Speakers:
William A. Satariano, Ph.D., M.P.H., University of California, Berkeley
Hyman B. Muss, M.D., University of Vermont, Fletcher Allen Health Care Center
Co-Chairs:
Hyman B. Muss, M.D., University of Vermont, Fletcher Allen Health Care Center
Kathy S. Albain, M.D., Loyola University Medical Center
Introduction
Aging-related health problems are common in newly diagnosed older cancer patients given that the median age range for most tumors is 70–74 years. To ensure high-quality cancer care, the health status of the aged host prior to the diagnosis of cancer must be considered. Participants in Working Group 3 considered the need to assess the influence of concurrent and previous illnesses on the course of cancer treatment in older patients and approaches to evaluating them.
In his introductory presentation, Dr. William Satariano summarized the potential impact of comorbidity (i.e., the presence of one or more health problems) on the cancer trajectory by noting that:
- Comorbidity elevates the risk of disability and death among cancer patients,
- Comorbidity is associated with the receipt of less definitive cancer therapy, and
- Less definitive therapy is associated with poorer outcomes after adjustment for comorbidity.
Many newly diagnosed older cancer patients have experienced age-related, chronic health problems of various types—such as heart disease, pulmonary disease, diabetes, osteoporosis, arthritis, and hypertension—and degrees of severity before a diagnosis of cancer. Older persons may also have preexisting abnormalities of peripheral nerves, mental status, and cardiac function; geriatric syndromes, such as frailty, urinary incontinence, and balance disorders; other age-related limitations, such as physical disabilities; and restricted functional reserve capacity in certain organ systems, such as decreased renal excretion.
Yet, chronological age should not serve as a proxy for comorbidity. Given the heterogeneity of the aging processes, a particular older patient may have numerous, some, or no age-related health problems and/or disabilities.
Fundamental mechanisms of the body decline progressively at different rates with age, giving way to a gradual incapacity for maintenance and repair. A specific age threshold cannot serve as a guide to treatment decisions.
The health status of older persons diagnosed with cancer and the severity of their concurrent problem conditions need to be assessed in conjunction with therapeutic decision making, which will result in better care for older patients. Comorbidity assessment can be applied in the public health domain (e.g., in oncology practice, in primary prevention, screening, and promotion of quality of life) as well as in research investigations (e.g., in clinical trials, epidemiologic studies, cancer control studies).
Methods of producing reliable information to enhance the diagnostic acumen of oncologists in the management and evaluation of older cancer patients are urgently needed. Assessment of the impact of preexisting health problems and conditions on the cancer treatment course of older patients is crucial to providing high-quality care to older individuals who are newly diagnosed with cancer. However, little information exists on the interaction between the older cancer patient's prediagnostic health status and the malignancy.
Research Questions
- How do older patients' comorbidities affect their tolerance of the additional stress of cancer treatment and survival?
- How are the atypical presentations of disease, fluctuating health problems, wavering nutritional status, and multiple medication usage that often characterize older persons addressed in cancer therapeutic planning?
- What is the impact on cancer treatment and recovery of the preexisting diseases and conditions that older persons are likely to experience?
- How are concomitant diseases and conditions managed in the course of cancer treatment?
- What is the impact on the therapeutic regimens prescribed for patients' preexisting illnesses and conditions, given the urgency for cancer treatment, and how might these regimens interact with cancer therapies?
- Do specific tumors require special comorbidity research questions due to their anatomic location, biologic behavior, disease stage, and effect on patients?
Learning the extent to which comorbidity increases risk of adverse treatment effects is essential. The severity of tumor stage and morbidity, together with the treatment modalities, must be carefully considered in relation to the age-associated comorbidities of older persons with cancer. The research goal is to develop optimum ways to characterize before cancer treatment the nature, severity, and likely effects of comorbidities in order to offset and reduce any deleterious impact of the patient's other health problems on the cancer course. The more the individual's comorbid health status is understood, the greater the chance of optimum treatment of the malignant tumor and of optimum recovery.
Cancer Center Role
The unique cancer center infrastructure and its critical mass of multidisciplinary expertise provides an ideal research setting for meeting the challenges inherent in characterizing the comorbidity burden of older cancer patients and its impact on cancer care and treatment. The disproportionate burden of cancer in the elderly is poorly understood and needs attention from a focused research community, which the cancer center research environment can provide. This will ensure creative development of comorbidity assessment technology.
Research Priorities
Participants in Working Group 3 identified three interdependent research priorities. Priority 1 is fundamental to the research proposed in priorities 2 and 3. The objective of all three priorities is to develop reliable and valid clinical assessment methods for physicians in oncology practice and clinical research.
- Develop a validated comorbidity assessment instrument that is user-friendly, efficient, culturally sensitive, and reasonable in cost. Comorbidity assessment is a newly emerging area of opportunity to apply cancer center leadership, expertise, and coordination to the issue of comorbidities in elderly cancer patients.
- The technology of assessment development requires a solid conceptual and clinical base.
- Scientific development of assessment technology within a network of cancer centers facilitates collaboration among experts from a wide range of relevant professional and disciplinary fields.
- Highly motivated multidisciplinary professional teamwork can lay the groundwork for a new level of technology for application to older cancer patients.
- The cancer center network provides the continuity needed to launch different levels of investigations, including instrument pretesting, feasibility assessment of administration in the clinical setting, and pilot demonstration studies. The design and testing recommended in priority 1 would be implemented in the applications suggested in priorities 2 and 3.
- Ascertain the impact of comorbidity on patient care and outcome. Cancer centers are intended to enhance the potential of institutions for discovery and its application to patients and the population at risk. Whether the impact of comorbidity should be assessed in the population base versus cancer center catchment areas needs to be determined. How comorbidity affects overall patterns of care in older patients and the differences in cancer treatment should be assessed.
- From a provider-driven perspective, the hypothesis is that systematic differences exist between treatment patterns, depending on whether the care is delivered from within a cancer center or from the community. Differences are largely attributed to comorbidity, frailty, and antiaging bias among cancer center providers or to the referral of patients to (or acceptance of patients by) cancer centers.
- The concerns of patients compared with those of professional cancer providers are complementary to the systematic differences between treatment patterns. The effect of patients' perceptions of their comorbidities on physicians' decisions about diagnostic evaluation, treatment, and outcomes needs to be identified. How these issues differ in medically underserved and minority populations must also be determined. Data-driven models are needed that incorporate severity and type of comorbid conditions, number and interaction of comorbidities, tumor stage and other disease parameters, previous malignant primary tumors, active (i.e., functional) life expectancy, and overall life expectancy.
- Who will benefit needs to be addressed. Specifically, research is needed on the age, stage, and other parameters at which treatment is of less value for older patients (e.g., conditional profiles) and how to discern whether short-term and long-term effects of toxicity diminish the benefits of treatment.
The impact of comorbidity on the selection of optimal care, as discussed in this priority, is congruent with the research priorities recommended by other working groups (e.g., the Patterns of Care and Efficacy of Treatment and Tolerance working groups).
- Develop predictive models to allow individual treatment decision making, with a focus on prevention and adjuvant therapy.
- Predictive models are intended to provide first for individual treatment decision making in the clinical setting.
- Models with a focus on adjuvant therapy and prevention are also important and will build on the predictive primary therapeutic models.
- The models should be constructed so as to be clinician friendly and enhance interactive communications among oncologists, primary care practitioners, and geriatricians for optimum decision making. The aim is to incorporate comorbidity assessment into initial cancer patient evaluations.
Research Barriers
- No gold standard or universally accepted assessment tool exists for comorbidity measurement. There are various means of collecting data on patient comorbidity from patients (i.e., self-reports), patient medical records, and administrative databases (e.g., hospital-based discharge data).
- Developers of the assessment tools used for various purposes are invested in and loyal to their methods. The tools used for clinical geriatric assessment tend to be excessive in length (requiring several hours or more) and not suitable for clinical oncology assessment.
- Comorbidity assessment in clinical research is complex. Research methods need to be consolidated, and a research infrastructure must be created to develop methods for incorporation into cancer treatment and care research. This is difficult to achieve, given the perception that comorbidity assessment is an unfunded mandate.
- An antiaging bias may exist in many cancer centers, expressed in the assumption that older patients have comorbid conditions or other factors related to aging that make them unable to withstand treatment or likely to respond poorly to treatment.
- Personnel, an appropriate infrastructure for comorbidity assessment development, and encouragement and support for multidisciplinary interaction are needed. The priority level of comorbidity assessment research needs to be raised.
- Even though comorbidity assessment of older cancer patients has evoked more interest in recent years, technology and methods development lag far behind the growing clinical- and population-based research needs.
