Abstract
As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient’s vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians—a shared care approach between surgical oncologists and geriatricians is required.
Highlights
Cancer is a disease of older people, with the incidence of the majority of cancers increasing with age [1]; the highest rates of cancer cases in the UK population in 2015–2017 was in the age group 85–89 years [2]
primary endocrine therapy (PET) should only be given to patients with a life expectancy of
The Patient-Centered Outcomes Research Institute (PCORI) has invested a significant amount in patient-centred research that targets the needs of older adults. They suggest that when comparing the benefit of two interventions in older adults the following should be considered: absolute risk difference, competing risks, life expectancy, the difference between chronological and physiological age, and patient preferences [27]. This topic of considerations of trial design in older adults with cancer has been summarised by Soto-Perez-De-Celis and Lichtman [28] who agree with expanding eligibility criteria, designing trials for frail individuals, selecting more realistic endpoints and utilizing novel trial designs such as allowing patients to choose between treatments with their surgeons and geriatricians as well as using components of geriatric assessment (GA) within clinical trials
Summary
Cancer is a disease of older people, with the incidence of the majority of cancers increasing with age [1]; the highest rates of cancer cases in the UK population in 2015–2017 was in the age group 85–89 years [2]. In this article we will discuss the main issues facing surgical oncologists and geriatricians at the present time including the differing evidence base upon which to make treatment decisions in older compared to younger adults, as well as how to select the right patient for the most appropriate treatment. We will discuss the concept of patient optimisation, where surgical treatment is deemed the most appropriate option and focus on developing the relationship between the surgical oncologist and the geriatrician. This article is not intended to give a systematic review of the literature on each subject but rather a comprehensive overview of the topic as a whole
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