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Elderly Oncology Introduction
Abstracted and Summarized by Ernest H. Rosenbaum, MD


The majority of the elderly and aging population comprises cancer patients, and they are the greatest recipients of chemotherapy. The largest segment of the U. S. population is becoming 65 years or older. With a life expectation of another 15 years, and it is hoped that they will remain functionally independent during this time. 75- to 85-year olds have an average life expectancy of 10 and 6 years, respectively.

More than half the new cancers diagnosed occur in the elderly. In a comprehensive geriatric assessment program (CGA), people measure:
1. Functional status with activities of daily living and instrumental activities of daily living.
2. Objective physical performance, measuring tests of physical performance and time up and go, which is getting up from a chair and walking eight feet and back.
3. Comorbidities, listing various medical problems, heart, diabetes, lung, kidney.
4. Nutritional status.
5. Social support, listing medical team, family and friends.
6. Cognition, testing for oriented memory and mental status.
7. Depression and psychological, with an assessment of depression and psychological problems.
8. Review of medications

Using this comprehensive approach helps in prognosis and calculating life expectancy. Not all patients are evaluable, but through generalizations, such as use of the Karnofsky or the ECOG, a physical assessment approach can be very helpful. A lot will depend on the type. of cancer, as well as the stage, therapy and response to therapy. With age, there are often psychological problems, and one of them is delirium, which is an acute disturbance of attention and arousal that is marked by many fluctuations daily. It can be either agitative or hypoactive, affecting physical and emotional functioning. Also, a general assessment of frailty via functional testing is often helpful, because advice can be given on how to prevent falls and how to improve functional living. If balance is a problem, an exercise rehabilitation program should be recommended.

ECOG Performance Status Grade
Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead

Karnofsky Performance Scale
100% No evidence of disease
90% Normal activity with minor signs of disease
80% Normal activity with effort: signs of disease
70% Cannot do normal activity, but cares for self
60% Requires occasional assistance
50% Requires considerable assistance and frequent medical care
40% Disabled: requires special care
30% Severely disabled; hospitalization may be indicated
20% Very sick; hospitalization necessary for supportive treatment
10% Moribund

Through this evaluation, one can hopefully predict future morbidity and mortality, and then proved function and longevity. Older patients with cancer often require functional assistance. The need increases as cancer survivors age. The use of the Karnofsky or ECOG (Eastern Cooperative Oncology Group )Performance Status is of help in the assessment. Also, an assessment of the activities of daily living and the aids necessary to improve self-care are important. Use an exercise rehabilitaton physical therapy program. There is often need for assistance at home or the need for institutional care. Treatment toxicity and recovery time are also important factors in the functional status. Current and projected comorbid conditions play a major role in geriatric care. Control of hypertension, diabetes, heart and lung disease are vital components of both psychological and functional status. With cancer patients, any deficit can make a major difference in daily living. For example, it is known that diabetes decreases the eight-year disease-free survival of stage three colon cancer equal to the beneficial effects of adjuvant chemotherapy. Hyperinsulinemia decreases the survival in prostate, colon and breast cancer patients. Obesity projects a worse prognosis for ovarian and other cancers. Thus, comorbidity affects survival, as well as functional life.

References:
Extermann, M. and Hurria, A., "Comprehensive Geriatric Assessment for Older Patients with Cancer," J Clin Oncol, 25: 1824-1831, 2007
Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: "Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group." Am J Clin Oncol 5:649-655, 1982.
Crooks, V, Waller S, et al. "The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients." J Gerontol. 1991; 46: M139-M144.



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First appeared November 30, 2007; updated December 1, 2007