The emerging field of geriatric oncology is changing the way cancer is treated in elderly patients. Geriatric oncologists consider patients' overall health and customize treatments instead of using a one-size-fits-all approach. They are conducting more clinical trials with elderly patients to develop safer and more effective treatments. Additionally, they address social issues like transportation that have prevented some elderly from receiving care. This revolution in care has the potential to prolong survival and quality of life for many elderly cancer patients.

1. MATURE ADULT HEALTH
A Cancer Revolution
From weekly tea parties after
chemotherapy to more aggressive
and tailored treaments, the
emerging field of geriatric oncology
is changing the way doctors fight
cancer in elderly patients.
by Christopher Johnston
C
hemotherapy doesn’t usually offer a patient
much to look forward to. But Nancy Hull makes
sure to schedule her treatments at the Cleveland
Clinic for Wednesday afternoons, so she can partake of
the weekly high tea held in the bistro on the first floor of
the Taussig Cancer Center.
On a recent Wednesday, as a pianist tickled the ivories
of the lobby’s grand piano and the scent of apple cinna-
mon tea wafted through the bistro, Hull relaxed in the
sunlight from the floor-to-ceiling windows along Carn-
egie Avenue.
“It’s quiet,” sighs Hull, 66, of Cleveland, before pick-
ing up her cream puff. “It also provides a nice break
from the sterile hospital scene.”
Hull enjoys selecting her favorite from the more than
150 fine china cups and saucers kept in two tall cabinets.
Donated by Clinic employees, each set displays the name
of the giver’s loved one who was a victim of cancer. The
Clinic has treated nearly 2,000 cancer patients, their fam-
ilies and friends and Clinic staff to tea since February.
Most of the 120 tea tipplers on a recent afternoon
were elderly. While the event is not on the same scale as
the Boston Tea Party, it is symbolic of a gradually un-
folding revolution in health care.
Cancer patients 65 and older used to be treated the
same as anyone else, even though they have a different
physiology and different medical demands. But as peo-
ple live longer, the medical profession is confronting the fact that Now, the emerging field of geriatric oncology is incorporating
it has much more to learn about how to treat elderly cancer pa- elderly special needs into treatment. Geriatric oncologists are also
tients. Nearly 60 percent of newly diagnosed malignant tumors conducting more clinical trials on elderly cancer patients, pursu-
are found in people age 65 and older, according to the National ing more aggressive and more carefully tailored cancer treatments
Cancer Institute, and these older patients account for 70 percent for them, and addressing the barriers that have kept many older
of all cancer deaths. cancer patients from getting good care.
“There is a growing population who could potentially have can- In July, University Hospitals Case Medical Center opened its
cer and may be amenable to treatment,” says Dr. Elizabeth O’Toole, new geriatric oncology clinic in the Ireland Cancer Center. UH
director of MetroHealth Medical Center’s division of geriatrics and was one of eight cancer research centers to receive grants from a
palliative care. “But we’re not sure how best to treat them, because five-year, $25 million initiative of the National Cancer Institute
of the changes that occur in their physiology and psychosocial is- and National Institute of Aging.
sues, which make the decision-making process more difficult.” The program helps elderly patients with needs ranging from
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2. [Mature Adult Health]
physical therapy to help with prescrip- pational therapists. Pharmacy services are vene in those problems,” says Dr. Cyn-
tion management to psychological and included because many older patients suf- thia Owusu, director of UH’s new geriat-
social challenges. Two geriatric oncolo- fer from over-prescribed, under-managed ric oncology center. “In the long term, we
gists team up with a social worker and a drug therapies. expect that will translate into fewer recur-
nurse practitioner trained in both geriat- “We’ll be able to identify problems that rences of cancer and prolonged survival.”
rics and oncology and physical and occu- are peculiar to older patients and inter-
Virginia and Leland Sholl, of Pickerington,
enjoy tea and goodies after an
G eriatric oncologists are also look-
ing for ways to aggressively treat
cancer patients in their 80s and 90s.
appointment at the Taussig Cancer Center,
which holds a weekly “high tea.”
For many years, doctors advised can-
cer patients at that age against the rig-
ors of painful and sometimes debili-
tating treatments. The doctors figured
those patients probably didn’t have
much longer to live anyway, so why
make them suffer?
“Twenty or 30 years ago, people
would say, ‘Well, he’s 90. What are you
going to do with cancer?’ ” says Dr. Derek
Raghavan, director of the Taussig Cancer
Center at the Cleveland Clinic and chair of
the Clinic’s cancer division. “But now we’re
looking at 90-year-olds who quite reason-
ably might expect to live to 100.”
An 85-year-old woman with a breast
cancer lump that hasn’t spread could po-
tentially have been written off in the past,
Raghavan says. “If you don’t manage it
correctly, that breast cancer could spread
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3. [Mature Adult Health]
and kill her in two years,” he explains. “If
you do manage it correctly, you have the
potential for her to be alive 10 to 15 years
without recurrence.”
To help doctors treat elderly patients,
geriatric oncologists are working to en-
roll more elderly patients in clinical trials.
“People are starting to realize that older pa-
tients are different and should be treated
differently,” says Owusu. “So, we need to
design trials to address that.”
Elderly patients are often deemed too
frail to handle the side effects of many can-
cer drugs, so they’re excluded from intense
chemotherapy treatments and clinical trials
of new drugs, Owusu says. Only 9 percent
of patients in clinical trials completed over
the past several years were 65 or older, she
says. That means sufficient data doesn’t yet
exist for elderly patients, so their physicians
must extrapolate from data on younger pa-
tients when they decide on chemotherapy
or radiation treatments for elderly patients.
“When you design clinical trials that
way, you cannot conclude that the treat-
ments are applicable to all patients,” Owu-
su says. “So, we may be giving these elderly
patients substandard therapy.” Some on-
cologists even conclude that since a clin-
ical trial didn’t include any 70-year-old
patients, the drug may not be safe for the
elderly, she adds.
UH’s geriatric oncology clinic currently
has three studies under way involving pa-
tients age 65 and older. One is a clinical
trial for a new biological agent with min-
imal side effects for patients with breast
cancer. Another study will evaluate the
effectiveness and benefits of the geriat-
ric oncology program itself, to determine
whether its interventions better enable
patients to complete their treatments in
a cost-effective way with fewer complica-
tions than treatments by oncologists only.
The Cleveland Clinic is studying che-
motherapy treatments, which sometimes
suppress elderly immune systems. It’s
looking for drugs that are not too toxic
for the elderly but still effective. Ragha-
van recently managed a multicenter
study of single-agent chemotherapy for
breast, bladder and colon cancer pa-
tients. It incorporated detailed histories
of the elderly patients, including their
other medical conditions, from depres-
sion to dementia, and what kind of so-
cial support they have. The study also
tested how well they could clear the drug
from their blood system.
“It is a very important study at a nation-
al level,” Raghavan says, “because it will
allow us to tailor chemotherapy schedules
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4. [Mature Adult Health]
specifically for an older age population.” may well do things that are quite differ- sion and dementia. However, doctors can
Over the past five years, research has ent,” Raghavan says. adjust their treatments to take patients’
demonstrated that elderly patients can The studies revealed that while some other conditions into account.
tolerate the same treatment regimens ad- elderly patients experience no problems
ministered to younger patients, as long as
physicians carefully evaluate the patient’s
entire physical health, according to the
with cancer treatment, others suffer se-
verely from the side effects. The stud-
ies concluded that patients are less likely
D octors are also tackling some of the
simplest reasons that the elderly of-
ten do not get effective cancer treatment.
National Cancer Institute. to tolerate treatments if they suffer from Raghavan identified three in a paper pub-
“If their chronological age is not com- other medical conditions typically found lished last year. First, older generations’
mensurate with their physical age — so in the elderly, from heart or lung disease cultural perspective can lead them to view
they are a ‘young’ 80-year-old, say — you and diabetes to poor nutrition to depres- cancer as an embarrassment to their fam-
ilies, rather than a medical disorder that
needs assessment and treatment. “For
people who were born around World War
II or earlier, the whole thought of having
cancer was seen as a socially unaccept-
able condition,” Raghavan says. “You just
didn’t talk about it.”
A second factor is “medical protection-
ism,” when doctors are overly protective of
elderly patients. Some doctors who are not
experts in cancer care for the elderly believe
subjecting them to the rigors of chemother-
apy, radiation or clinical trials will result in
unnecessary suffering or experimentation.
Doctors may keep patients from receiving
care that will ultimately help them.
Raghavan’s third factor was the all-
too-typical situation of older people not
possessing the resources to access proper
medical care. For instance, they may live
alone and have no means of transport.
D espite recent improved and enlight-
ened approaches to cancer care for
the elderly in some quarters, Raghavan be-
lieves a tremendous effort is still required
to educate primary care physicians and
oncologists about the geriatric oncology
revolution. “The elderly need to be looked
at as a multitiered system,” he says. “Just
looking at age isn’t the way to go.”
Owusu, who joined the first class of ge-
riatric oncology fellows at Boston Univer-
sity’s medical school in 2002, is focused
on developing an abbreviated geriatric
assessment that can be administered in
the short time most physicians have with
their patients during regular office visits.
She says she would like to see every oncol-
ogist receive training in how to adminis-
ter geriatric assessment tools. She is also
optimistic that geriatric oncology training
programs will continue to emerge at ma-
jor medical centers throughout the U.S. to
meet the growing need as the baby boom-
er generation ages.
“We in medicine realized that we had
better start planning now and training
people to cope with this issue,” Owusu
concludes. “Because it’s going to be a huge
problem a few years down the road.” n
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