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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #19, #21

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LEARNING OBJECTIVES

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Learning Objectives

  • Identify factors inherent in the aging process that may promote neoplasia.

  • Apply an understanding of lifespan and patient-centered choice to cancer screening recommendations.

  • Integrate the concept of comprehensive geriatric assessment (CGA) and personal choice into cancer treatment decisions and individual management plans.

  • Become aware of age-related factors that influence the risk of toxicity following radiation or chemotherapy.

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Key Clinical Points

  1. Aging is associated with an increasing risk of developing cancer, with a number of mechanisms likely contributing including duration of exposure to carcinogens, susceptibility to DNA and other cellular damage with impaired repair mechanisms, a proneoplastic environment (eg, low-level inflammation), and impaired immune surveillance.

  2. The 5-year survival rate for most cancers decreases with advanced age; many factors may contribute including altered tumor biology (ie, more aggressive tumor behavior), tolerance to therapy, and the presence of multiple comorbidities.

  3. Age bias in diagnostic and treatment decisions for older patients with cancer exists and older patients are continually underrepresented in clinical trials.

  4. Although performance status (eg, Eastern Cooperative Oncology Group [ECOG] performance score) is routinely applied to cancer patients, CGA that includes assessment tools to predict functional age of cancer patients based on physical function, comorbidities that may interfere with cancer therapy, nutritional status, polypharmacy, psychological and cognitive status, socioeconomic issues, and geriatric syndromes has been shown to add substantial prognostic information for older adults.

  5. Patients and their caregivers should continually discuss goals of care throughout the course of their disease with the treating oncologist.

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INTRODUCTION

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This chapter discusses many of the general relationships of oncology and aging. It focuses on the epidemiologic, basic etiologic, and biological relationships between the processes of aging and neoplasia, and, on the generalizable aspects of management of malignant disease in the older patient. This chapter discusses clinical management of individual malignancies only as an example of general principles. The approach to specific malignancies is covered in subsequent chapters related to the appropriate organ system. It is now well recognized that cancer is a major problem for older individuals. It is the second leading cause of death after heart disease in the United States and age is the single most important risk factor for developing cancer. About 60% of all newly diagnosed malignant tumors and 70% of all cancer deaths occur in persons 65 years or older according to the National Cancer Institute (NCI). If one examines incidence and mortality data obtained from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program (Figure 96-1), one sees that the total cancer incidence rises progressively through the middle years and then falls off in the later years. However, the age-specific cancer incidence rises progressively throughout the age range. Thus, while the rate of increase diminishes somewhat in the oldest age groups, and the rate actually falls slightly in the very ...

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