Senior Adult Oncology: Three Cases of Advanced Cancer in Patients of Advanced Age

Abstract

The American Cancer Society reports that more than 60% of all cancers and 80% of cancer-related deaths in the United States occur in patients older than age 65 (1,2). Epidemiologic data show that the likelihood of developing certain cancers in older age is higher than in younger individuals, and intuitively, this stands to reason, due to physiologic factors, time for the expression and development of genetically-related cancers, and a longer range of environmental exposures. However, many cancers may be more difficult to treat in older individuals due to higher incidence of medical co-morbidities, as well as the biology of certain tumors themselves. Heterogeneous behaviors of several cancers manifest as unique situations in elderly patients across a broad spectrum, including on average, more indolent estrogen-receptor-positive breast cancers, as well as more drug-resistant acute leukemias which may arise on a background of a long history of myelodysplasia. In addition, optimum dosing and prediction of treatment toxicity remains a difficult question, as older cancer patients are not well represented in clinical trials, for which often the inclusion criteria list a maximum age of 70. Furthermore, many cancers such as hematologic malignancies, may not be able to be treated with maximum aggressiveness such as high-dose chemotherapy followed by stem cell transplant or autologous stem cell rescue as would be tolerated by younger individuals (usually under the age to 60–65). In our quest as physicians to “first do no harm” (3,4), we wrestle with our best recommendations for our elderly patients, often in the face of frail physicality and potential for increased risk of infection and iatrogenically-induced side effects and morbidity. We present here 3 cases of advanced cancers in patients of advanced chronologic age, who also exhibit multiple medical co-morbidities. Their situations likely warrant specifically tailored treatment given their age, which would be markedly different if they presented in earlier decades of life. We pose the following clinical questions: (a) What treatments would you offer/feel comfortable offering these patients? (b) What factors are important in arriving at these decisions between and among the physician, patients, and families? (c) What modifications would you make to standard treatments if indicated for these particular patients?