As the baby boomer generation in the United States ages, the number of older patients with cancer is increasing. A 67% increase in cancer incidence is projected in those individuals aged ≥65 years, compared with an 11% increase among younger adults.1,2 Older patients with cancer have a higher prevalence of comorbidities, geriatric syndromes, and disabilities than younger patients and older patients without cancer.3,4 Older patients with conditions other than cancer also carry a high risk of developing significant chemotherapy toxicity, functional and cognitive loss, and physical decline while on treatment.5,6 The underrepresentation of older adults in clinical trials places them at risk of receiving inappropriate undertreatment or overtreatment for their cancer, leading to disparities in outcomes.5,7–9 For example, fit older patients are less likely to receive evidence-based standard-of-care cancer treatment than younger patients, whereas older patients with both cancer and comorbid conditions are too often treated with therapies with high toxicity rates and low likelihood of benefit.10
A recent Institute of Medicine report acknowledged that our current systems are ill-prepared to care for the most vulnerable patients with cancer—those who are older (especially those aged ≥80 years) and those who have health conditions other than cancer.11 Because older patients with cancer receiving treatment are often seen by their oncology teams more frequently than by their primary care providers (PCPs),12 community oncology practices should be equipped to recognize common age-related concerns. Despite the rapidly increasing population of older patients with cancer, most oncologists have received little geriatrics training, and therefore common aging-related conditions that influence outcomes are rarely detected.13–16
In this study, community oncologists were recruited to participate in 2 nationwide, geriatric oncology clinical trials in the University of Rochester Cancer Center's NCI Community Oncology Research Program (URCC NCORP). During enrollment, they completed a survey regarding their beliefs about and confidence in providing geriatric care.17 Similar to other studies,18–21 randomized vignettes were used to assess whether clinical factors influenced their cancer treatment decision-making. This study, however, is the first that assesses how common geriatric factors (ie, function and cognition) affect decisions related to first-line chemotherapy in older patients with advanced cancer.
Dr. Hurria has disclosed that she has received grant or research support from Celgene and Novartis, and has served as a consultant for Boehringer Ingelheim, Pierian Biosciences, and MJH Healthcare Holdings. The remaining authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.
This work was funded through a PCORI program contract (4634), UG1 CA189961 from the NCI, and R01 CA177592 from the NCI. This work was made possible by the generous donors to the WCI geriatric oncology philanthropy fund. All statements in this report, including its findings and conclusions, are solely those of the authors, do not necessarily represent the official views of the funding agencies, and do not necessarily represent the views of PCORI, its Board of Governors, or Methodology Committee.
Smith BD, Smith GL, Hurria A et al.. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009;27:2758–2765.
Hurria A, Dale W, Mooney M et al.. Designing therapeutic clinical trials for older and frail adults with cancer: U13 conference recommendations. J Clin Oncol 2014;32:2587–2594.
Mohile SG, Fan L, Reeve E et al.. Association of cancer with geriatric syndromes in older Medicare beneficiaries. J Clin Oncol 2011;29:1458–1464.
Mohile SG, Xian Y, Dale W et al.. Association of a cancer diagnosis with vulnerability and frailty in older Medicare beneficiaries. J Natl Cancer Inst 2009;101:1206–1215.
Hurria A, Mohile S, Gajra A et al.. Validation of a prediction tool for chemotherapy toxicity in older adults with cancer. J Clin Oncol 2016;34:2366–2371.
Wildes TM, Depp B, Colditz G, Stark S. Fall-risk prediction in older adults with cancer: an unmet need. Support Care Cancer 2016;24:3681–3684.
Quipourt V, Jooste V, Cottet V et al.. Comorbidities alone do not explain the undertreatment of colorectal cancer in older adults: a French population-based study. J Am Geriatr Soc 2011;59:694–698.
O'Neill CB, Baxi SS, Atoria CL et al.. Treatment-related toxicities in older adults with head and neck cancer: a population-based analysis. Cancer 2015;121:2083–2089.
Zeng C, Wen W, Morgans AK et al.. Disparities by race, age, and sex in the improvement of survival for major cancers: results from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program in the United States, 1990 to 2010. JAMA Oncol 2015;1:88–96.
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. Zeng C Wen W Morgans AK Disparities by race, age, and sex in the improvement of survival for major cancers: results from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program in the United States, 1990 to 2010. JAMA Oncol 2015; 1: 88– 96.
Dale W, Mohile SG, Eldadah BA et al.. Biological, clinical, and psychosocial correlates at the interface of cancer and aging research. J Natl Cancer Inst 2012;104:581–589.
Hurria A, Naylor M, Cohen HJ. Improving the quality of cancer care in an aging population: recommendations from an IOM report. JAMA 2013;310:1795–1796.
Hurria A, Balducci L, Naeim A et al.. Mentoring junior faculty in geriatric oncology: report from the Cancer and Aging Research Group. J Clin Oncol 2008;26:3125–3127.
Repetto L, Fratino L, Audisio RA et al.. Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. J Clin Oncol 2002;20:494–502.
Maggiore RJ, Gorawara-Bhat R, Levine SK, Dale W. Perceptions, attitudes, and experiences of hematology/oncology fellows toward incorporating geriatrics in their training. J Geriatr Oncol 2014;5:106–115.
Robinson BE, Barry PP, Renick N et al.. Physician confidence and interest in learning more about common geriatric topics: a needs assessment. J Am Geriatr Soc 2001;49:963–967.
Campbell KH, Smith SG, Hemmerich J et al.. Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making. BMC Nephrol 2011;12:47.
Tilburt JC, Miller FG, Jenkins S et al.. Factors that influence practitioners' interpretations of evidence from alternative medicine trials: a factorial vignette experiment embedded in a national survey. Med Care 2010;48:341–348.
Kunins HV, Sohler NL, Roose RJ, Cunningham CO. HIV provider endorsement of primary care buprenorphine treatment: a vignette study. Fam Med 2009;41:722–728.
Keating NL, Landrum MB, Klabunde CN et al.. Adjuvant chemotherapy for stage III colon cancer: do physicians agree about the importance of patient age and comorbidity? J Clin Oncol 2008;26:2532–2537.
Mohile SG, Velarde C, Hurria A et al.. Geriatric assessment-guided care processes for older adults: a Delphi consensus of geriatric oncology experts. J Natl Compr Canc Netw 2015;13:1120–1130.
Johnson M. Chemotherapy treatment decision making by professionals and older patients with cancer: a narrative review of the literature. Eur J Cancer Care (Engl) 2012;21:3–9.
Wan-Chow-Wah D, Monette J, Monette M et al.. Difficulties in decision making regarding chemotherapy for older cancer patients: a census of cancer physicians. Crit Rev Oncol Hematol 2011;78:45–58.
Extermann M, Boler I, Reich RR et al.. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer 2012;118:3377–3386.
Wildes TM, Ruwe AP, Fournier C et al.. Geriatric assessment is associated with completion of chemotherapy, toxicity, and survival in older adults with cancer. J Geriatr Oncol 2013;4:227–234.
Conroy T, Desseigne F, Ychou M et al.. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med 2011;364:1817–1825.
Gourgou-Bourgade S, Bascoul-Mollevi C, Desseigne F et al.. Impact of FOLFIRINOX compared with gemcitabine on quality of life in patients with metastatic pancreatic cancer: results from the PRODIGE 4/ACCORD 11 randomized trial. J Clin Oncol 2013;31:23–29.
Von Hoff DD, Ervin T, Arena FP et al.. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med 2013;369:1691–1703.
Tabernero J, Chiorean EG, Infante JR et al.. Prognostic factors of survival in a randomized phase III trial (MPACT) of weekly nab-paclitaxel plus gemcitabine versus gemcitabine alone in patients with metastatic pancreatic cancer. Oncologist 2015;20:143–150.
Amireault C, Beaudet J, Gaudet G et al.. FOLFIRINOX in the real-world setting: the multicentric experience of six Canadian institutions [abstract]. J Clin Oncol 2014;32(Suppl):Abstract 367.
Stone ME, Lin J, Dannefer D, Kelley-Moore JA. The continued eclipse of heterogeneity in gerontological research. J Gerontol B Psychol Sci Soc Sci 2017;72:162–167.
Berry MF, Worni M, Pietrobon R et al.. Variability in the treatment of elderly patients with stage IIIA (N2) non-small-cell lung cancer. J Thorac Oncol 2013;8:744–752.
Wright J, Doan T, McBride R et al.. Variability in chemotherapy delivery for elderly women with advanced stage ovarian cancer and its impact on survival. Br J Cancer 2008;98:1197–1203.
Alliot C. Undertreatment of breast cancer in elderly women: contribution of a cancer registry. J Clin Oncol 2005;23:4800–4801; author reply 4801–4802.
Lee IH, Hayman JA, Landrum MB et al.. Treatment recommendations for locally advanced, non-small-cell lung cancer: the influence of physician and patient factors. Int J Radiat Oncol Biol Phys 2009;74:1376–1384.
Kanesvaran R, Li H, Koo KN, Poon D. Analysis of prognostic factors of comprehensive geriatric assessment and development of a clinical scoring system in elderly Asian patients with cancer. J Clin Oncol 2011;29:3620–3627.
Palumbo A, Bringhen S, Mateos MV et al.. Geriatric assessment predicts survival and toxicities in elderly myeloma patients: an International Myeloma Working Group report. Blood 2015;125:2068–2074.
Hurria A, Wildes T, Blair SL et al.. Senior Adult Oncology, Version 2.2014: Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2014;12:82–126.
Hurria A, Gupta S, Zauderer M et al.. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 2005;104:1998–2005.
Hurria A, Akiba C, Kim J et al.. Reliability, validity, and feasibility of a computer-based geriatric assessment for older adults with cancer. J Oncol Pract 2016;12:e1025–1034.
McCleary NJ, Wigler D, Berry D et al.. Feasibility of computer-based self-administered cancer-specific geriatric assessment in older patients with gastrointestinal malignancy. Oncologist 2013;18:64–72.
Williams GR, Deal AM, Jolly TA et al.. Feasibility of geriatric assessment in community oncology clinics. J Geriatr Oncol 2014;5:245–251.
Caillet P, Canoui-Poitrine F, Vouriot J et al.. Comprehensive geriatric assessment in the decision making process in elderly patients with cancer: ELCAPA study. J Clin Oncol 2011;29:3636–3642.
Hamaker ME, Schiphorst AH, ten Bokkel Huinink D et al.. The effect of a geriatric evaluation on treatment decisions for older cancer patients—a systematic review. Acta Oncol 2014;53:289–296.
Magnuson A, Allore H, Cohen HJ et al.. Geriatric assessment with management in cancer care: current evidence and potential mechanisms for future research. J Geriatr Oncol 2016;7:242–248.
Peabody JW, Luck J, Glassman P et al.. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA 2000;283:1715–1722.
Peabody JW, Luck J, Glassman P et al.. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med 2004;141:771–780.