Issues surrounding cancer in the aging population were recently addressed by President Clinton's Cancer Panel in a public forum at the University of Michigan Turner Geriatrics Center. Researchers, clinicians, advocates, and other experts in the fields of cancer, geriatric medicine, and gerontology presented information to the Panel and public on critical issues shaping research and policy in this area. The President's Cancer Panel is a three-member, presidentially-appointed panel charged with examining the efficacy of the National Cancer Program by identifying barriers to its progress and making recommendations to the President.

A key issue raised was the need to develop a coordinated research agenda in the oncology and geriatric disciplines to address the impact that cancer in the aging population will have in the coming decades. The connection between aging and cancer is significant--more than 60 percent of all cancers occur among those over age 65. As the aging population increases and more people move into this high risk group-projected at 20 percent of our population (or 1 in 5 Americans) by the year 2030--there will be increasing burden of cancer in the elderly and more demands will be placed on the medical and research establishment to respond to this burden. Older-aged Americans are an important target population for cancer research and cancer control. The challenge now, as noted by the Panel, is to think ahead to better inform dialogue and policy tomorrow.

Another major issue brought to the attention of the Panel involved pharmacology and aging. There is a critical need to examine the pharmacological properties and toxicity of cancer drugs given to older patients, as well as to individualize drug therapy to address the diversity and changes in physiologic functioning that occur in older age. Molecular techniques for characterizing the ability of individuals to respond to various cancer drugs appear imminent, and could become very important. More attention must be paid to how the aging process affects individual response to anti-tumor drugs as well as to the management of other prescription and non-prescription medications given to the older patient for other health needs (i.e., comorbid conditions).

Many speakers indicated that cancer prevention, including chemoprevention, screening, and early detection, are not given enough attention in this population. Benefits can accrue from lifestyle changes at any age, i.e., regarding smoking, diet , exercise, sun exposure. Screening rates remain lower among the elderly, despite the high prevalence of cancer among this group. For example, less than 40 percent of women over age 60 report having a regular mammography, despite a higher risk of breast cancer. This was partly attributed to a lack of knowledge about the benefits of screening or the availability of health care benefits (i.e., Medicare, etc.), as well as the continued and sometimes confusing debate in the medical establishment about appropriate screening guidelines for older women.

A persistent theme throughout the day's discussion was the awareness that concurrent health problems--comorbid conditions--likely to be present in many older persons, influence therapeutic decisions and introduce an increased level of complexity in the management of older patients. In terms of cancer treatment, an underlying assumption appears to exist among clinicians that older persons cannot tolerate aggressive treatments. Based on data presented, it is the Panel's initial recommendation that clinicians carefully analyze individual patient physiology and response to seek the most appropriate and effective treatments based on those factors, and not on chronological age alone. As stated by Panel member Dr. Paul Calabresi, physicians should not be afraid to "push the envelope" and move ahead with any particular treatment, so long as it is appropriate for that individual.

Although drug toxicity is more common and severe with age, interesting developments in the use of hemopoietic growth factors were presented to the Panel as a means of mitigating toxicity. In the future, older patients may be able to look forward to better and more affordable cytoprotective and anti-nausea agents that enable better cancer treatment with less morbidity

The need for more clinical trials for older patients was addressed. Many older patients are automatically excluded from eligibility based on chronological age, when physiologically they may meet study criteria. Given that at least 60 percent of cancer patients are over 65, this age group seems to be an important group to target for clinical research. Unfortunately, the complexities of clinical research efforts focused on older Americans are largely unrecognized and, as a result, are unlikely to receive a high priority in the peer review process.

Issues of survivorship, supportive care, and education among the elderly were also presented to the Panel. Unique challenges face older-aged cancer survivors, including the existence of other comorbid conditions and issues of quality of life, social support, financial support, and long-term care. Some physicians are recognizing that cure by eradication of cancer may not be the only effective goal for older cancer patients, but that integrating disease control and palliative care may be equally successful. New models of supportive care being tested were discussed.

Although it has been accepted for some time that older people will get disease and are less likely to overcome it, it was clear from this Panel meeting that older Americans can and should look forward to improving their health and disease outcomes, the same as younger Americans. The Panel supports this position and recommends that collaborative efforts between geriatrics and oncology be strengthened and expanded.