Professor Margot Gosney University of Reading

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Professor Margot GosneyUniversity of Reading

• Treating Cancer in old age could we do better?

AAA Annual Scientific Meeting 2008
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Agenda

• Overview of epidemiology
• Screening
• Assessment of older people
• Special problems of old age
• Plans for the future

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Is cancer a common problemin old age?

• Increase in number of older patients
• Increased diagnostic certainty
• Certain malignant diseases rise with increasing
  age
• Over 50 of all cancers arise in patients 70
  years or above

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Table I. Age specific incidence rates per100,000
males in Merseyside and Cheshire,1986-1995
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Table II. Age specific incidence rates per
100,000females in Merseyside and Cheshire,
1986-1995
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Colon Cancer Men 1996-99
Number of Cases 1 yr 5 yr survival survival
15-39 447 79 60 40-49 1214 77 53 50-59 3784 75
48 60-69 8592 72 44 70-79 11838 67 34 80-99 6102
55 19 Total 31,977 67.3 35
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AAA Annual Scientific Meeting 2008
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Colon Cancer Women 1996-99
Number of Cases 1 yr 5 yr survival survival
15-39 419 79 57 40-49 1075 80 54 50-59 3208 78
52 60-69 6517 74 48 70-79 11154 67 39 80-99 9870
51 21 Total 32,243 66.9 39
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AAA Annual Scientific Meeting 2008
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Stage, age, CRC, 1976-1999 all patients
Stage
1976-87 ()
1988-99 ()
lt75
I,II
48.4
53.4
III
22.1
21.6
advanced
29.5
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gt75
I,II
42.6
50.4
III
15.2
20.7
advanced
41.2
28.9
Advanced Stage IV and unresectable
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Treatment of elderly patients

• In 1985 19,945 papers on cancer management
• Only 11 were specifically about elderly patients
• In 1995 32,421 papers on cancer management
• Only 26 were specifically about elderly patients
• In 2005 76,942 papers on cancer management
• Only 370 were specifically about elderly patients

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Screening
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Does the US lead the way?

• 41 believed that an 80 year old who chose not to
  be investigated with mammography was
  irresponsible
• 32 believed that an 80 year old who chose not to
  be tested by colonoscopy was irresponsible
• most wanted to know about the presence of cancer
  regardless of its implications
• two thirds said that they wanted to be tested for
  cancer even if nothing could be done
• 56 wanted to be tested for slow growing
  non-death producing cancers
• 73 would prefer to receive a total body CT scan
  rather than a 1000 in cash

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Screening / Diagnosis in CRC

• FOBT
• Barium enema
• Sigmoidoscopy
• Colonoscopy
• CT colonography
• Symptomatic vs asymptomatic

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Who should be screened?

• 19 of population develop adenomatous polyps
• 5 of population develop CRC
• Most cancers are in 65-75 years
• ? screening for over 50 years
• Most relevant is those with family history

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What is the role of faecal occult bloods,
sigmoidoscopy and other investigations in the
screening for colorectal cancer?
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Faecal Occult Blood

• Denmark study 1989
• 30,970 screened
• 30,968 controls
• Age 45 to 74 years
• Hemoccult-II on two separate occasions
• 215 and 159 positive tests

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Early lesions more frequentin screened group

• Less extensive surgery low post operative
  mortality
• Lower number of deaths from colorectal cancer
• Reduction in mortality of 27 (51 deaths in
  controls versus 37)

Kronborg et al, 1989 Kronborg et al, 1996
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10 yr follow up of Denmark study

• 70,672 (67) completed first screening round
• 90 accepted repeated screenings
• During 10 years, 481 in screening group
  diagnosis of colorectal cancer versus 483
  unscreened
• 205 deaths (colorectal) in screening versus 249
  in control

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UK Faecal Occult Blood Screening

• Feb 1981 to Jan 1991
• 152,850 people aged 45-74 years
• FOB screening - 76,466 (controls 76,384)
• Screening group received hemoccult FOB test kit
  with instructions from GP
• No dietary restrictions
• Individuals with negative FOB at first screening,
  plus those positive, but normal colonoscopy
  invited for screening every 2 years
• FOB tests between 3 to 6 times
• Screening positive offered full colonoscopy

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Findings

• 59.6 of the screening group, completed at least
  one screening
• 38.2 of these completed all FOB tests offered
• 21.4 completed at least one screening, but not
  all
• 40.4 did not complete any tests
• Of 893 cancers (20 Stage A) 26.4 were detected
  by FOB screening
• 360 deaths in screening group, versus 420 in
  control group (odds ratio 0.85 i.e. 15
  reduction)

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Evidence in older patients

• 1,053 (506 in screening group) were aged 75 years
  or older

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Number ( of age and sex subgroup)who accepted
first screening
Age (years)
Men
Women
45-49 50-54 55-59 60-64 65-69 gt 70
469 (34) 4067 (51) 4159 (52) 4047 (54) 3447
(54) 2395 (49)
575 (43) 4654 (59) 4822 (59) 4620 (58) 3913
(54) 3046 (47)
Total ( of total screening group)
18584 (51)
21630 (55)
Hardcastle et al, 1996
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Relative benefits of screeningfor different
groups

• Mortality reduction
• 0.87 for men
• 0.83 for women
• 0.81 for individuals less then 65 years at study
  entry
• 0.90 for those aged 65 or greater at entry
• 0.87 for cancers proximal to the sigmoid colon
• 0.84 for distal cancers

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Assessment

• Before treatment?
• During treatment?
• After treatment?
• Old age specific or oncology specific?
• Is there a gold standard?

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Why do we needassessment?

• No such thing as a typical 80 year old
• Effect of pre-morbid state
• Physical, social and psychological
• Effect of gender, age, marital status, country
  and wealth

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General Assessment

• Functional assessment
• Surgical assessment scales
• Comorbidity scales
• Overarching comprehensive assessments

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Functional AssessmentScores

• Barthel Index
• Karnofsky performance status
• Activities of daily living dependency score (ADL)

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Barthel Index

• Described in 1965
• Observational
• Particularly useful in assessment of patients
  after stroke
• 10 sections scoring a total of 0-20
• 4 total dependency
• 20 normal
• limitations include cognitive impairment,
• communication problems and delirium

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Barthels Index of activities of daily living
(BAI)
1. Bowel Status
0 points Incontinent (or needs to be given
enema) 1 point Occasional accident (once a
week) 2 points Fully Continent
2. Bladder Status
0 points Incontinent or catheterized and unable
to manage 1 point Occasional accident (max once
per 24 hours) 2 points Continent (for more than
seven days)
3. Grooming
0 points Needs help with personal care
face/hair/teeth/shaving 1 point independent
(implements provided)
4. Toilet Use
0 points Dependent 1 point Needs some help
but can do something alone 2 points Independent
(on and off/wiping/dressing)
5. Feeding
0 points Unable 1 point Needs help in
cutting/spreading butter/ etc 2 points
Independent (food provided within reach)
6. Transfer
0 points Unable (as no sitting balance) 1 point
Major help (physical/one or two people) 2
points Can sit minor help (verbal or
physical) 3 points Independent
7. Mobility
0 points Immobile 1 point Wheelchair-independe
nt (including corners etc) 2 points Walks with
help of one person (verbal or physical) 3 points
Independent
8. Dressing
0 points Dependent 1 point Needs help but can
do about half unaided 2 points Independent
(including buttons/zips/laces etc)
9. Stairs
0 points Unable 1 point Needs help
(verbal/physical/carrying aid) 2 points
Independent up and down
10. Bathing
0 points Dependent 1 point Independent
bathing or showering
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Barthel Score (max 20)______________
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Karnofsky Performance StatusScale

• Targeted to measure functional ability in
  patients with cancer
• Well validated in younger patients
• Clinicians assessments therefore often poor in
  elderly patients
• Not sensitive to change in patient status

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Karnofsky Performance StatusScale Definitions
Rating () Criteria
Able to carry on normal activity and to work no
special care needed.
100 90 80
Normal no complaints no evidence of disease Able
to carry on normal activity minor signs or
symptoms of disease Normal activity with effort
some signs or symptoms of disease
Unable to work able to live at home and care for
most personal needs varying amount of assistance
needed.
70 60 50
Cares for self unable to carry on normal
activity or to do active work. Requires
occasional assistance, but is able to care for
most of his personal needs. Requires considerable
assistance and frequent medical care.
Unable to care for self requires equivalent of
institutional or hospital care disease may be
progressing rapidly
40 30 20 10 0
Disabled requires special care and
assistance. Severely disabled, hospital admission
is indicated although death not imminent. Very
sick hospital admission necessary active
supportive treatment necessary. Moribund fatal
processes progressing rapidly. Dead
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Activities of daily livingdependency

• Can be obtained from patients and surrogates
• Is validated in older individuals
• Not designed to assess patients with cancer
• Good collation between score and both morbidity
• and mortality

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Surgical Assessment ScalesAPACHE II-Acute
Physiologyand Chronic Health Evaluation

• 12 physiological measurements which include age
  and the presence or absence of severe chronic
  health problems
• Good predictor of intensive care unit morbidity
• and mortality
• Ignores nutritional status
• Does not help decide whether elderly people
• should undergo cancer treatment - only if they
• are likely to die post operatively (a little
  late!)

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POSSUMPhysiological and Operative Severity
Scorefor Enumeration of mortality and morbidity

• 12 physiological and 6 operative variables
• Does predict morbidity and post operative
• mortality in patients with lung cancer and
• Colorectal cancer
• POSSUM includes ECG findings (APACHE does not)

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Comorbidity Scores

• Geriatric Index of Comorbidity (GIC)
• Adult co-morbidity Evaluation ASA-27
• Cumulative Index Rating Scale for Geriatrics
  (CIRS-G)
• Charlson Index

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Comorbidity Scores

• Geriatric Index of Comorbidity
• No validation in elderly patients with cancer
• ASA-27
• OK with cancer, but most data due to
  retrospective extraction

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Comorbidity Scores

• The Charlson Index
• Poor correlation with other ageing comorbidity
  ratings
• Lacks sensitivity merely yes/no i.e. no
  severity
• CIRS-G
• Measures burden of physical illness
• Mainly validated in residential care
• Poor validation in cancer

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Comprehensive GeriatricAssessment (CGA)

• Multi disciplinary approach
• Physical and psychological ability, as well as
• symptoms
• Provides assessment before a decision to treat
• or not to treat
• Highlights areas where additional input is needed
• Can be used in an abbreviated form
• Should not be used solely as a decision making
  tool

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Multi-disciplinary teams

• Geriatrician, breast surgeon and anaesthetist
• Nottingham weekly clinics
• One or two women
• Pre op assessment, optimise giants of geriatric
  medicine
• Little validation (yet)
• Expensive but Rolls Royce Service

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Special problems of old age

• Pharmacodynamics / Pharmacokinetics
• Renal / hepatic / cardiac / pulmonary function
• Post op delirium
• Neutropaenia
• Compliance

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Chemotherapy

• More problems with neutropenia
• Less hair loss
• Less nausea / vomiting
• Decreased clearance of drugs due to reduced
  glomerular filtration

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Radiotherapy

• Prolonged supine position
• Immobilisation
• Daily attendance
• Left ventricular function
• Decreased vital capacity

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What do patients want?

• The truth
• Equal access
• Choice of therapy
• Multidisciplinary input
• Decision-making on clinical grounds not by age

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What is the role of theGeriatrician?

• Act as patients advocate
• Screening / early detection
• Treatment decisions
• Support of patient and carers
• Palliative care / end of life care
• Management of multiple pathology
• Education re aging
• Liaison with other specialtiesh
• (Research, education and influence policy)

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