.battisti@rmh.nhs.uk
Caring for older individuals is a significant part of the routine practice for adult oncologists since more than half of new cancer cases and 70% of related deaths occur over the age of 65 years [1]. Nonetheless, there is a substantial gap of knowledge supporting treatment decisions in this age group. Older adults have always been under-represented in the clinical trials constituting the evidence base for the management of cancer [2, 3]. Where data are available, this is not easily applicable to older individuals in the real world as patients enrolled in clinical trials are typically fitter and this limits the external validity of guidelines and evidence-based recommendations [4].
There is a substantial risk of over- and under-treating older adults with cancer [5]. This risk is related to the substantial heterogeneity of this population where fitness and frailty are a continuum: on one hand, there may be patients who are seemingly frail but actually able to tolerate and benefit from standard treatments; on the other hand, apparently fit individuals may be particularly prone to experiencing undue side effects and require modified treatment plans. Nonetheless, standard considerations on chronological age and performance status offer little insight on their ability to tolerate and benefit from standard therapeutic approaches and are poor descriptors of the complexity of this population.
Managing cancer in older individuals requires careful consideration of a number of challenges which are unique to this age group. Organ function decline may involve several systems including liver, kidney, bone marrow, heart and muscle:[6, 7]these changes may alter the pharmacokinetics, metabolism and distribution of systemic therapeutic agents and increase the risk of complications of standard approaches. A higher prevalence of comorbidities may impact on prognosis, reduce expected benefits and increase the risk of side effects of anticancer treatments [8]. In the context of a shorter life expectancy, older adults may favour quality over quantity of life, although little is known on the impact of oncological therapies on patient-reported outcomes [9]. Polypharmacy may increase the risk of harmful interactions with systemic agents and affect compliance [10].
Comprehensive geriatric assessment (CGA) is instrumental to the appropriate management of cancer in this population of patients and to capture their complexity. Robust evidence suggests that CGA can predict complications on anticancer treatments and functional decline, estimate survival, aid decision-making, detect problems which are usually neglected by routine assessments, and improve the mental health, well-being and pain control in older individuals diagnosed with malignancy. International guidelines and recommendations issued by the American Society of Clinical Oncology, the National Comprehensive Cancer Network and the International Society of Geriatric Oncology set CGA as the current standard of care [11-14]. Moreover, this year has been remarkable for clinicians and investigators focusing on the management of cancer in older adults: at the recent 2020 American Society of Clinical Oncology virtual meeting, four clinical trials have demonstrated the benefit of integrated oncogeriatric care on harder endpoints, including toxicity, quality of life and hospitalizations [15-18].
In this special issue, we feature five articles covering different aspects of the care of older adults with cancer. First, we publish an overview on the care of older patients with cancer in the United Kingdom authored by Dr Fabio Gomes from The Christie NHS Foundation Trust of Manchester. This review maps the services available in different hospitals across the UK focusing on the care of this group of patients. Moreover, the article highlights the instrumental role of various initiatives at the National Health Service (NHS) level which support the implementation of oncogeriatric care in routine practice, such as the NHS RightCare Frailty Toolkit and the Specialized Clinical Frailty Network. Finally, the authors outline also the importance of charities and scientific societies in the development of geriatric oncology across the country.
We also feature a review of the care of older adults with cancer in Mexico authored by Dr Carolina Gomez-Moreno from Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán of Mexico City. This review describes the epidemiology of cancer in older adults in Mexico and the specific challenges for implementing geriatric oncology care in the country. Nonetheless, the article highlights the projects currently ongoing which suggest that there are considerable opportunities to improve the care of older individuals with cancer in this setting.
This issue also includes a review of the scope of geriatric oncology in France authored by Dr Hauchecorne from the Gustave Roussy Cancer Campus of Paris. The support of subsequent national cancer plans has been historically instrumental to the thriving of this subspecialty in France. The dissemination of oncogeriatric care in France has involved the creation of specific units in different regions and several opportunities of clinical research on this topic. Scientific organisations such as the Francophone Society of Geriatric Oncology and the UNICANCER Oncogeriatrics group have also been crucial to the development of clinical research in the field.
We then present the report of an observational study of older patients with platinum-sensitive advanced ovarian cancer receiving the PARP inhibitor olaparib led by Dr Gabor Liposits from Herning, Denmark. This study highlights the need to evaluate outcomes of novel anticancer agents in real-world population of patients and points out the need to enrol older adults and incorporate geriatric assessments in clinical trials to ensure that their findings remain valid for a broader population of patients.
Finally, we feature a review of the definition and assessment of frailty in older patients based on the points of view of a surgeon, an anaesthetist and a medical oncologist authored by Dr Lorenzo Dottorini from Bergamo, Italy. This article outlines that assessing frailty is crucial also in the preoperative setting for older patients with cancer undergoing surgery and should always involve a holistic and multidisciplinary approach.
During the last two decades, oncologists have become increasingly used to driving treatment decisions based on the presence or absence of a number of molecular biomarkers [19]. Geriatric oncology offers similar opportunities to provide precision medicine. An accurate evaluation of older patients with the validated tools included in CGA and its integration in routine care also represents personalised care. This special issue confirms that there is increasing and global interest in geriatric oncology. The many recent advances in this field suggest that the time is now to implement the principles of geriatrics to the routine care of older adults with cancer and to maximise their inclusion in clinical trials [20].
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