Treating Cancer as Patients Age

George Sheehan, 77, of Diamond Springs, California, enjoyed excellent health until he was stricken with a persistent sore throat in 2016. His ear, nose and throat specialist diagnosed the problem as acid reflux, but after months of treatment with traditional therapies brought no relief, Sheehan sought a second opinion from his gastroenterologist. Sheehan was referred to the University of California, Davis, where a biopsy confirmed that the retired manager had stage 4 squamous cell carcinoma of the larynx.

“They sat me down, explained I had cancer and said it would be best if they removed my larynx,” Sheehan recalls. “The cancer was isolated so I didn’t need chemo- therapy or radiation. I was very fortunate.”

Sheehan received a voice prosthesis and met regularly with a speech therapist. At the same time, Sheehan’s wife, Paula, also a cancer survivor, learned from visiting nurses and instructional videos how to help her husband keep his stoma clean and regain his ability to speak. When Sheehan was well again, the couple celebrated with a cross-country motorcycle trip.

George and Paula Sheehan celebrated his improved health with a cross-country motorcycle trip.

Despite losing his larynx, Sheehan was luckier than many patients with cancer his age. Geriatric patients with cancer, defined as those 65 and older, often have health and other issues that can make cancer treatment difficult. Caring for this population has always been a challenge, but cancer care specialists are making strides to ensure that they receive the same level of support provided to younger patients.

Cancer Risk and Age

Cancer can strike at any age but is most prevalent among adults as they age. According to a 2008 study published in the journal Cancer, about 60% of cancer incidence and 70% of cancer mortality occurs among adults aged 65 and older. This also happens to be the fastest-growing population in the United States, notes the National Cancer Institute, with a projected population of 84 million by 2050.

As patients age, they can be divided into three groups, says Dr. Stuart Lichtman, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York. The first is the well elderly, who tend to be the minority. This is followed by the vulnerable elderly, who can be well functioning and independent but have other medical issues that make them vulnerable to side effects of cancer treatment. The third group is the frail elderly, such as patients in nursing homes. Some frail elderly patients are strong enough to receive treatment for their cancer, Lichtman says, but others may be so vulnerable that treatment is not even a consideration.

“Medicine is never black and white,” Lichtman notes. “You can’t just look at age. You have to look at the whole patient. Geriatric oncology is ‘the ultimate in personalized medicine’ because everyone is a little different. Everyone at that point in their life has had issues in the past and it affects treatment decisions as well as wishes and goals.”

Aging Patients Excluded

Only within the past few decades has a greater focus been placed on the unique needs of aging patients with cancer, thanks to the efforts of advocates such as medical sociologist Rosemary Yancik, who served many years at the National Institutes of Health and was instrumental in founding the International Society of Geriatric Oncology in 2000. One of the most important concerns for advocates such as Yancik has been the lack of patients 65 and older enlisted in clinical drug trials because of safety concerns.

“In the early days of cancer treatment, the thinking was that people above the age of 65 would not be able to tolerate treatment, so the upper age was 65 for clinical trials,” notes Dr. Martine Extermann, program leader in the senior adult oncology program at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida. “Dr. Yancik pushed for programs designed to help older cancer patients, and one of the first in the United States was here at Moffitt.”

Sheehan's wife, Paula, took care of him when he came home from the hospital, which she says was challenging at times.

A lack of aging trial participants can have serious consequences in cancer treatment, says Dr. Supriya Mohile, a geriatric oncologist at the University of Rochester Cancer Center in New York. “The challenge for us as oncologists is that data regarding the safety and efficacy of therapeutics comes from clinical trials that do not include older adults to the prevalence they have in the community,” she explains. “The therapies we have are tested on patients who are younger and in better health. When we see older adults who may have other health problems, we often don’t know how to appropriately manage that patient because we don’t have the data.”

Thankfully, attitudes regarding the inclusion of aging patients in clinical trials are starting to shift. The Cancer and Aging Research Group, in collaboration with the National Institute on Aging and the National Cancer Institute, reviewed gaps in knowledge about the care of patients age 65 and older with cancer and developed a series of recommendations to improve their participation. They include the following:

• design trials specific to this patient population;
• modify trial designs to collect more data on aging patients;
• leverage population cohort studies to answer commonly posed questions in geriatric oncology regarding the feasibility, dosing and toxicity of a selected regimen;
• conduct concurrent differential dosing trials for these patients; and
• broaden further eligibility criteria.

Ed Cutler, 75, of Tampa, Florida, after standard-of-care chemotherapy for 16 months, participated in two separate phase 1 immunotherapy trials as part of his treatment for lung cancer with metastases to the liver. The first drug combo — Imfinzi (durvalumab) and tremelimumab, two drugs known as checkpoint inhibitors, beginning in 2015 — reduced the size of the tumor in Cutler’s lung by 70% but side effects including severe colitis forced him to stop after seven months. A year later, Cutler began receiving taminadenant, another immunotherapy drug known as an adenosine receptor antagonist, in a phase 1 trial conducted at the Moffitt Cancer Center, again with positive results.

“I’m still an active participant of the trial and have been stable since early 2017,” Cutler says. “I am not cancer free. There is still something there, but it is not growing and it’s not getting any smaller. The treatment appears to be keeping my cancer stable.”

Comorbidities and Treatment

Cutler says that, to the best of his knowledge, his age was never considered a factor by his care team, likely because he was in relatively good physical health at the time with no comorbidities.

But that’s not the case for the majority of aging patients with cancer. Comorbidities tend to become more common with age and are a very important factor when developing a treatment plan. Especially concerning are illnesses that can negatively affect treatment and recovery such as obesity, diabetes, kidney disease, liver disease and heart issues.

“From a physiologic point of view, 20-year-olds are essentially the same. Everyone is healthy with no other diseases,” Extermann explains. “That changes as we get into our 70s and 80s. We need to understand the disease, but in addition, we need a knowledge of the patient that is much deeper than you would have for younger patients. We need to evaluate which diseases they have as well as their function and reserve, which is their capacity to rebound.”

One of the most useful tools available to geriatric oncologists is the comprehensive geriatric assessment (CGA), which helps determine if a patient will benefit from treatment or would be better off with palliative care. The CGA evaluates physical functioning, comorbid conditions, cognitive performance, psychological and nutritional status, social support, current medications and the presence of geriatric syndromes.

“With some patients, the screening may tell us that the patient is really very fit and should receive a full treatment,” Lichtman notes. “Another person may look pretty good, but when you start looking at their function, you discover all kinds of vulnerabilities, and if you start treatment with a full-dose regimen, you are going to harm that patient. We have to modify the dose and use a lighter treatment for the patient to get the best benefit.”

Ed Cutler believes his age was not taken into consideration by his care team because of his relatively good health.

In a trial conducted by the University of Rochester Cancer Center, the CGA was found to improve care delivery and patient/caregiver satisfaction, Mohile reports. A second trial found that the tool also improves decision-making and reduces cancer treatment toxicity.

“We need to learn how to implement the comprehensive geriatric assessment better and make patients and care- givers aware of it,” says Mohile. “If patients demand this evidence-based practice of their doctors, practices will adopt it more.”

Challenges at Home

Home care — both during and after treatment — can present its own challenges for aging patients with cancer. Many require continued support from their medical team, which may include a home nurse, speech therapist, physical therapist, nutritionist, wound care specialist, social worker and others. However, daily assistance typically is provided by family and friends, which can result in caregiver burnout.

“Just because a patient is married, oncologists shouldn’t assume they have a caregiver because the spouse may be in worse condition than the patient,” Extermann says. “You have to ask patients about their arrangements.”

“Our system is not a good one for caregivers,” Mohile acknowledges. “We barely address caregiver needs in our clinical encounters, and there is not a lot of support for care- givers in general. This can affect the patient. If the caregiver is stressed or has their own health needs that are being affected by caregiving, the patient is not going to do well. We need to think about them as a team.”

Paula Sheehan did all she could to meet her husband’s care needs when he returned home from the hospital. Yet despite the support she received from nurses and others, she found the experience emotionally stressful. “I took it upon myself,” she says. “You have to learn how to care for your spouse when they get home, and it’s a shock, really. You have a lot on your shoulders. It was difficult, but we got through it together. I’m really proud of him.”

"I am not cancer free. There is still something there, but it is not growing and it's not getting any smaller." - Ed Cutler

Numerous organizations provide resources for home caregivers including the American Cancer Society, the Cancer and Aging Research Group, the American Society of Clinical Oncology, Susan G. Komen for the Cure, the LUNGevity Foundation, the GO2 Foundation for Lung Cancer and the National Cancer Institute.

Importance of Self-Advocacy

Aging patients are encouraged to be their own advocates and not hesitate to ask questions about their treatment options, goals and more. “One important question patients should ask is, what is the evidence for this treatment plan for patients like me? The doctor should be honest regarding the available data,” says Mohile.

Another essential question is how a particular treatment will affect the patient’s ability to function, Extermann adds. “Function matters a lot to older patients,” she notes. “Everyone wants to live longer but no one wants to grow old.”

Before surgery, patients and caregivers should look into appropriate support groups at their local hospital or cancer organization, Paula Sheehan suggests. “That was very helpful to us both,” she says. “Speaking with other laryngectomy patients before and after surgery helped us know what to expect.”

Cutler also encourages patients 65 years and older to talk not only to their medical care team but also to other patients with cancer who have been through it. “I think they are more valuable than anybody,” he notes. “A connection to other patients through the LUNGevity Foundation helped me personally and really began my journey of advocacy.”

While aging patients with cancer face unique challenges, it’s important to understand that treatment options are broad and the prognosis is good for most. “Nowadays, most cancers are either curable or manageable so that you can live several years with it,” says Extermann. “It’s not necessarily a death sentence.”

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