Geriatric oncology field comes into its own
Growing field advances but care questions remain
From a newly launched journal to recently developed professional education programs to an active multicenter research group, geriatric oncology's time has come, say leaders in the field. “The field is really growing, and the quality of research has improved,” says Arti Hurria, MD, director of the Cancer and Aging Research Program at City of Hope in Duarte, California. “It's why we felt a critical need for the journal.”
Dr. Hurria is the editor-in-chief of the new Journal of Geriatric Oncology, a quarterly that published its first issue in June 2010. Published by the International Society of Geriatric Oncology, the journal focuses on all aspects of geriatric oncology, including basic and clinical research, education, and policy development. “We felt a critical need to have a forum where experts in the field could review and publish research in a common place,” Dr. Hurria notes.
There is so much we need to do in the field quickly because of the rapid growth of the patient population.
—Arti Hurria, MD
Previously, research in the field was spread across several journals, which not only made it more difficult for readers to locate studies but also did not always enable articles to be reviewed by experts with dual expertise in geriatrics and oncology. The journal answers both of those needs, she says.
Among the variety of studies highlighted in the first issue were “Enhancing Geriatric Oncology Training to Care for Elders: A Clinical Initiative With Long Term Follow-Up,” “Cognitive Effects of Androgen Deprivation Therapy in an Older Cohort of Men With Prostate Cancer,” and “Cancer in Nonagenarians: Profile, Treatments and Outcomes.”
A Recently Growing Area
Dr. Hurria, who is dually trained in geriatrics and oncology, says the field is finally gaining a critical mass that is enthusiastic about advancing research. Lodovico Balducci, MD, one of the original leaders in the field, agrees. He is senior adult oncology program leader at the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida. He also is an author of 5 texts on geriatric oncology, including the first textbook in the field, Geriatric Oncology (Springer-Verlag NewYork, LLC, 1992), and NCCN Clinical Practice Guidelines in Oncology: Senior Adult Oncology.1
“Twenty years ago, the field was grossly underexplored,” Dr. Balducci notes. But that scenario gradually has evolved over the years, beginning with a joint symposium held by the National Cancer Institute (NCI) and National Institute onAging (NIA) in 1983 to explore the prevention and treatment of cancer in the elderly.
“There was very little written in the field when I first founded our program in 1993, but now many more people are interested,” Dr. Balducci says. “There are a lot of important biological and clinical issues that need to be addressed, including why cancer is more common in older people and whether cancer is different in older people versus younger people.”
One group that has emerged as a result of this growing focus is the Cancer and Aging Research Group, which held its first meeting in 2007, supported by City of Hope and the John A. Hartford Foundation. That meeting, held in collaboration with the NIA and NCI, brought together junior investigators in the field from across the country along with a senior mentoring team.
The Cancer and Aging Research Group's goal is to improve care for the elderly population over the next 10 years by encouraging collaboration among investigators in geriatrics and oncology, developing education and training initiatives, and generating newresearch. The group has identified 3 priority areas:
Assessment of physiologic age being included in all clinical trials of people age 70 years and older;
Studies to evaluate the pharmacology of new cancer therapies in older adults (for example, agerelated changes in kidney function may affect the pharmacokinetics and pharmacodynamics of cancer therapies); and
Research into the long-term impact of cancer therapy on older survivors.
“There is somuchwe need to do in the field quickly because of the rapid growth of the patient population,” Dr. Hurria notes.
Geriatric Oncology Patients and Clinical Trials
Because older patients are routinely excluded from phase 1 and 2 clinical trials, little information is available concerning the basic pharmacokinetics of new drugs in these patients. Furthermore, older patients comprise only 30% of those enrolled in clinical trials, according to the May/June 2009 issue of City of Hope's Physician's Bulletin.
Researchers must take into account that clinical trial design and research methodology may be different for this population as well, Dr. Hurria notes. She and another researcher, Martine Extermann, MD, presented separate studies this year at the American Society of Clinical Oncology (ASCO) annual meeting on predictive models that use various factors to determine which older patients are at highest risk for chemotherapy toxicity.
There are a lot of important biological and clinical issues that need to be addressed, including why cancer is more common in older people and whether cancer is different in older people versus younger people.
—Lodovico Balducci, MD
“Two people may both be in their 70s, but one can be much older physiologically than the other,” Dr. Balducci notes. “Some of the factors we consider in age assessment are functional independence, comorbidities, and social support. Age alone shouldn't disqualify people from receiving curative or life-prolonging treatment.”
Another question to be addressed through research is whether older people benefit from cancer screening. “I advise any woman with a life expectancy of 5 years or more to have some form of breast cancer screening,” Dr. Balducci says. “I also advise colon cancer screening because [colon cancer] becomes more frequent with aging, and it's better to diagnose it early.”
Studying cancer in older patients can be quite complex, he adds.The disease can bemore aggressive in older patients in some cases (for example, acute leukemia) and less aggressive in others (such as breast cancer). Older patients also can be more susceptible to carcinogens,which may help explain the 7-fold increase in brain tumor incidence noted between 1970 and 1990 among people in their 70s.
Although many scientists previously believed research should be focused primarily on helping young people with cancer to prolong their lives, that mindset is changing, experts agree. “Cancer may not kill a patient for years, but it may cause a lot of pain,distress, and fatigue,” Dr. Balducci says. “And with people living longer, prolonging an active life is important.”