Management of pain in the older person with cancer

Pain in older cancer patients is a common event, and many times it is undertreated. Barriers to cancer pain management in the elderly include concerns about the use of medications, the atypical manifestations of pain in the elderly, and side effects related to opioid and other analgesic drugs. The care of older cancer patients experiencing pain involves a comprehensive assessment, which includes evaluation for conditions that may exacerbate or be exacerbated by pain, affecting its expression, such as emotional and spiritual distress, disability, and comorbid conditions. It is important to use appropriate tools to evaluate pain and other symptoms that can be related to it. Pain in older cancer patients should be managed in an interdisciplinary environment using pharmacologic and nonpharmacologic interventions whose main goals are decreasing suffering and improving quality of life. In this two-part article, the authors present a review of the management of pain in older cancer patients, emphasizing the roles of adequate assessment and a multidisciplinary team approach.     

Prevention of cancer in the older person

Cancer is the most common cause of death up to the age of 85 years and is also a major cause of disability. Screening asymptomatic patients for cancer is the most promising strategy to reduce cancer-related morbidity and mortality in the older population. Though the information related to older people is scanty, it is reasonable to recommend that the screening of older individuals be based on life expectancy, tolerance of screening, and tolerance of antineoplastic therapy. Some form of screening for breast cancer appears indicated for individuals with life expectancy of 5 and more years. If screening for prostate cancer is indicated at all, it should be limited to men with a life expectancy of at least 10 years. The value of screening asymptomatic individuals for lung and ovarian cancer is explored in ongoing clinical trials.     

Management of pain in the older person with cancer. Part 2: treatment options

Pain in older cancer patients is a common event, and many times it is undertreated. Barriers to cancer pain management in the elderly include concerns about the use of medications, the atypical manifestations of pain in the elderly, and side effects related to opioid and other analgesic drugs. The care of older cancer patients experiencing pain involves a comprehensive assessment, which includes evaluation for conditions that may exacerbate or be exacerbated by pain, affecting its expression, such as emotional and spiritual distress, disability, and comorbid conditions. It is important to use appropriate tools to evaluate pain and other symptoms that can be related to it. Pain in older cancer patients should be managed in an interdisciplinary environment using pharmacologic and nonpharmacologic interventions whose main goals are decreasing suffering and improving quality of life. In this two-part article, the authors present a review of the management of pain in older cancer patients, emphasizing the roles of adequate assessment and a multidisciplinary team approach.     

Care and the older person with cancer

Care of older people with cancer has received relatively little attention in the literature and this area of caring practice has yet to be firmly established in professional discourse. References to the increasing proportion of older people in the population are common, as are references to the problems associated with old age, whether these are seen as medical, or as inevitable consequences of natural processes. Health care for older people has sometimes been reported to be routinized or basic, and as taking little account of individual perspectives, and the 'discourse of senescence' represents a tendency to understand old age and the aged body in terms of degeneration and deterioration. Here, it is argued that older people are often portrayed as separate and diminished, and have little control over the definition of themselves as users of health services. This represents a constraint upon the possibilities of caring practice. Divesting ourselves of the 'discourse of senescence' may be a fundamental part of developing caring practice for older people with cancer in the future.     

Cancer in the older person

Cancer in the older person is an increasingly common problem, due to the progressive prolongation of the life-expectancy of the Western population. This article reviews the mechanisms associating aging and cancer, age-related changes in cancer biology, assessment of the older person to estimate life-expectancy, treatment tolerance, and medical and social conditions that may interfere with cancer treatment, effectiveness of cancer prevention and cancer treatment in older individuals. A comprehensive geriatric assessment (CGA) is commonly used to predict life-expectancy and functional reserve and to unearth conditions that may jeopardize cancer prevention and treatment. In the interest of cost and time, shortened forms of CGA are being explored. Chemoprevention of cancer is a promising form of prevention that at present has no conclusive clinical indications. Early diagnosis of breast and colon cancer through screening of asymptomatic patients at risk may be beneficial for individuals with a life-expectancy of 5 years or longer. Early detection of lung cancer in ex-smokers is undergoing clinical trials, as this disease is becoming more and more common. Age should not prevent appropriate treatment of cancer in older individuals, especially in those with adequate life-expectancy and functional reserve. The National Cancer Center Network (NCCN) has issued a series of guidelines to minimize the toxicity and promote the effectiveness of cancer in older patients. Important interventions include prevention of neutropaenic infections with filgrastim and peg-filgrastim, prevention of anaemia with epoietin or darbepoietin, and prevention and early management of mucositis.     

Cancer in the older person

The incidence and mortality rate of cancer increases with age. With a worldwide increase in life expectancy, the clinical problems associated with cancer and old age are becoming more and more widespread. The clinical questions relating to cancer and old age can be divided into three main areas: 1) Why does the incidence and prevalence of cancer increase with age? 2) Does age affect the biology of cancer? 3) Is the prevention and treatment of cancer beneficial to elderly patients? 4) What are the psychosocial consequences of treating elderly patients with cancer?     

Sexual rehabilitation of urologic cancer patients: a practical approach

Sexual rehabilitation is an important aspect of preserving a patient's quality of life after treatment for urogenital cancer. Sexual rehabilitation does not usually require a specialized program, but can be an integral part of cancer treatment. Members of the health care team can provide sexual information for the patient and partner, as well as assess the need for more intensive marital or sex therapy. This paper presents specific sexual issues related to prostate, bladder, testicular, and penile cancers.     

Melanoma in the older person

Melanoma accounts for the majority of skin cancer deaths worldwide and has dramatically increased in incidence over the past half-century. Despite recent trends showing improved survival, and stabilization of incidence rates in younger Americans, melanoma incidence and mortality continue to rise unabated in older individuals, particularly in men over age 65. Efforts at early clinical detection of melanoma in older individuals should take into account the differences in melanoma subtypes in older individuals, potentially reduced access to medical specialists in this population, as well as comorbidities that may affect ability to undergo treatment for advanced disease. Secondary melanoma prevention should be focused on targeted education to older men and their spouses for early detection and reduction of mortality in this extremely high-risk group.     

Multidimensional geriatric evaluation in elderly cancer patients: a practical approach

Management of cancer in the elderly population is currently perceived as one of the major challenges for clinical research in medical oncology. Multidisciplinary evaluation of the malignant disease and multidimensional assessment of the host represent the key element for correct decision making. Standard methods developed by pioneer geriatric oncologists will be summarized in this review, along with some practical suggestions on when and how they should be employed. Future perspectives concerning some critical issues in multidimensional geriatric assessment will be discussed as well.     

Geriatric oncology: a clinical approach to the older patient with cancer

Due to the ageing of the population and the sharp increase in life expectancy, cancer in the older person has become an increasingly common problem in the Western world. Although several authors have stressed that elderly cancer patients deserve special attention as a target group for research efforts, older aged patients are still less likely to be offered participation in clinical trials. The cellular and molecular mechanisms regulating the physiological process of ageing and senescence are far from understood, although inflammation is likely to play an important role, at least in some cancers. In addition, the relationship between ageing and cancer risk is also far from understood. One of the most intriguing aspects of ageing is how different the ageing process is from person to person; the basis for this variation is largely unknown. Population-based studies and longitudinal surveys have shown that comorbidity and physical and mental functioning are important risk factors; thus, a meaningful assessment of comorbidity and disability should be implemented in clinical practice. Modern geriatrics is targeted towards patients with multiple problems. Such patients are not simply old, but are geriatric patients because of interacting psychosocial and physical problems. As a consequence, the health status of old persons cannot be evaluated by merely describing the single disease, and/or by measuring the response, or survival after treatment. Conversely, it is necessary to conduct a more comprehensive investigation of the 'functional status' of the aged person. A geriatric consultation provides a variety of relevant information and enables the healthcare team to manage the complexity of health care in the elderly; this process is referred to as the Comprehensive Geriatric Assessment (CGA). The use of CGA is now being introduced into oncological practice. The definition of frailty is still controversial and represents a major issue of debate in clinical geriatrics. As the frail population increases, clinical trials in frail persons are needed. The usefulness of these trials requires a consensus as to the definition of frailty. Clearly, the management of older persons with cancer requires the acquisition of special skills in the evaluation of the older person and in the recognition and management of emergencies as well as experience in geriatric case management.     

Management of colorectal cancer in pregnancy: a multimodality approach

Colorectal cancer (CRC) is one of the 3 most common types of cancer in women, but CRC during pregnancy is rare, with a reported incidence of approximately 0.002%. Synchronous colon cancer during pregnancy presents a diagnostic and therapeutic challenge for clinicians because there are no generally accepted guidelines regarding diagnosis or treatment. The diagnosis is challenging because the presenting signs/symptoms of CRC are often attributed to the usual complications of pregnancy, which could delay the diagnosis and allow the cancer to progress to an advanced stage. Carcinogenesis of colon cancer in pregnancy is not clear, but a few studies suggest that the increased levels of estrogen and progesterone related to pregnancy stimulate the growth of CRC with their receptors. The aim of treatment is to start therapy for the mother as early as possible and to simultaneously deliver the baby at the earliest time allowable. The management mandates a multidisciplinary approach involving experts in obstetrics, neonatology, gastrointestinal surgery, and medical oncology. The medical community should be able to diagnose colon cancer earlier in pregnancy in order to improve prognosis. The primary care physician or obstetrician should refer the pregnant patient with significant gastrointestinal symptoms to the gastroenterologist for evaluation. Likewise, the gastroenterologist should be prepared to perform sigmoidoscopy (preferably without endoscopic medications) for significant lower gastrointestinal symptoms such as persistent rectal bleeding. Herein, the author reviews the literature concerning the diagnosis and treatment of CRC in pregnancy and discusses the role of newer agents approved for the treatment of CRC.     

Management of lung cancer in older adults

Lung cancer is the leading cause of cancer death in the United States. At the time of diagnosis, most patients are older than 65 years and have Stage III or IV disease. More than 80% of patients have non-small cell lung cancer and the rest have small cell lung cancer. Age is not a significant prognostic factor for overall survival and response to treatment for patients with either type of lung cancer. Treatment options should be tailored to older patients based on the same selection process and benefits seen in the population as a whole. This article reviews the available data regarding surgery, radiation, and systemic treatment for older patients with lung cancer and considers the role of geriatric assessment in the evaluation of older patients.     

Management of colorectal cancer in older patients

An increasing body of evidence suggests that geriatric patients can benefit from and tolerate standard chemotherapy similarly to younger patients in the settings of both early- and advanced-stage colorectal cancer. Assessment of this unique population requires more comprehensive evaluation in addition to routine history, physical examination, and laboratory tests. Specific considerations of their physiologic functional changes will help physicians better manage these patients. Ongoing studies are now designed to better understand the decisionmaking process, safety profile, and efficacy of various treatment regimens in geriatric patients.     

Addressing the quality of life needs of older patients with cancer: a SIOG consensus paper and practical guide

Around 60% of people living with cancer are aged 65 years or older. Older cancer patients face a unique set of age-associated changes, comorbidities and circumstances that impact on their quality of life (QoL) in ways that are different from those affecting younger patients. A Task Force of the International Society of Geriatric Oncology recommends and encourages all healthcare professionals involved in cancer care to place greater focus on the QoL of older people living with cancer. This paper summarizes current thinking on the key issues of importance to addressing QoL needs of older cancer patients and makes a series of recommendations, together with practical guidance.     

Management of castrate-resistant prostate cancer in older men

Prostate cancer is the most common cancer diagnosed in men with the highest incidence in older men. Older men are more likely to present with metastatic disease compared with younger patients and eventually all will develop castrate resistant disease. In recent years, a number of new treatment options have demonstrated survival benefits for metastatic castrate resistant prostate cancer. However, the lack of randomized trials directly comparing the different available options results in some uncertainty on how best to choose and sequence therapy. In this paper, we outline the therapeutic options available to men with metastatic castrate-resistant prostate cancer, including cytotoxic therapy, hormonal agents and bone-directed therapy. We focus particularly on the evidence for specific treatment options and the challenges faced in choosing the appropriate therapy for the older patient.     

Management of advanced colorectal cancer in older patients

Many elderly individuals have substantial life expectancy, even in the setting of significant illness. There is evidence to indicate that elderly individuals derive as much survival benefit as younger patients from standard chemotherapy approaches in advanced colorectal cancer. Effective treatments should not be withheld from older patients on the basis of age alone. Treatment decisions should be based on functional status, presence of comorbidities, and consideration of drug-specific toxicities that can be exacerbated in older individuals due to decreased functional reserve. Infusional and weekly fluorouracil (5-FU) regimens are better tolerated than bolus and monthly regimens. Oral capecitabine (Xeloda) reduces the frequency of a number of toxicities compared with bolus 5-FU, including stomatitis, a particularly debilitating toxicity in many elderly patients. The effectiveness and tolerability of oxaliplatin and irinotecan (Camptosar) appear to be similar in older and younger patients. Older patients can also receive bevacizumab (Avastin), although caution is warranted in those with cardiovascular disease. Overall survival in metastatic colorectal cancer improves with the availability of multiple effective chemotherapeutic agents. The full range of effective therapies in advanced colorectal cancer should be extended to elderly patients.     

Management of bladder cancer in older patients: Position paper of a SIOG Task Force

Median age at bladder cancer (BC) diagnosis is older than for other major tumours. Age should not determine treatment, and patients should be fully involved in decisions. Patients should be screened with Mini-Cog™ for cognitive impairment and the G8 to ascertain need for comprehensive geriatric assessment. In non-muscle invasive disease, older adult patients should have standard therapy. Age does not contraindicate intravesical therapy. Independent of age and fitness, patients with muscle-invasive BC should have at least cross-sectional imaging. Data suggest extensive undertreatment in older adult patients, leading to poor outcomes. Standard treatment for a fit patient differs between countries. Radical cystectomy and trimodality therapy are first-line options. Radical cystectomy patients should be referred to an experienced centre and prehabilitation is mandatory. Older adult patients should be considered for neoadjuvant and adjuvant therapy, according to guidelines. In urinary diversion, avoiding bowel surgery for reconstruction of the lower urinary tract significantly reduces complications. If a patient is unfit for or refuses standard treatment, RT alone, or TURBT in selected cases should be considered. In metastatic BC, older adult patients should receive standard systemic therapy, depending on fitness for cisplatin and prognosis. Efficacy and tolerability of immunotherapy (IO) appears similar to younger patients. Second line IO is standard in platinum pre-treated patients, with benefit and tolerability in the older adult similar to younger patients. The toxicity profile seems to favour IO in the older adult but more data are needed. Patients progressing on IO may respond to further systemic treatment. In metastatic disease, palliative care should begin early.