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Geriatric Oncology
Ernest H. Rosenbaum, MD

Introduction
Memory and Cognition Status
Nutritional Status
Psychological Status and Support
Maintenance Drug Therapy
Helpful Interventions


Introduction
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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 expectancy of another 15 years and hopefully will remain functionally independent during this time. A 75- to 85-year old has 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, 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. Memory, cognition, testing for oriented memory and mental status.
7. Depression and psychological, with an assessment of depression and psychological problems.

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.

As our population ages, there is going to be a greater need for knowledge and state-of-the-art treatments for our geriatric patients. A comprehensive geriatric assessment (GCA) should include:
1. An evaluation of the functional status
2. Comorbid medical conditions
3. Nutritional status
4. Memory status, cognition
5. Psychological status
6. Social support
7. Review of medications

Through this evaluation, one hopes to predict future morbidity and mortality, The goal is to streamline treatments necessary to enhance improved function and longevity. Older patients with cancer often require functional assistance. The need increases as cancer survivors age. The use of the Karnofsky or 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. 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.


Memory and Cognition Status
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As people with cancer age, between 25-50% have some cognitive abnormalities, which may affect their oncologic care. Cognitive dysfunction can alter decisions on cancer therapy and treatment plans. Also, cancer therapy, be it chemotherapy, radiation or surgery, can affect cognitive function.


Nutritional Status
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Several studies have shown that weight loss is an important prognostic factor for survival in cancer patients. Even a 5% weight loss can have significance. It was also noted that a poor nutritional status correlated with depression.

Overweight is also a major problem, leading to several comorbid conditions. In one study, 71% of geriatric cancer patients had a BMI greater than 25 and had improvement on a weight-loss diet.


Psychological Status and Support
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In the Nurses' Health Study, socially isolated women had a 66% increased risk of all-cause mortality and a two-fold increased risk of breast cancer-specific mortality. Much of this was related to lack of assess to care from family and friends. Social isolation is a major problem for older adults in general and is a risk factor for psychological distress. Depression is a major problem. Psychosocial and family support is important, as depression does affect the outcome of older patients.

In a study of ovarian cancer patients treated with platinum-based chemotherapy, depression was the strongest prognostic factor for survival.


Maintenance Drug Therapy
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It is often important to take multiple drugs, and there is great confusion and frequent errors in how drugs are taken. The inclusion of a pharmacist consultation and aid is very helpful in reducing the risks of poly-pharmacy, as well as being more cost-effective.


Helpful Interventions
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Support through nursing services, telephone calls and medical team support is very helpful in aiding older cancer patients live as normal a life as possible. There are a variety of ways and interventions that can be used. Screening for physical and psychosocial problems is part of the assessment process. This can be done most often by a geriatric specialty nurse. In conclusion, a comprehensive geriatric assessment is vital to the care and quality of life of aging cancer patients. Through good supportive techniques, quality of life can be improved. New strategies are currently being developed.

Reference: Extermann, M. and Hurria, A., "Comprehensive Geriatric Assessment for Older Patients with Cancer", J Clin Oncol, 25: 1824-1831, 2007




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