A Q&A with Nicolò Matteo Luca Battisti, MD, Medical Oncologist at The Royal Marsden NHS Foundation Trust, London, United Kingdom, and Chair of the Young Interest Group of the International Society of Geriatric Oncology (SIOG); nicolo.battisti@gmail.com
Q: Everyone knows that the practice of pediatric oncology is very different from adult oncology. How does the growing field of oncogeriatrics differ from usual adult oncology?
A: In my opinion geriatric oncology is a large part of the routine oncology practice, and every oncologist is a geriatric oncologist. Cancer is a disease of older adults, and currently, approximately 50 percent of all cases and 70 percent of related deaths occur in adults aged 65 or older. In the context of ongoing demographic changes, with average life expectancy increasing worldwide, the incidence of cancer in older adults is obviously expected to increase.
Moreover, older adults have always been underrepresented in clinical trials investigating the management of cancer and which have defined the current standard of care. Older patients are more frequently excluded due to strict inclusion and exclusion criteria that are very difficult for them to match, logistical barriers that sometimes make enrollment quite challenging for this age group, and concerns and misconceptions of treating physicians. This limits the external validity of the evidence base that currently guides management of cancer in older patients.
Older adults are a very heterogeneous patient population due to a number of challenges unique to this age group. First, we observe a gradual decline in function and reserve of organs—including the liver, the kidneys, bone marrow, the heart, and muscle—which may affect the pharmacokinetics of drugs and increase the risk of complications for systemic and local anticancer treatments. Second, an increased burden of comorbidities may affect the life expectancy of these patients and again affect treatment outcomes. In this age group, polypharmacy is a common issue that makes patients particularly prone to the risk of drug interactions. Functional impairment is also prevalent in this cohort and may increase the risk of adverse events independently of other factors, including comorbidities. Older adults also tend to value quality of life over “quantity of life,” which may make decision-making in this age group even more complicated. Further issues may also involve psychological and social aspects, financial toxicity, and the presence and role of caregivers.
All these factors make the management of cancer in older adults particularly challenging, as oncologists are not able to simply apply guidelines and consensus in this age group. A comprehensive geriatric assessment should always guide decision-making in this population.
On the other hand, this increased complexity makes the field particularly rewarding, since these challenges provide oncologists a unique opportunity to aim for a truly personalized approach. This does not necessarily involve only new biomarkers and fancy new systemic treatments, but also a more holistic approach which should take into consideration all the aspects that I briefly mentioned here in order to recommend the most appropriate treatment plan in the context of life expectancy and our patients’ preferences.
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