Older patients with cancer: evidence-based care needs evidence
Authors: None The Lancet Healthy Longevity
Journal: The Lancet Healthy Longevity (2021)

Increasing age is the single biggest risk factor for developing cancer. In the USA, incidence rates climb with advancing age until reaching more than 1000 per 100 000 people aged 60 years and older; the median age of diagnosis for cancer of any site is 66 years. As we see an increase in ageing populations worldwide, the number of older patients with cancer will rise correspondingly, and across resource settings. In a consensus statement published earlier this year, the International Society for Geriatric Oncology re-issued its top priorities for improving care for older patients with cancer as an update from those published in 2011. Strikingly, despite some advances in the intervening decade, the priorities remain broadly similar. They reflect a lack of availability of education in specialist geriatric care, age-specific treatment guidelines, and research into cancer in older people.It is against this background that in this issue and together with The Lancet Haematology, we publish a Series of five papers looking specifically into provision of care for older people with haematological malignancies. This is an especially pertinent topic because older people with haematological malignancies generally have a worse prognosis than their younger counterparts, although, encouragingly, this margin appears to be reducing with the introduction of some newer agents. The Series papers cover treatment options for a variety of different malignancies, the role of haematopoietic stem-cell transplantation, frailty assessment, haematological-specific palliative care recommendations, and how best to implement geriatric-specific haematology programmes in low-resource settings (both in low-income and middle-income countries but also within lower-resource settings within high-income countries, like underserved rural areas). We hope that the Series will prove to be a useful resource for geriatric oncologists and haematologists alike in managing care for their older patients. Additionally, in this issue we also publish a study by van der Plas-Krijgsman and colleagues, who used the national Dutch Cancer Registry to develop and validate a predictive tool (PORTRET) for patients with breast cancer aged 65 years and older. This tool can provide accurate predictions for 5-year overall survival in even the oldest patients (those aged 85 years and older), allowing clinicians to discuss better-informed treatment decisions with their patients.All of these elements are important pieces in a gigantic puzzle. But to ensure the best possible management of care for this patient population, more primary research needs to be done. Older people with cancer remain under-represented in primary research, especially in randomised controlled trials. Although this has been flagged as a research concern for decades, a worrying analysis shows that inclusion of older patients with cancer in primary research is in fact decreasing. Ludmir and colleagues examined phase 3 randomised controlled trials registered at ClinicalTrials.gov for patients with one of the four most common cancer disease sites (breast, prostate, colorectal, and lung, all of which have age as a risk factor). 302 trials were identified; for all trials, the trial population was a median 6·49 years (95% CI, −7·17 to −5·81 years; p<0·001) younger than the population median age. Concerningly, by use of linear regression modelling, they also found that the disparity between enrolled and population median age was significantly increasing over time. The worst disparities were found in industry-sponsored trials and those using targeted systemic therapies—ie, the newest agents.Excluding older patients from such trials, either from explicit age-cutoffs in enrolment criteria, or by refusing patients with common age-related comorbidities, risks painting an inflated picture of an intervention's efficacy and a more flattering one of its toxicity.Such research is crucial not only for improving the lives of older patients but also, as has been suggested, if cancer biology changes with increasing age. If this is the case what is most needed is not just wider enrolment criteria but clinical trials specifically designed for older people, which incorporate geriatric assessment as standard, in order to determine the true physiological costs and benefits of a putative treatment. As is the case with so many areas, representation matters. We cannot have evidence-based care without the evidence. Increasing age is the single biggest risk factor for developing cancer. In the USA, incidence rates climb with advancing age until reaching more than 1000 per 100 000 people aged 60 years and older; the median age of diagnosis for cancer of any site is 66 years. As we see an increase in ageing populations worldwide, the number of older patients with cancer will rise correspondingly, and across resource settings. In a consensus statement published earlier this year, the International Society for Geriatric Oncology re-issued its top priorities for improving care for older patients with cancer as an update from those published in 2011. Strikingly, despite some advances in the intervening decade, the priorities remain broadly similar. They reflect a lack of availability of education in specialist geriatric care, age-specific treatment guidelines, and research into cancer in older people. It is against this background that in this issue and together with The Lancet Haematology, we publish a Series of five papers looking specifically into provision of care for older people with haematological malignancies. This is an especially pertinent topic because older people with haematological malignancies generally have a worse prognosis than their younger counterparts, although, encouragingly, this margin appears to be reducing with the introduction of some newer agents. The Series papers cover treatment options for a variety of different malignancies, the role of haematopoietic stem-cell transplantation, frailty assessment, haematological-specific palliative care recommendations, and how best to implement geriatric-specific haematology programmes in low-resource settings (both in low-income and middle-income countries but also within lower-resource settings within high-income countries, like underserved rural areas). We hope that the Series will prove to be a useful resource for geriatric oncologists and haematologists alike in managing care for their older patients. Additionally, in this issue we also publish a study by van der Plas-Krijgsman and colleagues, who used the national Dutch Cancer Registry to develop and validate a predictive tool (PORTRET) for patients with breast cancer aged 65 years and older. This tool can provide accurate predictions for 5-year overall survival in even the oldest patients (those aged 85 years and older), allowing clinicians to discuss better-informed treatment decisions with their patients. All of these elements are important pieces in a gigantic puzzle. But to ensure the best possible management of care for this patient population, more primary research needs to be done. Older people with cancer remain under-represented in primary research, especially in randomised controlled trials. Although this has been flagged as a research concern for decades, a worrying analysis shows that inclusion of older patients with cancer in primary research is in fact decreasing. Ludmir and colleagues examined phase 3 randomised controlled trials registered at ClinicalTrials.gov for patients with one of the four most common cancer disease sites (breast, prostate, colorectal, and lung, all of which have age as a risk factor). 302 trials were identified; for all trials, the trial population was a median 6·49 years (95% CI, −7·17 to −5·81 years; p<0·001) younger than the population median age. Concerningly, by use of linear regression modelling, they also found that the disparity between enrolled and population median age was significantly increasing over time. The worst disparities were found in industry-sponsored trials and those using targeted systemic therapies—ie, the newest agents. Excluding older patients from such trials, either from explicit age-cutoffs in enrolment criteria, or by refusing patients with common age-related comorbidities, risks painting an inflated picture of an intervention's efficacy and a more flattering one of its toxicity. Such research is crucial not only for improving the lives of older patients but also, as has been suggested, if cancer biology changes with increasing age. If this is the case what is most needed is not just wider enrolment criteria but clinical trials specifically designed for older people, which incorporate geriatric assessment as standard, in order to determine the true physiological costs and benefits of a putative treatment. As is the case with so many areas, representation matters. We cannot have evidence-based care without the evidence. Palliative care of patients with haematological malignancies: strategies to overcome difficulties via integrated carePalliative care, hospice care, and end of life care have been the focus of increased attention over the past two decades; palliative care has shifted from being introduced only at the end of life to becoming an integrated part of routine care for patients. Currently, the timing and extent of the integration of palliative care into standard medical care practice depends on the underlying disease. Patients with haematological malignancies receive less palliative care initiated at a later disease stage compared with patients with other types of cancer. Full-Text PDF Open AccessImplementation of geriatric haematology programmes for the treatment of older people with haematological malignancies in low-resource settingsIn 2020, about 600 000 people aged 65 years and older were diagnosed with a haematological malignancy worldwide, and this number will increase to almost 1 million by 2040, with the largest growth taking place in regions with less developed economies. Health-care systems globally are ill-prepared to face this impending increase in the burden of haematological malignancies among older people, and geriatric oncology and haematology are not properly developed in most low-income and middle-income countries, as well as in many community settings in high-income countries. Full-Text PDF Open AccessFrailty assessment in the care of older people with haematological malignanciesFrailty, defined as an age-related state of increased vulnerability to acute stressors, is a major challenge in the care of older people with haematological malignancies. Growing evidence from multiple studies suggests that a systematic evaluation of frailty in these patients by use of appropriate assessment tools might help clinicians to make appropriate treatment decisions and initiate frailty interventions. Here, we summarise current knowledge on the origin, decision relevance, assessment methods, and possible treatments of frailty in older people with haematological malignancies. Full-Text PDF Open AccessPriorities for the global advancement of care for older adults with cancer: an update of the International Society of Geriatric Oncology Priorities InitiativeIn 2011, the International Society of Geriatric Oncology (SIOG) published the SIOG 10 Priorities Initiative, which defined top priorities for the improvement of the care of older adults with cancer worldwide.1 Substantial scientific, clinical, and educational progress has been made in line with these priorities and international health policy developments have occurred, such as the shift of emphasis by WHO from communicable to non-communicable diseases and the adoption by the UN of its Sustainable Development Goals 2030. Full-Text PDF Is cancer biology different in older patients?Roughly 50% of cancer cases occur in people aged 65 years or older. Older people are often diagnosed at a later stage and might receive less (intensive) treatment, which might affect the outcome. In addition, an older age might be associated with biological differences in tumour and microenvironment behaviour, a domain that has been poorly studied so far. In this narrative Review of published literature, we explored the reported differences in tumour biology according to age in five major cancer types: breast, colorectal, prostate, lung, and melanoma. Full-Text PDF Open AccessDevelopment and validation of the PORTRET tool to predict recurrence, overall survival, and other-cause mortality in older patients with breast cancer in the Netherlands: a population-based studyThe PORTRET tool can accurately predict 5-year recurrence, overall mortality, and other-cause mortality in older patients with breast cancer. The tool can support shared decision making, especially since it provides individualised estimated benefits of adjuvant treatment. Full-Text PDF Open Access