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Year : 2021  |  Volume : 58  |  Issue : 4  |  Page : 479--480

Older patients with cancer require and deserve more!

Anant Ramaswamy, Vanita Noronha 
 Department of Medical Oncology, Tata Memorial Hospital (Homi Bhabha National Institute), Mumbai, Maharashtra, India

Correspondence Address:
Vanita Noronha
Department of Medical Oncology, Tata Memorial Hospital (Homi Bhabha National Institute), Mumbai, Maharashtra

How to cite this article:
Ramaswamy A, Noronha V. Older patients with cancer require and deserve more!.Indian J Cancer 2021;58:479-480

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Ramaswamy A, Noronha V. Older patients with cancer require and deserve more!. Indian J Cancer [serial online] 2021 [cited 2022 Jan 27 ];58:479-480
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Common refrains with regard to a majority of population studies include comments on an increasing proportion of aging and older adults. Similarly, reports on age-related incidents in various cancers also show that a significant proportion of older adults are being diagnosed with cancer. In the usual scenario, a growing proportion or a majority in a group tend to take steps to take care of their own. Unfortunately, older patients with cancer are a vulnerable and potentially weaker section with under-representation in terms of trial enrolment, access to optimal care, medical management tailored to their needs, and most importantly, lack of universal recognition as a specific group for whom treatment policies need to be made.[1],[2]

A major aspect of the lacunae in terms of caring for older patients with cancer is their near systematic exclusion from prospective studies evaluating systemic therapy as well as other aspects of cancer care.[3] This has resulted in a majority of oncologists extrapolating and modifying data based on individual experience in treating older patients with cancer. This is buttressed to some extent by retrospective data, which have provided pointers on how to treat this cohort of patients. Commonly used scales such as the Cancer Aging Research Group (CARG) and Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) have been studied in multiple cohorts and proven to be of benefit in modifying treatment regimens in older patients.[4],[5] However, the practice and uptake of these scales have not been universal.

The current issue of IJC reports the results of a retrospective study from China that evaluated factors predicting the tolerance to therapy as well as survival in patients with cancer aged greater than 80 years.[6] Such patients form a niche group, even in the geriatric subgroup, with lesser data compared to younger cohorts of the older patient category. The study looked at simple clinical variables as well as certain components of a geriatric assessment and identified the number of comorbidities, increased medications, lower Activities of Daily Living (ADL) scores, and poor performance status (PS) as predictors of poor tolerance to chemotherapy. Most of these variables have biological feasibility in terms of correlation with tolerance, even in younger patients being treated with cancers; thus, it is not surprising that these variables appear significant in older patients with cancer. In institutions and regions where geriatricians or geriatric oncologists are not available, community clinicians can use such simple variables to make rational decisions on how they treat their older patients.[7] Validated tools such as the CARG chemotherapy toxicity risk assessment tool should be strongly considered given its correlation with tolerance as well as the limited time taken to perform and score the scale. While the authors also discuss differential outcomes, the small numbers and the heterogenous nature of the cohort preclude any major significance of these findings. It would be interesting to note whether the authors take their findings forward in terms of examining the factors identified in a larger study as well as the implications of these factors in the entire cohort of older patients with cancer.

Small studies like the one discussed above are valuable in terms of their scientific output and by adding to the growing realization of the lacunae that exist in treating older patients with cancer. Recognition of the older populace with cancer as a distinct group of patients needs to be pursued while guidelines for cancer management are being considered. Besides management, the variation in expectations, especially in terms of quality of life, for this group of patients also needs to be understood by treating oncologists.[8],[9] A 75-year-old patient with stage IV gastric cancer will have markedly different expectations from treatment than a middle-aged patient with the same diagnosis, and this has been repeatedly shown in multiple studies.[10] Approaches to management as shown in the GO2 (similar outcomes despite dose reductions) and the GAP70 studies (the importance of a complete geriatric assessment with tailored recommendations in markedly reducing treatment-related side-effects) need to be ingrained in clinical practice as well as taught during oncology training to sensitize oncologists as to their importance.[11],[12] It is almost unacceptable that a significant vulnerable proportion of patients with cancer are treated without their specific needs being recognized and accorded due diligence. Apart from the science of geriatric oncology and the need for increasing the specialty, the Indian philosophy of recognizing elders as an important and active component of society mandates that we ensure their well-being and comfort. There is no valid reason why a similar approach is not considered for the same group of patients when they are probably at their most vulnerable, that is, with cancer.


1Hutchins LF, Unger JM, Crowley JJ, Coltman CA, Albain KS. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 1999;341:2061-7.
2Parks RM, Holmes HM, Cheung K-L. Current challenges faced by cancer clinical trials in addressing the problem of under-representation of older adults: A narrative review. Oncol Ther 2021;9:55-67.
3Pandey A, Singh A. Treating the older patients with 'younger' evidence-based therapy: Time to tailor to suit the fragility. Cancer Res Stat Treat 2019;2:226-7.
4Extermann M, Boler I, Reich RR, Lyman GH, Brown RH, DeFelice J, et al. Predicting the risk of chemotherapy toxicity in older patients: The chemotherapy risk assessment scale for high-age patients (CRASH) score. Cancer 2012;118:3377-86.
5Hurria A, Mohile S, Gajra A, Klepin H, Muss H, Chapman A, et al. Validation of a prediction tool for chemotherapy toxicity in older adults with cancer. J Clin Oncol 2016;34:2366-71.
6Xu Y, Ding L, Zhang YQ. Predictors of chemotherapy tolerance and survival benefit in a geriatric patient population with advanced solid tumors. Indian J Cancer 2021;58:591-7.
7Noronha V, Talreja V, Joshi A, Patil V, Prabhash K. Survey for geriatric assessment in practicing oncologists in India. Cancer Res Stat Treat 2019;2:232.
8Scotté F, Bossi P, Carola E, Cudennec T, Dielenseger P, Gomes F, et al. Addressing the quality of life needs of older patients with cancer: A SIOG consensus paper and practical guide. Ann Oncol 2018;29:1718-26.
9Noronha V, Kalra D, Ramaswamy A, Gattani SC, Menon N, Patil VM, et al. Oncologists' perceptions of the need for assessing individual domains in the geriatric assessment and worthwhile outcomes in treating older patients with cancer: A questionnaire-based survey. Cancer Res Stat Treat 2021;4:492-8.
10Parikh PM, Chaitanya K, Boppana M, Kumar MS, Shankar K. Geriatric oncology landscape in India – Current scenario and future projections. Cancer Res Stat Treat 2020;3:296-9.
11Hall PS, Swinson D, Cairns DA, Waters JS, Petty R, Allmark C, et al. Efficacy of reduced-intensity chemotherapy with oxaliplatin and capecitabine on quality of life and cancer control among older and frail patients with advanced gastroesophageal cancer: The GO2 phase 3 randomized clinical trial. JAMA Oncol 2021;7:869-77.
12Mohile SG, Mohamed MR, Xu H, Culakova E, Loh KP, Magnuson A, et al. Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): A cluster-randomised study. Lancet 2021;398:1894-1904.