Are “Silver Survivors” Too Old for Treatment? How Chronologic and Functional Age Can Influence Treatment-related Effects

There exist unique challenges with respect to managing and treating the elderly with cancer, and functional age, determined by geriatric assessment (GA) can influence treatment related effects and health outcomes, according to research presented at the 2019 HOPA Annual Conference by Ginah Nightingale, PharmD, BCOP, Associate Professor of the Department of Pharmacy Practice Jefferson College of Pharmacy, Thomas Jefferson University.

Most cancer diagnoses and deaths occur in older adults, which is important to note considering that by the year 2050 most counties across Europe and Asia “will have 30% of their population comprised of older adults.” However, chronological age does always equal functional age. The true hallmark of aging occurs due to reduced physiologic reserves. This “fuel available” is not always apparent when a person is at rest, and usually becomes more obvious with the involvement of a stressor.

A factor other than chronological age that predicts both morbidity and mortality for seniors with cancer is geriatric assessment (GA), and key domains for GA assessment (and how they influence treatment) include:

• Functional Status – If the patient is unable to manager and administer their medications independently, they incur an increased risk of medication errors.
• Comorbidity – If the elderly patient has multiple comorbidities, they stand an increased chance of their cancer therapies exacerbating their chronic conditions.
• Cognition – Patients with a lower baseline cognitive reserve have an augmented risk of further cognitive deterioration when treated by certain medications (e.g. anti-androgen therapy).
• Nutrition – Any elderly patient that is unable to manage their nutrition or is malnourished stands an increased risk of medication errors.
• Psychological State & Social Support – Social isolation is associated with increased chemotherapy toxicity, and if that patient lacks reliable caregiver support, decision making, treatment/lab tests, and management of complex therapies can be affected.
• Polypharmacy – This GA component can affect the patient if they are taking several medications, or a potentially inappropriate medication.

Dr. Nightengale noted in a presentation slide that “using GA to evaluate patients beyond chronologic age and/or age-related physiologic organ impairment provides a complementary and robust characterization of an older adult’s fitness for cancer therapy.”

While few studies have incorporated GA assessments into cancer trial methodology, the presenter indicated on a concluding slide that “broadening cancer therapy trials to capture not only chronological age but functional age would allow clinicians to better identify subsets of older adults who are most vulnerable to morbidity and mortality.”