Enrique Soto Pérez-de-Celis and Ana Patricia Navarrete-Reyes work at the National Institute of Medical Science and Nutrition Salvador Zubiran, Mexico City. They tweet at @EnriqueSoto8 and @patsnavarrete
Although cancer can affect any person, regardless of their age, most people with cancer and most cancer survivors are older adults. Cancer is a disease of ageing, and in an ageing world, the role of the geriatrician in the management of the older adult with cancer is progressively becoming more and more relevant.
Between 2010 and 2050, older adults will represent the age group with the highest proportional expansion in the world. While the population of people younger than 64 will increase 0.2-fold, those over 65 will increase 1.8-fold. Even more alarming is the fact that the number of people aged 85 or older will increase 3.5-fold. As a matter of fact, by 2050 21.1% of the world population will be over 60 years of age, and 392 million people will be aged 80 years or over (the “oldest old”). This change in the demographic structure of the world’s population will inevitably bring a dramatic increase in the incidence of diseases associated with aging, cancer among them. This will be particularly challenging for low and middle income countries, since 8 out of 10 of the world’s older adults will live in the less developed regions of the world, where poverty and poor coverage by social protection systems are a pressing issue.
According to the projections published by the WHO and the GLOBOCAN in 2012, the number of incident cases of cancer (excluding non-melanoma skin cancer) will rise by 39% in people younger than 65 by the year 2035. On the other hand, for people aged 65 or older, this increase will be of 104%, with an estimated number of new cases of cancer among older adults of 13,689,934 in the year 2035 alone. This will inevitably transform the practice of all oncologists into a de facto geriatric oncology practice, and as such, the entire workforce will have to prepare for this “silver tsunami”. In 2013, The Institute of Medicine (IOM) of the National Academies of the United States published the report entitled: “Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis”. In this report, the IOM underlined the fact that, in face of an ageing population and with a projected shortage in the number of providers with geriatric expertise, more emphasis on educating all members of the healthcare system in geriatric aspects of care was needed. Although in European nations, such as the UK, the number of geriatricians is high (with some regions having 1 geriatrician per 46,000 of the population), the predicted workforce requirement for oncologists is of a minimum of 500 posts, according to the Royal College of Physicians. However, in the United States, the demand for both oncologists and geriatricians far exceeds the supply, and this is even more of a problem in developing countries, were the shortage of specialized physicians is critical.
In the context of a worldwide workforce shortage and a rising vulnerable patient population, there is an increasing need to place a substantial focus on healthcare infrastructure in order to provide skilled care for older adults with cancer. A possible solution to this issue is to develop multidisciplinary teams guided by geriatric principles in which several healthcare professionals (physicians, nurses, rehabilitation technicians, nutritionists and social workers) can interact with the patient and his/her caregivers in order to deliver comprehensive, efficient and patient-centered care. In this model, members of the cancer care team can coordinate with each other and with other geriatric care teams in order to develop interprofessional education programs aimed at both, the rest of the workforce and the caregivers. Achieving such a model, of course, requires an increase in the geriatric training provided to healthcare providers during their education, and this should be one of our priorities going forward.
In our Institution (@geriatriainnsz), we have developed a multidisciplinary team aimed at providing comprehensive care for older adults with cancer. Our Cancer Care in the Elderly Clinic aims to be a highly functional model of a geriatric oncology clinic in the setting of a public academic hospital. Each patient is evaluated by medical oncology, geriatric medicine, nutrition and rehabilitation medicine. The patient is classified according to the stages of aging described by Balducci as fit, vulnerable or frail based on a comprehensive geriatric assessment. Fit patients have the highest level of health and are candidates for almost any cancer treatment with good outcomes. Frail patients have multiple comorbidities, geriatric syndromes and disability for activities of daily living and can be expected to have very poor outcomes during treatment. Vulnerable patients have some dependence in one or more instrumental activities of daily living and one geriatric syndrome. These patients require the most individualized approach and may have some benefit from modifications of the treatment plan in order to achieve a good outcome. Our team provides the treating oncologist with feedback regarding the functional status of the patients, as well as with recommendations regarding modifications of therapy. Additionally, we assess the priorities of the patient and help in establishing a patient-centered and goal oriented treatment plan.
Today we know that factors other than chronological age predict morbidity and mortality in older adults with cancer. Functional status, comorbidities, nutritional status, cognition, psychological state and social support are all part of a very complex array of interactions that influence the way in which older adults tolerate both cancer and its treatment. Using a comprehensive geriatric assessment we can better understand the “functional age” of cancer patients and uncover problems which are usually not detected by a standard clinical interview. Additionally, we can use these tools to better predict the risk of side effects related to cancer treatments and to implement interventions aimed at improving patient outcomes.
In the next decades, we will be faced with the enormous challenge of providing high quality healthcare to an aging population. Although it is unrealistic to believe that someday every older adult with cancer will be treated by a geriatric oncologist, we should make every effort to offer geriatric training to all healthcare professionals and to create bridges between geriatrics and other medical specialties. By implementing multidisciplinary models, we must attempt to incorporate geriatric assessment into standard practice in order to better inform decision making and reach the goal of providing all older adults with cancer with personalized tailored care utilizing evidence based medicine with a comprehensive approach.
Picture credit: Paulisson Miura via flickr