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Communicating Treatment Options to Older Patients: Challenges and Opportunities

Arti Hurria

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Management of Elderly Patients With Cancer

Arti Hurria

Whether a patient is a candidate for cancer therapy goes far beyond the person’s age. To evaluate an older adult for cancer treatment, oncologists must understand the benefits and quantify the risks of the proposed treatment, determine the patient’s decision-making capacity, and make the decision in collaboration with the patient’s preferences and values. In her presentation at the NCCN 18th Annual Conference, Dr. Arti Hurria discussed the major components in the comprehensive geriatric assessment in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Senior Adult Oncology, focusing on functional (rather than chronologic) age, comorbidities, nutritional status, cognitive impairment, and psychosocial support. By uncovering problems possibly left undetected on a routine history and physical examination, this assessment may lead to interventions that improve health and wellbeing in older people with cancer.

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Determining Chemotherapy Tolerance in Older Patients With Cancer

Jerome Kim and Arti Hurria

Older adults with cancer constitute a heterogeneous group of patients who pose unique challenges for oncology care. One major concern is how to identify patients who are at a higher risk for chemotherapy intolerance, because a standard oncology workup may not always be able to distinguish an older individual’s level of risk for treatment-related complications. Geriatric oncologists incorporate tools used in the field of geriatrics, and have developed the Comprehensive Geriatric Assessment to enhance the standard oncology workup. This assessment pinpoints problems with daily activities, comorbidities, medications, nutritional status, cognitive function, psychological state, and social support systems, all of which are risk factors for treatment vulnerability in older adults with cancer. Additional tools that also serve to predict chemotherapy toxicity in older patients with cancer are now available to identify patients at higher risk for morbidity and mortality. Together, these instruments complement the standard oncology workup by providing a global assessment, thereby guiding therapeutic interventions that may improve a patient’s quality of life and clinical outcomes.

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Advocating for Older Adults With Cancer: Merging Medicine and Law

Arti Hurria and Laura A. Levit

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Challenges in the Management of Older Patients With Colon Cancer

Efrat Dotan, Ilene Browner, Arti Hurria, and Crystal Denlinger

Most patients with colon cancer are older than 65 years. Their treatment poses multiple challenges, because they may have age-related comorbidities, polypharmacy, and physical or physiologic changes associated with older age. These challenges include limited data on the ability to predict tolerance to anticancer therapy and the appropriate use of treatment modalities in the setting of comorbidity and concurrent frailty. The low number of older patients enrolled in large clinical trials results in a paucity of evidence to guide oncologists in the appropriate management of this population. In early-stage disease, clinical dilemmas arise regarding the ability of older patients to undergo successful curative surgical procedures and the risk/benefit ratio of adjuvant chemotherapy. The management of metastatic disease raises questions regarding the clinical benefit of various anticancer therapies and the role of combination therapy with possible increased toxicity in the noncurative setting. Overall, the available evidence shows that fit older patients are able to tolerate treatment and derive similar clinical benefits to younger patients. Limited data are available to guide treatment for less-fit, more-vulnerable older patients. This lack of data leads to variations in treatment patterns in older adults, making them less likely to receive standard therapies. This review provides an overview of the available data regarding the management of older adults with colon cancer in the adjuvant and metastatic settings.

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Research Priorities in Geriatric Oncology: Addressing the Needs of an Aging Population

Arti Hurria, Supriya Gupta Mohile, and William Dale

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Geriatric Assessment in Older Patients with Breast Cancer

Heidi Klepin, Supriya Mohile, and Arti Hurria

Most cases of breast cancer are diagnosed in older adults. Older women have an increased risk for breast cancer–specific mortality and are at higher risk for treatment-associated morbidity than younger women. However, they are also less likely to be offered preventive care or adjuvant therapy for this disease. Major gaps in evidence exist regarding the optimal evaluation and treatment of older women with breast cancer because of significant underrepresentation in clinical trials. Chronologic age alone is an inadequate predictor of treatment tolerance and benefit in this heterogeneous population. Multiple issues uniquely associated with aging impact cancer care, including functional impairment, comorbidity, social support, cognitive function, psychological state, and financial stress. Applying geriatric principles and assessment to this older adult population would inform decision making by providing estimates of life expectancy and identifying individuals most vulnerable to morbidity. Ongoing research is seeking to identify which assessment tools can best predict outcomes in this population, and thus guide experts in tailoring treatments to maximize benefits in older adults with breast cancer.

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Treatment of Non–Small Cell Lung Cancer in the Older Patient

Apar Kishor Ganti, Mollie deShazo, Alva B. Weir III, and Arti Hurria

Lung cancer is a disease of the elderly, with a median age at diagnosis of 70 years. However, there is a dearth of good quality evidence to guide treatment in this population and most of the data are extrapolated from younger patients. Current research is directed toward establishing simplified instruments to quantify fitness of older patients for various forms of therapy. Although current evidence suggests that outcomes after standard therapy are similar to those seen in younger patients, older patients have an increased incidence of adverse events. Until better predictive markers are available to guide treatment, therapy should be individualized using available instruments, including a comprehensive geriatric assessment. If an older patient is deemed to be fit, it is reasonable to use the treatment options recommended for younger individuals. This article summarizes the available data on the treatment of non–small cell lung cancer in the older patient.

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Hematopoietic Stem Cell Transplantation for Hematologic Malignancies in Older Adults: Geriatric Principles in the Transplant Clinic

Tanya M. Wildes, Derek L. Stirewalt, Bruno Medeiros, and Arti Hurria

Hematopoietic cell transplantation (HCT) provides a life-prolonging or potentially curative treatment option for patients with hematologic malignancies. Given the high transplant-related morbidity, these treatment strategies were initially restricted to younger patients, but are increasingly being used in older adults. The incidence of most hematologic malignancies increases with age; with the aging of the population, the number of potential older candidates for HCT increases. Autologous HCT (auto-HCT) in older patients may confer a slightly increased risk of specific toxicities (such as cardiac toxicities and mucositis) and have modestly lower effectiveness (in the case of lymphoma). However, auto-HCT remains a feasible, safe, and effective therapy for selected older adults with multiple myeloma and lymphoma. Similarly, allogeneic transplant (allo-HCT) is a potential therapeutic option for selected older adults, although fewer data exist on allo-HCT in older patients. Based on currently available data, age alone is not the best predictor of toxicity and outcomes; rather, the comorbidities and functional status of the older patient are likely better predictors of toxicity than chronologic age in both the autologous and allogeneic setting. A comprehensive geriatric assessment (CGA) in older adults being considered for either an auto-HCT or allo-HCT may identify additional problems or geriatric syndromes, which may not be detected during the standard pretransplant evaluation. Further research is needed to establish the utility of CGA in predicting toxicity and to evaluate the quality of survival in older adults undergoing HCT.

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Socioeconomic and Clinical Factors Are Key To Uncovering Disparity in Accrual Onto Therapeutic Trials for Breast Cancer

Carolyn E. Behrendt, Arti Hurria, Lusine Tumyan, Joyce C. Niland, and Joanne E. Mortimer

To monitor and address disparity in accrual, patient participation in cancer clinical trials is routinely summarized by race/ethnicity. To investigate whether confounding obscures racial/ethnic disparity in participation, all women with breast cancer treated by medical oncologists at City of Hope Comprehensive Cancer Center from 2004 through 2009 were classified by birthplace and self-reported race/ethnicity, and followed for accrual onto therapeutic trials through 2010. Undetectable on univariate analysis, significantly reduced participation by subjects of African, Asian, Eastern European, Latin American, and Middle Eastern ancestries was revealed after accounting for age, socioeconomic factors, tumor and oncologist characteristics, and intrapractice clustering of patients.