You've Lived a Good Life
Authors: Brendan F. Curley
Journal: Journal of Clinical Oncology (2015)

DOI: 10.1200/JCO.2015.63.3206 Our aging population places a strain on all aspects of the health care system, including oncology services. In an article published in The ASCO Post, Holland and Greenstein discussed the need to prepare younger oncologists to care for much older patients. I typically prepare for new patients by reviewing their pathology, radiology, and comorbid conditions. Age is always listed, and although it is something I think about, I need to see the patient to truly get a feeling for his or her performance status, level of social support, and comorbid conditions. We have all seen patients who appear their stated age and patients who do not. Sometimes, we can obtain useful information from performance status or the descriptor of frail included in the medical record; however, the accurate decisions are made in the examination room, whether the patient is 59 or 89 years of age. Several months ago, I met Ted, an 89-year-old patient who was in fantastic shape. He liked to tinker around the house, tend his garden, and spend time with his girlfriend. He did his own grocery shopping, liked a glass (or two) of wine with his lunch, and had a great social support system. He presented to his primary care physician in January after an abnormal chest x-ray and computed tomography (CT) scan showed a 3-cm mass, noted by radiology to likely be lung cancer. “Wait and see,” he was told. Well, he waited, and it grew. Repeat scans in March (CT and positron emission tomography/CT) and July (CT) showed that the mass was growing. Ted continued to live his life, but wondered, “Why is no one going after this?” He saw his pulmonologist and was told that the mass was likely lung cancer, but testing for lung cancer was so hard—biopsy, more scans, chemotherapy. Who wants that? Well, Ted wanted that. He was 89 years old, but he felt much younger. Older patients are often excluded from clinical trials in oncology, either because of rigid eligibility criteria or because of bias on the part of enrolling oncologists. The problem with the older patient is the other things that come with them, such as frailty, multiple medical comorbidities, and worsening social support systems, all of which may interfere with the patient’s ability to withstand anticancer therapy. So what is the oncologist to do? Back to Ted. He followed up again in October, 9 months after the mass was initially identified. The scan now showed that the primary mass had continued to grow and that there were enlarged lymph nodes and bone lesions suggestive of metastatic disease. There was now little doubt that he had progressive lung cancer and that his window of opportunity for curative therapy had closed. Finally, Ted put his foot down and demanded a biopsy. It was, as expected, primary non–small-cell adenocarcinoma of the lung. Magnetic resonance imaging of the brain was negative, and he was evaluated by radiation oncology, but no therapy was offered, because what had been localized disease was now metastatic. He saw a medical oncologist and was offered singleagent chemotherapy, not a standard platinumbased doublet. Why? He was too old. He was told by his oncologist, “You’ve lived a good life.” There is always a debate in an oncologist’s mind about who should receive chemotherapy and who should not. We have predictive models, guidelines, Eastern Cooperative Oncology Group performance status requirements, and geriatric assessment tools that allow us to estimate an individual’s ability to tolerate chemotherapy, but in the end, it is frequently a gut decision. I always tell my patients with advanced disease that my goal is to optimize their quantity and quality of life. If one of these is compromised, we need to re-evaluate our goals of care. I met Ted 3 days before Christmas for his initial consultation, a full 11 months since the first CT of his chest showed probable lung cancer. He was still sharp as a tack, and I was a little embarrassed to admit that he was dressed much more sharply than I was. All of his records and scans were available for my review. I was interested in his functional status and asked my office staff if he had walked in by himself. Did he come alone? Ted was interactive, gregarious, and entertaining. He brought his A game to see me and was ready to fight. I spoke with his daughter via cell phone, and she confirmed that he was extremely active at home. His girlfriend was with him. He told me he wanted someone to believe in him. I consulted my former fellowship classmates and my partner in the office next door for advice. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 34 DECEMBER 1 2015