trevor a. jolly mbbs cancer and older adults: care and treatment november 19, 2015 why worry about...
TRANSCRIPT
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
123
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!