Older patients require tailored treatments

Anaheim, Calif. - In older patients with skin cancer and other cancers, doctors must weigh the aggressiveness of treatments against the impact they could have on other health conditions and patients' overall quality of life.

"In general, one should not use a patient's age as an indicator of what kind of treatment to use, to some extent. The mantra is, evaluate the patient on the basis of their organ function," not on preconceived notions, says William B. Ershler, M.D., director of the Institute for Advanced Studies in Aging, Washington.

"There's unequivocal data at this point that older people are less likely to be treated with the same amount of fervor as are younger patients with the same disease and stage, for a number of reasons, some of which are valid, others of which are not," he says.

Individualizing treatment That said, Dr. Ershler offers the caveat that perhaps chemotherapy can be avoided if an elderly patient possesses an indolent tumor that's less likely to diminish the patient's quality of life.

"For example, prostate cancer in an 80-year-old is likely to grow very slowly and can be watched, as opposed to treated, because the treatment has a fair amount of toxicity. One needs to individualize the treatment. That's the bottom line - one must perform an assessment of the person's function and social circumstances. And then one must balance that with concerns for what the tumor is like - is the tumor likely to cause a problem within the person's estimated lifespan?"

One also must factor in coexisting conditions.

He says, "Usually, if one has a 40-year-old with breast cancer, that's typically her only problem. An 80-year-old woman who (presents) with a breast lump also may have congestive heart failure, diabetes or lung disease. That makes everything a little more complicated. But patients should be given a comprehensive geriatric assessment to determine what the 'host' is like" before one draws conclusions about the appropriateness of a given treatment.

"The most prevalent tumor in old patients is skin cancer, namely squamous cell carcinomas (SCCs)," he adds. "These are usually nonlethal. But they, along with basal cell carcinomas, need to be treated because they can definitely inhibit quality of life, and they can become aggravating local problems."

Recent research questions Over the past couple decades, the Institute's research regarding cancer and elderly patients has also focused on the following questions:

Why does cancer occur more commonly in old people?

"All cancers, with few exceptions, are more prevalent in older people, particularly skin cancer. The median age of onset for all cancers in the United States is about 70 years," he says.

The correlation between cancer and advanced age exists, in part, because tumor development takes time.

"There are a number of molecular and genetic factors that are involved," Dr. Ershler explains. "For example, some researchers look at the number of mutations it takes to go from a benign-appearing tissue to a malignant tissue. It's not just one hit, then cancer. It usually takes several hits, and they occur in a rather stochastic way. The best model for this is human colon cancer, in which at least eight genetic events commonly occur, but they don't all occur at once."

Such a pattern can be especially dangerous in light of observed declines the body's ability to repair DNA damage as it ages.