1017 Geriatric Oncology 0. J. Kennedy, M.D? Harvey Jay Cohen, M . D . ~ , ~ University of Minnesota Medical School, Minneapolis, Minnesota. Duke University, Durham, North Carolina. Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina. C Address for reprints: B.J. Kennedy, University of Minnesota, Division of Oncology, 420 Delaware St. SE, Box 286, Minneapolis, MN 55455. Received November 24.1995: accepted December 1. 0 1996 American Cancer Society ancer is a major cause of death and morbidity in older persons, with 60% of new cancer cases occurring in Americans aged 65 years or older, and more than 50% of cancer deaths occurring in persons older than 70 years of age. When the average baby-boomer becomes 70 years old in the year 2020, the population will have increased 12% over that of 1990,but the total cancer incidence will have increased 60%.' This disparity between population growth and total cancer occurrence is due to the large proportion of the population being in the older age groups that have a substantially increased risk of developing cancer. The problem is magnified by the rapid population growth that will occur over the next decade among those older than 85 years of age. Because cancer is predominantly a disease of older persons, cancer care for the elderly will become a significant medical, public health, economic, and social challenge. Recognizing this impending problem, the Hartford Foundation has sponsored a new initiative to integrate geriatrics and gerontology into the subspecialties of internal medicine.' Medical oncology received a high priority. Funded by a grant to the American Geriatrics Society, efforts have already begun utilizing the mechanism of the Geriatrics Education Retreat involving each of a number of medical subspecialties, such as endocrinology, cardiology, infectious disease, and oncology. The plan of the retreat is to bring together geriatricians and subspecialists in internal medicine whose teachings, research, and clinical interests already reflect the geriatric aspects of their subspecialty with others in the individual subspecialty who can influence the training curriculum of that subspecialty. The goal is to establish the appropriate curriculum content of geriatrics within subspecialty training to enrich the education of medical students, residents, fellows, and practitioners in those special aspects of caring for the elderly in their subspecialty, reflecting the ever-aging demography of patients under their care. The initiative derived from the recognition that subspecialists not only will be involved in the care of a progressively aging, complex, and challenging population, but also will be the principle teachers of future trainees in the subspecialties in American academic health centers. These retreats will also attempt to address which important areas of research are needed to continually improve the care for older persons in that subspecialty domain. The concept of who is an older patient has changed over time, espe- 1018 CANCER March 15,1996 / Volume 77 / Number 6 cially with the increasing life expectancy of the U.S. population. Although traditionally age 65 years and older has been considered “elderly,” from the medical perspective, it’s probably more reasonable to regard patients older than age 75 as old and those older than age 85 as the oldest old. It is at these more advanced ages that the impact of age related physiologic changes, as well as the increasing comorbidities seen with increasing age, tend to make their greatest impact on the care of the individual with a new d i ~ e a s e . ~ The care of geriatric patients should be a collaborative activity involving generalists such as internists, family physicians, geriatricians, and orher specialists. Although the overall care for such individuals may be delivered by the generalist, when such a patient contracts a new and dominating disease (for example, cancer), care is often shared between the generalist and subspecialist. Thus, it becomes incumbent upon the subspecialist, as well as the generalist, to have a working knowledge of the biologic, physiologic, psychologic, and socioeconomic changes that occur during the aging process. This becomes critical for the effective management of such patients. Accurate knowledge of issues such as the actual life expectancy for patients at advanced ages (for example, that a 70-year-old woman has an additional life expectancy of more than 15 years), and changes in physiologic function (for example, renal function changes affecting drug excretion, hepatic changes affecting drug metabolism, and other changes relevant to drug toxicities) will be important if we are to improve care for the geriatric patient .’,4 The developing and increasing knowledge of aging and the care of older persons is increasingly being incorporated into general medical training. It is anticipated that an increased research focus in this area will help obtain a more desirable quality of life with aging, and that an emphasis on preventative and positive measures can shorten the later period of morbidity. However, it is quite clear that a major cancer load will persist well into the 21st century, even if attempts at prevention are a major success. The importance of the care of the older person in oncology was recognized more than 25 years ago when the subjects of relevance to medical oncology training were specified, but this area has not received a great deal of attention in most training programs, and indeed in most oncology specialty programs.’ For these reasons, it was felt that a Geriatrics Education Retreat in oncology would be of special importance. The retreat is currently being planned under the auspices of the above mentioned grant, inviting national leaders in the subspecialty of oncology along with geriatricians and oncologists who have already been working at the interface of cancer in the elderly patient. The format will include didactic ses- sions to share the status of our knowledge about elderly cancer patients and small group interactive sessions to discuss the best ways to integrate current knowledge into clinical training programs, as well as the best ways to increase the breadth and depth of our knowledge through clinical and basic research. There are many other issues that must be considered. For example, it has already been recognized that a large portion of older patients are never seen in academic medical centers and teaching hospitals. Therefore, trainees frequently do not see enough older oncology patients, resulting in minimal experience and comfort in dealing with the problems mentioned above. Thus, considerations of oncology training will need to include methods of reaching out into the community to allow greater exposure of trainees to the older population. Similarly, clinical research studies and clinical trials must involve the community, and design trials appropriate for older patients that can be used in the settings in which older patients may prefer to be treated. It is hoped that this effort will be only part of an overall attempt to address means to optimize cancer treatment for older adults. Other mechanisms that could be invoked would include an increased focus of attention on geriatric oncology at national meetings, such as the American Cancer Society, the American Society of Clinical Oncology, and the American Association for Cancer Research, as well as the formation of a council on geriatric oncology similar to that which has been formed in geriatric cardiology, and an increased focus of attention by the cancer cooperative groups on this issue. The Cancer and Leukemia Group B, for example, has recently formulated a working group on cancer in the elderly to catalyze clinical research in this area for the cooperative group. The National Institute on Aging and the National Cancer Institute, as well as other agencies such as the Agency for Health Care Policy and Research, have had working group meetings on this subject and have proposed funding initiatives that could stimulate clinical research activities. We suggest that there are many valid reasons for an emphasis on the care of older persons in oncology practice. As noted, older people represent a rapidly growing population that accounts for a major component of the oncologist’ practice. The implications for the future care of older patients with cancer will include changing methods of care and changing economic, social, ethical, and biologic issues. Educational programs and training need to take into account this rapidly expanding and evolving aspect of the cancer problem, and research in geriatric oncology is needed to optimize methods of care and outcomes of cancer management in the future. With the planning of the upcoming Geriatric Education Retreat in Medical Oncology, as well as in other areas already mentioned, we would encourage the input from the broad Geriatric Oncology/Kennedy and Cohen community of medical oncologists and hope that by having medical oncologists working together with geriatricians and gerontologists, we can evolve this new subset area of oncology to enhance the care of the rapidly increasing number of older cancer patients. 2. 3. 4. REFERENCES 1. Kennedy BJ, Bushhouse SA, Bender AP. Minnesota population causes risk. Cancer 1994;73:724-9. 5. 1019 Hazzard WR. Geriatrics curriculum development conference and initiative. Am / Med 1994;97(4A):15-595. Cohen HI. Oncology and aging: general principles of cancer in the elderly. In: Hazzard WR,Bierman EL, Blass JP, Ettinger WH, Halter JB. Principles of geriatric medicine and gerontology. New York: McGraw-Hill, 1994:77-89. Cohen HI. Biology of aging as related to cancer. Cancer 1994; 74(Supplement 7):2092-2100. Kennedy BI, Calabresi P, Carbone P, Frei 111 E, Holland I, Owens A, et al. Training programs in medical oncology. Ann Intern Med 1973;78:127-30.