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Caring for the Elderly Cancer Patient: Training the Next Generation of Oncologists

Cancer is primarily a disease of aging representing the leading cause of death for both men and women between 60 and 80 years of age.¹ In fact, increasing age, undoubtedly, represents the strongest risk factor for developing cancer.² In addition to the millions of cancer survivors living into their later years, it is estimated that nearly one in three septuagenarians will develop a new cancer diagnosis during the remainder of their lives.¹ In addition to the impact of the disease on affected patients and their families, there is a considerable societal cost associated with cancer in elderly individuals. Investigators at the National Cancer Institute have recently estimated the aggregate 5-year net direct costs of cancer care to Medicare at more than $21 billion.³ Such figures, however, do not reflect the enormous nonmedical, indirect and out-of-pocket expenses for cancer care which have been estimated to equal or exceed these numbers.⁴

Gary H. Lyman, MD, MPH, FRCP(Edin)

While there has been an encouraging decrease in cancer-related mortality among younger patients, the same trend has not been observed in the very elderly. Until recently, most clinical trials systematically excluded elderly cancer patients. While considerable progress has been made in addressing such selection bias, particularly by the major cancer cooperative groups, a study in this issue of the Journal of Oncology Practice (JOP) by Basche et al, and elegantly discussed in the accompanying commentary by Cohen highlights the numerous remaining barriers to participation of the elderly in early phase cancer clinical trials.^5,6 These concerns, as well as the rapid increase in the proportion of the population older than the age of 65, has spawned professional societies, textbooks, guidelines, and an enormous volume of research and resulting publications addressing a broad range of issues related to cancer in older patients with cancer.^7–9 A search of the National Library of Medicine Medline database reveals nearly half a million citations on cancer in the elderly. JOP recently devoted an entire issue to the topic of geriatric oncology.²

At the same time, there has also been considerable discussion about the appropriate preparation of medical specialists, including oncologists, in the specialized needs of the rapidly growing elderly population with cancer. The past decade has witnessed the emergence of subspecialty tracks in geriatric oncology with concentrated training of a limited number of individuals in both medical oncology and geriatrics. Formal training programs were developed at a number of major centers fostered largely by efforts of the American Society of Clinical Oncology (ASCO) and funded by the Hartford Foundation. While these programs focus considerable attention on the specialized needs of the older patient with cancer, it has always been clear that the majority of elderly patients with cancer will continue to be cared for by medical oncologists in practice. As pointed out in the accompanying article by Rao et al in this issue of JOP, both the Accreditation Council for Graduate Medical Education (ACGME) in their guidelines for adult hematology-oncology fellowships and the American Board of Internal Medicine in recent board certification examinations have devoted increasing attention to the education and evaluation of oncologists in the specialized challenges and appropriate management of the older patient with cancer.¹⁰ It is noted, however, that trainees in hematology-oncology at most institutions still complete their fellowship without formal training in the care of older patients with cancer.

The article by Rao et al presents the conclusions and recommendations of a 2-day consensus conference funded by the Donald W. Reynolds Foundation held at Duke University, and aimed at developing a strategy for developing a core curriculum in geriatric oncology for medical oncology training programs. In addition to surveying current fellowship program directors and previous fellows completing formal geriatric oncology training, funding is being sought for a large conference including the above individuals and other thought leaders in the field to develop a core geriatric oncology curriculum for integration into conventional hematology-oncology training. Key curriculum areas that should be incorporated into fellowship training include the appropriate management of both solid and hematologic malignancies in older patients, the biology of cancer and aging, the pharmacology of cancer therapies in the elderly, and training in comprehensive geriatric assessment and methods of providing optimal supportive care to such patients. As discussed in the last issue of JOP, the elderly patient presents recognized challenges to and opportunities for the delivery of optimal cancer treatment.^11,12

With the support and guidance of professional organizations, such as ASCO and ACGME, as well as concerned philanthropy from such organizations as the Hartford and Reynolds Foundations, the goals and objectives put forward in the consensus statement can become reality. The appropriate and comprehensive training of the next generation of oncologists must represent a high priority for the entire profession culminating in greater awareness and appreciation among future cancer specialists of the pervasive yet very special needs of the expanding population of elderly patients with cancer.

	Notes

 
Gary H. Lyman, MD, MPH, FRCP(Edin), is Professor of Medicine and Director, Health Services and Outcomes Research in Oncology and Senior Fellow, Center for Clinical Health Policy Research at Duke University in Durham, North Carolina. Dr Lyman also serves as Associate Editor of the Journal of Oncology Practice.

	References

Top References

 

1. Jemal A, Siegel R, Ward E, et al: Cancer statistics, 2008. CA Cancer J Clin 58:71-96, 2008[Abstract/Free Full Text]
2. Lichtman SM, Balducci L, Aapro M: Geriatric oncology: A field coming of age. J Clin Oncol 25:1821-1823, 2007[Free Full Text]
3. Yabroff KR, Lamont EB, Mariotto A, et al: Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 100:630-641, 2008[Abstract/Free Full Text]
4. Lyman GH: Time is money for both the healthy and the sick. Med Care 43:637-639, 2005[CrossRef][Medline]
5. Basche M, Baron AE, Eckhardt SG, et al: Barriers to enrollment of elderly adults in early-phase cancer clinical trials. J Oncol Pract 4:162-168, 2008[Abstract/Free Full Text]
6. Cohen H: Overturning barriers will take heavy lifting. J Oncol Pract 4:169-170, 2008[Free Full Text]
7. Balducci L, Lyman GH, Ershler WB, et al: Comprehensive Geriatric Oncology, ed 2, London, United Kingdom, Taylor and Francis, 2004
8. Balducci L, Cohen HJ, Engstrom PF, et al: Senior adult oncology clinical practice guidelines in oncology. J NCCN 3:572-590, 2005
9. Lichtman SM, Wildiers H, Chatelut E, et al: International Society of Geriatric Oncology Chemotherapy Taskforce: Evaluation of chemotherapy in older patients–an analysis of the medical literature. J Clin Oncol 25:1832-1843, 2007[Abstract/Free Full Text]
10. Rao AV, Hurria A, Kimmick G, et al: Geriatric oncology: Past, present, future. J Oncol Pract 4:190-192, 2008[Free Full Text]
11. Field KM, Kosmider S, Jefford M, et al: Chemotherapy dosing strategies in the obese, elderly and thin patient: Results of a nationwide survey. J Oncol Pract 4:108-113, 2008[Abstract/Free Full Text]
12. Lyman GH: Undertreatment of cancer patients with chemotherapy is a global concern. J Oncol Pract 4:114-115, 2008[Free Full Text]

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