Communicating Treatment Options to Older Patients: Challenges and Opportunities
Authors: Arti Hurria
Journal: Journal of the National Comprehensive Cancer Network (2012)

We've been hearing that the United States population is aging and that the number of older adults is expected to double between 2010 and 2030, as life expectancy increases and "baby boomers" reach age 65.These forecasts seemed like they were far in the future; but now, as healthcare providers, we are seeing the graying of society in our waiting rooms.Today we are encountering first-hand the demographic shift in progress.We clearly see the association between cancer and aging, and this is only the beginning, since cancer incidence is expected to rise by 67% between now and 2030 in people older than 65. 1 Although the numbers are growing, older adults are the minority of individuals enrolled in most clinical oncology trials. 2 Therefore, outlining treatment choices to older adults, including the risks and benefits, is uncertain territory, because it requires extrapolating recommendations from studies performed in younger patients.Furthermore, these studies often excluded older adults with comorbid conditions or organ dysfunction, who nonetheless form a large part of the older cancer population.So even if the benefits of therapy are comparable across the age spectrum, the risks of therapy are surely magnified by the rise in comorbid conditions and declines in organ function associated with aging.For example, a review of 3 CALGB breast cancer clinical trials showed that only 7% of patients enrolled in clinical trials were older than age 65.That 7%, however, showed an increased risk of treatment-related side effects, early discontinuation of therapy, and treatment-related mortality. 3How would these risks affect older patients who were not even eligible for the study because of comorbidities or poor health?This remains unknown.One way to remedy the low enrollment of older adults in clinical trials is to prespecify that the age distribution in the study mirror that of patients with the disease.This is especially important for studies that will be used for FDA approval of new therapeutics.Although oncology therapeutics undergo a stringent approval process under FDA regulations, older adults are inexplicably under-represented in registration trials.As of 1993, federal law has mandated that the NIH include and adequately represent women and minorities in clinical research studies.This leaves us with the question: Why isn't there a similar mandate for adequate representation of all age categories?If the concern is that toxicity would be too high in older adults, then the investigator should be required to justify the promise of a cancer treatment that is potentially too toxic for most patients who have cancer.Another challenge of describing treatment options to older adults is whether the information from clinical trials addresses the values that are vital to that individual's decision-making.Oncology clinical trials often focus on disease-free and overall survival.The potential impact of therapy on short-and long-term physical and cognitive function also plays a critical role in the decision-making process, however, it is usually not addressed in clinical trials.A survey of older adults from Fried et al 4 showed that the impact of therapy on function and cognition carried greater weight in treatment decision-making than the impact of therapy on overall survival.In fact, in that survey, most respondents said they were willing to forgo life-sustaining therapy that might cause either physical dependence or cognitive decline.These findings are also important on a societal level because most care in this country is performed by family or friends: if therapy impacts function, a caregiver is needed.