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Assessing the ‘Fit’ Older Patient for Chemotherapy
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Assessing the ‘Fit’ Older Patient for Chemotherapy
July 15, 2014 | Oncology Journal [1], Older Patients [2]
By Arti Hurria, MD [3] and Eduardo P. Siccion, MD [4]
Making appropriate treatment decisions for older adults with cancer is one of the most important
challenges that oncologists face in daily practice, as the therapy selected depends on an assessment
of the patient’s “fitness.”
Making appropriate treatment decisions for older adults with cancer is one of the most important
challenges that oncologists face in daily practice, as the therapy selected depends on an assessment
of the patient’s “fitness.” The majority of cancer diagnoses and cancer mortalities occur in older
adults, so oncologists make such assessments in this patient group at least several times a day.[1]
Often the assessment is based on a gestalt “She appears younger than her stated age”; or the
patient’s fitness is indicated by Karnofsky[2] or Eastern Cooperative Oncology Group[3] performance
status scores.
However, the aging process is more complex than a gestalt or a single-item assessment of function.
In this article, we discuss specific considerations for evaluating patients who appear to be “fit” for
chemotherapy treatment, and outline methods for integrating the principles of geriatric medicine to
form a clear picture of an older adult’s level of fitness and thus his or her individual risk of significant
toxicity from cancer therapy.
Defining Fitness
Although aging is universally associated with a decrease in physiologic reserve, this process is
heterogeneous, often being unapparent during times of rest and only unmasked during times of
physical or emotional stress. One can think of the aging process as similar to the gauge on a car’s
gas tank. Life starts off on “full.”
At around 30 years of age, people begin to experience a progressive decline in physiologic reserve,
which proceeds at a unique pace; hence, the “gas” begins to be used up. Thus, an individual may
seem “fit” (ie, have enough “gas”) prior to the start of treatment; however, when placed under
stress (ie, cancer therapy), the amount of reserve becomes apparent as the patient “runs out of gas”
(manifested as a dose-limiting toxicity).
Calculating Risks of Chemotherapy Toxicity
A variety of tools are available to gauge an individual’s level of reserve, and these should be used
even when a patient seems to be “fit” for cancer therapy. In a Cancer and Aging Research Group
multicenter study, a total of 500 older adults with cancer were deemed by their treating oncologists
to be “fit” for the treatment prescribed and received treatment at their oncologist’s discretion
(including the drugs, dosing, and schedule). Fifty-three percent of the cohort experienced a grade
3–5 toxicity as determined by the National Cancer Institute Common Toxicity Criteria for Adverse
Events, and among this group there was a 2% incidence of treatment-related mortality. The
assessment of “fitness” based on Karnofsky performance status did not adequately identify those at
risk—but a predictive model including tumor and treatment variables, laboratory values, and
geriatric assessment questions could have better stratified that risk (see Table 1 and Figure).[4]
Another model, called CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients), which
was developed by Extermann and colleagues, predicts the risk of hematologic and nonhematologic
toxicity in older adults.[5] These tools can pinpoint an older adult’s risk of significant toxicity with
chemotherapy. They provide a specific platform from which to discuss risk with patients and families.
Geriatric Assessments Identify Vulnerability and Guide Interventions
Chemotherapy prediction tools identify where a patient falls on the spectrum of toxicity risk from
cancer therapy by pinpointing areas of vulnerability. A geriatric assessment should also be used, to
provide a sense of the “functional age” of a given older adult patient. In addition to an evaluation of
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Assessing the ‘Fit’ Older Patient for Chemotherapy
Published on Cancer Network (http://www.cancernetwork.com)
an individual’s functional status, comorbidity, psychological state, social support, cognition, and
nutritional status, the geriatric assessment includes a medication review, to evaluate for
polypharmacy and potentially inappropriate medications with a high risk of side effects in older
adults.[6]
Although the term “geriatric assessment” may sound time-consuming and even daunting, this
process can be tailored to an oncology practice in order to meet its specific needs and accommodate
time constraints. Geriatric assessment is important because it can identify potential areas of
vulnerability in an older adult and serve as a basis for targeted interventions. The components of a
geriatric assessment are summarized in Table 2.[7] Functional status is measured by the ability to
perform activities of daily living (those required to maintain independence in the home, such as an
ability to bathe, dress, toilet, transfer, feed oneself, and maintain continence) and instrumental
activities of daily living (those needed to maintain independence in the community, such as the
ability to shop, take transportation, manage one’s finances, take medications, prepare meals).[8,9]
An assessment of comorbidity evaluates other health problems and their potential impact on cancer
therapy, as well the risk of overall mortality independent of cancer treatment. Nutritional status can
be evaluated by simple metrics such as unintentional weight loss or low body mass index, which
predict chemotherapy toxicity and increased risk of mortality. An evaluation of psychological state
includes an assessment of anxiety and depression, which are often underdiagnosed in patients with
cancer in general, but particularly in older adults who may present with more somatic symptoms
compared to younger patients. Last, an assessment of social support determines whether support is
present to assist the patient through treatment, especially if a decline in functional status occurs, as
well as the patient’s ability to seek medical attention if he or she experiences chemotherapy toxicity.
Part of this assessment should include an appraisal of whether the patient is a caregiver for another
person, such as an aging spouse. Back-up provisions must be discussed in case the patient is unable
to attend to caregiving duties during chemotherapy treatment.
There are many ways to perform a geriatric assessment, and one size does not fit all. Although time
is often cited as a constraint, today more efficient screening tools are available. Furthermore, a
primarily self-administered geriatric assessment, devised by the Cancer and Leukemia Group B,
covers well-validated measures of geriatric assessment.[10] Feasibility data show that approximately
80% of patients can complete the patient self-report portion without assistance.[10,11] An
internet-based version provides a summary of results for the healthcare team (www.mycarg.org).
Key Ways to Assess the Fitness of an Older Patient With Cancer
Make use of available tools to gather a detailed assessment of individual levels of physical
reserve.
The primary chemotherapy risk assessment tools include chemotherapy toxicity calculators
and web-based geriatric assessments, which include a wide range of measurement scales.
Chemotherapy risk assessments should additionally include specific considerations regarding
organ function in the older patient.
Specific Considerations Regarding Organ Function
Specific considerations regarding organ reserve should be evaluated in addition to performing a
geriatric assessment.[12] Older adults are at risk for chemotherapy toxicity because of decreased
bone marrow reserve, which occurs with aging. Receipt of polychemotherapy, in particular, can place
an older adult at risk for toxicity; hence, single sequential-agent regimens should be considered, and
further research regarding the efficacy of this approach is needed, particularly in the adjuvant
setting. Primary prophylaxis with growth factors should be considered as per guidelines, with
recognition that age ≥ 65 years is a risk factor for neutropenia-associated complications.[13,14]
Aging brings a decline in renal function, and because of the reduction in muscle mass that occurs
with aging, serum creatinine levels can remain “normal” even in the setting of reduced renal
function. A creatinine clearance test is needed in order to accurately characterize renal function and
to dose renally metabolized drugs accordingly. As with patients of any age, cardiac function should
be assessed prior to using drugs that pose a risk of cardiac toxicity. Hepatic function should be
considered in patients of any age. Hypertension and heart-related conditions are the most common
comorbidities facing older adults, and even if a cardiac ejection fraction test is normal, efforts should
be made to decrease/optimize cardiac risk factors prior to and during cancer therapy. Patients
should be encouraged to use their eyeglasses and/or hearing aides as necessary, especially when
discussing risks/benefits of cancer therapy and specific side effects that will require immediate
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Assessing the ‘Fit’ Older Patient for Chemotherapy
Published on Cancer Network (http://www.cancernetwork.com)
attention. Instructions should be written in large black letters on white paper, to maximize
readability. If the patient is hearing-impaired and does not have a hearing aid, use a hand-held
amplifier to improve communication.
Summary
Oncologists are called on daily to assess “fit” older persons for cancer therapy. An individual’s level
of physiological reserve becomes unmasked during cancer therapy when the need arises to rely on
this reserve. An in-depth assessment is essential in quantifying the level of an older adult’s fitness.
Tools can assist with this evaluation, including chemotherapy toxicity calculators and web-based
geriatric assessment scales. Integrating these tools into oncology practice will be well worth the time
and effort for both the patient and the oncology care team.
Financial Disclosure: Dr. Hurria receives research support from Celgene and GlaxoSmithKline and
is a consultant to GTx and Seattle Genetics. Dr. Siccion has no significant financial interest or other
relationship with the manufacturers of any products or providers of any service mentioned in this
article.
Figure: Ability of (A) Risk Score vs (B)
Physician-Rated Karnofsky Per...
Table 1: Predictors of Chemotherapy Toxicity,
and Scoring Algorithm
Table 2: Geriatric Assessment: Key Questions for
the Oncologist to Con...
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Assessing the ‘Fit’ Older Patient for Chemotherapy
Published on Cancer Network (http://www.cancernetwork.com)
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Source URL:
http://www.cancernetwork.com/oncology-journal/assessing-fit-older-patient-chemotherapy
Links:
[1] http://www.cancernetwork.com/oncology-journal
[2] http://www.cancernetwork.com/older-patients
[3] http://www.cancernetwork.com/authors/arti-hurria-md
[4] http://www.cancernetwork.com/authors/eduardo-p-siccion-md
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