Fundamentals of Geriatrics Oncology 2023

Fundamentals of Geriatric Oncology

1. Fundamentals of Geriatric Oncology By Dr. Ayush Garg

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3. INTRODUCTION 3 Aging 60% > 65 years 70% by 2030 What is the age criteria? Young old 65-70 years Old 70-85 years Old adult > 85 years

4. INTRODUCTION 4 WHO —which describes ageing populations as those over aged 60 years Societal point of view- age of retirement-entitlement (usually around 65 years in many countries). In politics- 70 or 75 years and above Geriatric institutions- 85 years and older Onco-geriatric sense- A threshold around 70–75 years might be appropriate

5. Frailty Age=85 3+ comorbidity 1+ geriatric syndromes 1+ ADL Primary goal of treating frail patients is palliation.

6. National cancer registry Program, ICMR Population based cancer registry reports In India, according to registry data about 45–50% of all the cancers in males and 35–41% of all cancer in females occur above the age of 60. 50% 38% 6.5 out of 10 males… 2.3 females… INTRODUCTION

7. Disadvantages in Old Age Decreased life expectancy Increased comorbidities Decreased functional reserve Decreased renal and hepatic functions Decreased hematopoietic reserve Altered pharmacokinetics/dynamics Limited oncology evidence base

8. Age bias Numerous studies in oncology have shown that older people are Less aggressively screened Less systematically staged Receive less standard surgical therapy Receive less adjuvant radiation/chemotherapy Receive less cosmetic surgical reconstruction consultation Receive less dose-intense chemotherapy Receive CSF’s less often with chemotherapy Receive strong analgesic and anti-emetic drugs less often

9. CANCER TREATMENT 9 Surgery Risk of post operative complications Increased duration of hospital stay Increased death in emergency surgery Increased need of assistant post surgery Increased 6 months post surgery morbidity

10. CANCER TREATMENT 10 Radiotherapy More tolerable than surgery and chemotherapy Concurrent chemotherapy to be used cautiously, alternatives like Gefitinib can be tried Dose modification required Pain management and nutritional assessment

11. CANCER TREATMENT 11 Chemotherapy Decreased excretion of drug leading to more side effects Decreased volume of distribution leading to less effective Increased dose adjustment Prophylactic use of GCSF/ Peg GCSF Hb>12g/dL

12. CANCER TREATMENT 12 Targeted therapy Reduced therapeutic compliance in comparison to others More complications

13. CANCER TREATMENT 13 Hormone therapy Safer than others

14. ASSESSMENT TOOLS Zubrod scale KPS/ ECOG CGS

15. SCREENING TOOLS 15 To identify patients in need of GA and multidisciplinary approach CGA G8 QUESTIONNAIRE

16. G8 Recommended by SIOG 8 items in 5 minutes Developed for the cancer population Compared with CGA in 8 studies Sensitivity 65-92%; specificity 3-75% (>60 in 4 studies) high sensitivity for functional decline predictive of chemo toxicity in some Food intake Weight loss Mobility Neuropsych BMI Medications Self report of health status Age

17. Other screening tools Vulnerable Elders Survey-13 (VES-13) Groningen Frailty Indicator Barber Questionnaire Identification of Seniors At Risk (ISAR) Oncogeriatric screen Abbreviated Comprehensive Geriatric Assessment etc.

18. (CGA) 18 Comprehensive Geriatric Assessment

19. COMPREHENSIVE GERIATRIC ASSESSMENT For better Quality of Life To see estimate Life expectancy Functional reserve Comorbidities Social resource availability

20. ADVANTAGES OF CGA 20 Reduces the risk of hospitalization Nursing home placement Improves QoL Compliance and safety of cancer treatment Assess outcome of treatment

21. MAJOR COMPONENTS OF CGA 21 Core components that should be evaluated are as follows: Functional capacity Fall risk Cognition Mood Polypharmacy Social support Financial concerns Goals of care Advance care preferences

22. MAJOR COMPONENTS OF CGA 22 Additional components may also include evaluation of the following: Nutrition/weight change Urinary continence Sexual function Vision/hearing Dentition Living situation Spirituality

23. Geriatric Syndromes Delirium, Incontinence, Dementia, Depression, Falls, Failure to thrive, and Neglect and abuse.

24. ACTIVITIES OF DAILY LIVING 24 An older adult's functional status can be assessed at three levels: Basic activities of daily living (BADLs) Instrumental or intermediate activities of daily living (IADLs) Advanced activities of daily living (AADLs)

25. Basic activities of daily living 25 BADLs refer to self-care tasks which include: Bathing Dressing Toileting Maintaining continence Grooming Feeding Transferring

26. Instrumental or intermediate activities of daily living 26 Shopping for groceries Driving or using public transportation Using the telephone Performing housework Doing home repair Preparing meals Doing laundry Taking medications Handling finances Ability to use a cellphone or smartphone Ability to use the internet Ability to keep a schedule of activities IADLs refer to the ability to maintain an independent household which include:

27. Advanced activities of daily living 27 These advanced activities include The ability to fulfill societal, community, and family roles Participate in recreational or occupational tasks

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29. Impact of the CGA Reduction in: Adverse events Hospitalizations Patient stress Mortality May reduce relative risk of death by 15.3% (in breast cancer adjuvant therapy) Impact of a geriatric intervention (experimental arm) on the survival of older patients with early or late stage cancer. McCorkle R, et al. A specialized home care intervention improves survival among older postsurgical cancer patients(2000).

30. Toxicity more common & severe in the elderly Hematologic Cardiomyopathy Mucositis Delayed nausea & vomiting Central & peripheral neuropathy

31. Prophylactic use of filgrastim or pegfilgrastim for patients treated with moderately toxic regimens (CHOP, AC, FEC) and when dose intensity is required for response or cure. Hematologic toxicity & age

32. Cardiotoxicity Age is risk factor due to decreased myocardial reserve MUGA scans have limited predictive value Myocardial damage rare <=300mg/m2

33. Prevention of cardiotoxicity Caution with use of anthracyclines , trastuzumab Alternative schedules Continuous infusion Weekly administration Monitor LVEF & clinical symptoms Alternative drugs, eg . Mitoxantrone , epirubicin , liposomal anthracyclines

34. Prevention & treatment of mucositis Should be always treated aggressively in older individuals. Early hospitalization Provide nutritional support Oral cryotherapy , ie . Ice Dose & schedule selection Rapid correction of dehydration Treatment of secondary infection

35. Summary Cancer disproportionately affects older adults in terms of incidence, morbidity, and mortality Older patients with cancer have more comorbidity, disability, polypharmacy, and altered pharmacology that impact all aspects of oncology research and practice Age is not a contraindication to anti-cancer treatment Older cancer patients may benefit from anti-cancer treatment irrespective of age

36. MULTIDISCIPLINARY TEAM 37 Oncologist Geriatrician Palliative medicine specialist Oncology nurse practitioner Pain specialist General practitioner Nutritionist Important consultants to the oncology team such as: Dermatologist Cardiologist Neurologist Pneumologist Endocrinologist Surgeon Nephrologist Psychiatrist Ear, nose and throat specialist (ENT) Rheumatologist Ophthalmologist Sexual health specialist Psycho-oncologist Social worker Physiotherapist Pharmacist Clerics (or spiritual helper) Volunteers Care-home staff Self-help and support groups

37. CGA

38. “If you are not a pediatric oncologist, you are a geriatric oncologist” - Source Unknown Thank You