Executive Summary

Cancer Burden for Persons 65 Years and Older

The workshop, Exploring the Role of Cancer Centers for Integrating Aging and Cancer Research, was organized by the National Institute on Aging (NIA) and the National Cancer Institute (NCI) to provide a forum for leaders in cancer and aging research to express their views on pressing research needs. Representatives from the NCI-designated cancer centers were invited to formulate research priorities specifically focused on persons 65 years and older, the age group most vulnerable to cancer and in which the highest cancer incidence and mortality rates occur.

Advancing age is a high risk factor for cancer. Close to 60% of all newly diagnosed malignant tumors and 70% of all cancer deaths are in persons 65 years and older according to the NCI Surveillance, Epidemiology, and End Results (SEER) program data for 1994–1998. The age-adjusted cancer incidence rate for persons 65 years and older (2151.2 per 100,000 population) is ten times greater than the rate for persons under 65 years (208.8 per 100,000 population). The age-adjusted cancer mortality rate (1068.3 per 100,000 population) for persons 65 years and older is over 15 times greater than the rate for persons under 65 (67.3 per 100,000 population). Pancreas, stomach, rectum, lung, leukemia, non-Hodgkin’s lymphoma, liver, kidney, and ovarian cancers account for two-thirds to three-quarters of cancer deaths in persons age 65 years and older. Over 75% of cancer deaths are due to urinary bladder, colon, and corpus uterine cancers. Breast cancer accounts for 59% of deaths in women in this age group. Ninety-two percent of prostate cancer mortality occurs in men 65 years and older.

Aging America

The cancer statistics showing the disproportionately high burden of cancer for older Americans take on even greater significance when cast against the changing demographics of the aging population in the United States. The number of older persons diagnosed with cancer is expected to increase because of the overall aging of the U.S. population and an unprecedented expansion of the 65 years and older age group in the next three decades.

Three factors contribute to our nation's changing age structure: changing mortality patterns, decreased fertility, and the aging of the baby boom cohort born between 1946 and 1964 (75 million persons). These factors, in particular the aging of the baby boom generation, will have far-reaching effects on the future overall health status and cancer burden of Americans. This phenomenon must be factored into our cancer research efforts. By 2030, 20% of the U.S. population will be 65 years and older. Age shifts within the 65 years and older segment of the population will increase the proportion of persons 85 years and older from our current 4.3 million to 8.9 million individuals over the next decades.

Workshop Objectives

Participants in the NIA/NCI workshop were asked to identify a concise set of priorities to address the aging/cancer research interface that were consistent with the research themes developed by the workshop planning committee for each of the seven participating working groups. They were to:

1. Identify promising scientific areas at the aging/cancer interface that could be pursued in the cancer centers given their unique resources and expertise.
    
2. Recommend opportunities in aging and cancer research that will advance medical progress at the aging/cancer research interface. Each working group was asked to select the top three research priorities.
    
3. Suggest various strategies and approaches for integrating aging and cancer research on behalf of older persons.

The focus designated by the workshop planning committee was on human cancer. Participants were encouraged to make recommendations for research implementation and research barriers as well.

Workshop Design and Participants

The NIA/NCI workshop was convened on the NIH Campus, Bethesda, MD, June 13–15, 2001. Two plenary sessions (held in the Lister Hill Center Auditorium) and the seven breakout groups (convened in the Natcher Conference Center) provided the forum and setting for brainstorming and the exchange of ideas and insights from participants. Each breakout group was Co-Chaired by two representatives from the cancer centers who were selected at the NIA/NCI workshop planning meeting. Seven scientific presentations were incorporated into the first plenary session to orient participants for their breakout group sessions. Breakout group reports were presented in the second plenary session.

Approximately 120 individuals—medical oncologists, geriatricians, health professionals, basic scientists, social scientists, epidemiologists, patient advocates, NIA and NCI staff, and others from relevant disciplines and professions participated in the NIA/NCI workshop. One or more participants, including 17 cancer center directors and senior program leaders, represented 44 of the 50 NCI comprehensive and clinical centers. Two of the ten basic science centers were represented. Dr. Richard J. Hodes, Director, NIA, and Dr. Richard D. Klausner, Director, NCI, welcomed workshop participants. Dr. John H. Glick, Director, University of Pennsylvania Cancer Center, chaired the workshop.

Research Themes and Priorities Identified

Many valuable suggestions were derived from the plenary and breakout group discussions. The full report identifies the domain of research issues and concerns that cut across institute, disciplinary, and professional boundaries and call for the integration of aging and cancer research. The Working Group Co-chairpersons, speakers, and themes are identified and abbreviated versions of the research priorities are indicated below.

Group 1. Patterns of Care [studies with a focus on older patients using both prospective and retrospective data that could include community-based studies, patient management, cancer site-specific studies, and maximizing existing data (e.g., SEER special studies, HCFA linkage, tissue banks, family network studies)]

Research Priorities:

1. Develop a key data matrix of content area items from relevant databases in the public domain that are pertinent to conducting patterns of quality cancer care research on the treatment of older patients. Some suggested databases include NCI SEER, Medicare, Managed Care, Insurance Encounter data, American College of Surgeons National Cancer Data Base, Veterans Administration studies, and Minimal Data Set reports in skilled nursing facilities.
    
2. Develop a dictionary of data elements (i.e., a compendium of items and their intended use) as a resource for investigators. While crafting geriatric assessments anew is not desirable, instruments are available that may be applicable to older cancer patients. Whether some instruments already exist that could be applied at the aging/cancer research interface should be determined.
    
3. Incorporate the clinical expertise from NCI projects, particularly the NCI SEER projects, that is available in cancer centers to improve the quality of care of the medically underserved, aging population. The cancer surveillance efforts should be enhanced to improve the clinical information base on cancer in older persons in SEER. NCI-designated cancer centers and NCI SEER registries that facilitate special studies on cancer in the elderly should be identified in strategic geographic locations.

Group 2. Treatment Efficacy and Tolerance [clinical trials, pharmacology of anti-cancer drugs, radiation therapy, surgery, available technology, other modalities, characterization of inadmissible older patients to clinical trials]

Research Priorities:

1. Develop predictive models for tolerance to therapy. Hypothesis-generating work should be done in focused trials with older cancer patients and coordinated by an interdisciplinary team of cancer and aging research specialists in the cancer center research environment.
    
2. Study tumor-host interactions as a predictor of outcome. This is complementary to, but distinct from, changes in tumor biology in older patients.
    
3. Develop clinical trials that are specifically designed for older cancer patients. Trials based in cancer centers could address issues that would not likely be addressed in NCI cooperative group clinical trials and would be more appropriate for the cancer center environment.

Group 3. Effects of Comorbidity on Cancer [studies could include problems of diagnosis and treatment, disability, functional limitations, assessment, recurrence, detection of second primaries]

Research Priorities:

1. 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.
    
2. 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.
    
3. Develop predictive models to allow individual treatment decision making, with a focus on prevention and adjuvant therapy.

Group 4. Prevention, Risk Assessment, and Screening [impediments for older-aged persons asymptomatic or with symptoms precluding their entrance to the preventive and health care system (e.g., delay behavior, insufficient knowledge of cancer risk), changes that occur in cancer risk as a function of aging]

Research Priorities:

1. Develop and test interventions to decrease screening barriers. Colon and rectum cancers should receive high priority because of their associated morbidity and mortality in the elderly and the lack of prior research in this area.
    
2. Conduct chemoprevention and lifestyle change trials to decrease dependency, deterioration in quality of life, and mortality. The effects of chemoprevention should be studied, beginning at different ages, to identify the optimal age to start enrolling cohorts and determine the agents that should be promoted.
    
3. Develop models for decision making at the individual and clinical levels, including population forecasting for specific tumors. Develop models of academic research and community networks.

Group 5. Psychological, Social, and Medical Issues [quality of life, quality of cancer survival, family and caregiver resources, early and late effects of treatment, quality cancer care, tumor recurrence, multiple primary tumors]

Research Priorities:

1. Develop a core set of instruments to assess the quality of life of older cancer patients. An individualized evaluation that includes functional status, activities of daily living, cognitive and emotional functioning, and socioeconomic status would standardize the assessment of older patients across cancer centers.
    
2. Examine the cancer caregiver's own functioning and quality of life and their impact on the older cancer patient's care and treatment trajectory. Caregiver strain is likely to be associated with the new primary responsibility for providing cancer care in the home setting.
    
3. Develop interventions to prevent or reduce the medical and psychological effects of cancer treatment in older adults. The prevalence of long-term medical and psychosocial effects should be determined.

Group 6. Palliative Care, End of Life Care, and Pain Relief [studies focused on patients with advanced cancer and associated issues in palliative care including caregiver and family support]

Research Priorities:

1. Organize descriptive work that is relevant to older cancer patients in a well thought out manner.
    
2. Develop and test service delivery models of care to provide palliative care to the elderly in a variety of contexts that include acute care, home care, and nursing homes.
    
3. Test and facilitate the use of evidence-based guidelines for pain relief and symptom control. Examine drug selection, pharmacokinetics, effects of drugs on surgery, and drug-drug interactions as they relate to agents for comorbidities, chemotherapy, and palliative care medications.

Group 7. Biology of Aging and Cancer [genetics, molecular signatures, bench to bedside application, translational research, age-related changes as they contribute to mortality, a focus on older persons who are vulnerable to cancer as contrasted with those who are not (e.g., sibship studies)]

Research Priorities:

1. Identify the processes and parameters of carcinogenesis in aging cells. Determine what to look for in cancer progression as it relates to aging.
    
2. Characterize cancers and cancer cells of the major tumors that are common in older persons. Determine whether the same types of cancer manifest themselves differently in older and younger hosts.
    
3. Explore elderly populations at low risk for cancer (i.e., with an age-resistant phenotype). Identify the genetic or epigenetic changes associated with this protective phenomenon. Conversely, develop insights into older cancer patients who are at high risk for multiple primary tumors. Identify the key shared predisposing or protective factors for development of multiple primary tumors.

Conclusion

The NIA/NCI workshop goal and outcome in research priority specification is an important step forward in the research planning and program development for the aging/cancer research interface. Creative ideas stemming from this workshop, which included scientists from diverse disciplines and professions, have the potential to produce groundbreaking research programs that facilitate collaborative studies to integrate aging and cancer research. The NCI-designated cancer centers are crucial in expanding the knowledge base on cancer in older persons. The cancer center workshop priorities encourage scientific productivity in critical areas on behalf of our nation's older citizens.

Organization of the NIA/NCI Workshop Report

A combination of expertise and rich ideas has produced the foundation for a research agenda directed at the complex interface of aging and cancer. The full report of the NIA/NCI workshop is organized into five sections:

1. Introduction
2. Goal and Objectives
3. Working Group Reports
4. Participant Roster
5. Appendices
   1. Agenda
   2. Speaker Abstracts
   3. Planning Committee Roster
   4. Cross-Cutting Issues in Working Group Reports