trevor a. jolly mbbs cancer and older adults: care and treatment november 19, 2015 why worry about...

Trevor A. Jolly MBBS

Cancer and Older Adults: Care and Treatment

November 19, 2015

Why Worry About Cancer As We Get Older

The Tsunami of Cancer and Aging

The US Population is Aging

1965 1985 1990 2005 2030

9.5

12 12.6 13.1

20US Population 65 and older

Population Age 65+ in North Carolina, 2000

12% or less

12.1% to 13.0%

13.1% to 14.4%

14.5% to 15.9%

More than 16%

Mean = 12.0%.

Range = 6.3% to 23.6%

Population Age 65+ in North Carolina, 2030*

12% or less

12.1% to 13.0%

13.1% to 14.4%

14.5% to 15.9%

More than 16%

Mean = 17.7%.

Range = 10.5% to 35.2%

*Based on July 2006 population projections

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4

5

1 Cellular Water2 Kidney Blood Flow3 Maximum Breathing Capacity4 Nerve Conduction Velocity5 Heart Output

Age (years)

Percent Reserve Capacity

Remaining

100

80

60

40

20

00 20 40 60 80

Organ Reserve and Age

Baker and Martin, Geriatric Medicine, 1996

Comorbidity and AgePrevalence of various comorbid ailments by severity across the age spectrum.

Piccirillo et al. Crit Rev Oncol Hematol. 2008 Aug;67(2):124-32.

Dementia Heart Failure

Prior Cancer HIV/AIDS

Diabetes Hypertension

Erikson, C. et al. J Oncol Pract; 3:79-86 20070

Age-specific cancer incidence rates/100,000 year 2000

The Median Age of a Cancer Diagnosis in US

is 67 !

Cancer incidence and Age

Cancer Mortality and Age

Smith B D et al. JCO 2011;29:4647-4653

Cancer Survivorship and Age

18 Million Cancer Survivors Projectedin 2022

Projected Future Need for Geriatricians

The Present:1 Geriatrician: 2620

The Future: 1 Geriatrician: 3798

2000 2010 2013 2020 2030 2040 20500

1000

2000

3000

4000

5000

6000

7000

8000

9000

Year

Num

ber

of G

eria

tric

ians

Projected future need for geriatricians in 2030: 30,623

AGS: Geriatric Workforce Policy Study Center

Important Points• The US population is aging• Cancer is associated with age• The number of older cancer patients and survivors

will increase• The majority of cancer mortality occurs in older adults• Other medical conditions increase with age• There are not enough geriatricians to care for older

adults with cancer.

Assessing Older Adults

Assessing Older Adults

• Oncologist– General

– Chronological age– History and Physical Examination

– Functional Status– Karnofsky performance status– Eastern Cooperative Oncology (ECOG) Group performance

status

Age

Tumor CharacteristicsPerformance status

Age

Function deficits

Comorbidities

Nutritional deficits

Psychosocial dysfunction

Polypharmacy

Falls

Cognitive impairment

Social Support

Organ function

The Geriatric Oncology Iceberg

Geriatric Assessment….

The Value of Geriatric Assessment

Uncovers problems not found routinely Many problems have beneficial

interventions– Improve function– Quality of life– Survival

Allows for accurate life-expectancy estimate Can predict cancer related toxicity

Brief Geriatric AssessmentDOMAIN ASSESSMENT MEASURE

Health Professional Self Reported

Functional Status

Timed Up and GoKPS- Physician Rated

Activities of Daily Living (ADL)Instrumental Activities of Daily LivingKarnofsky Self ReportedNo. of Falls in the last 6 months

Co-morbidityNumber /Type of Comorbid ConditionsNo. of MedicationsVision and Hearing Assessment

CognitionBlessed Orientation

Memory-Concentration

Psychologic Mental Health Index-17

SocialSocial Activity Limitation Measure (MOS)Social Support Survey (MOS)

Nutrition BMI Unintentional Weight Loss 6 mths

10 minutes

20-30 minutes

Deficits in Normal PS Patients

Frequency (%)

Professionally-Assessed KPS 

 Patient-Rated KPS

<50 

60-70 

80-100 

Total 

<50 8 (0.8%) 3 (0.3%) 8 (0.8%) 19 (2%)60-70 10 (1%) 38 (4%) 89 (9%) 137 (14%)80-100 4 (0.4%) 28 (3%) 796 (81%) 828 (84%)Total 22 (2%) 69 (7%) 893 (91%) 984 (100%)

Sarcopenia….

Molecular Aging….

p16 (CDKN2A)

Cyclin-dependent kinase inhibitor 2A – inhibits CDK4

Codes tumor suppressor protein– helps regulate the cell cycle

mutations increase risk of developing a variety of cancers

Increased expression with aging Ned Sharpless UNC world expert

Interventions….

Walking Intervention• Leigh Callahan UNC• Effective in Arthritis

↓ pain and stiffness

• ScalablePt sets pace

Can do anywhere

• Goal 30 min 5 x weeks• Pilot trial In AI and now

R-21 randomized trial

HBM/June 2014

1/22/15

Thank You!