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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.
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