Challenges and opportunities to improve the care of older adults with cancer in Europe
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Challenges and opportunities to improve the
care of older adults with cancer in Europe
Nicolò Matteo Luca Battisti
Medical oncologist
Breast Unit - The Royal Marsden NHS Foundation Trust
Breast Cancer Research Division – The Institute of Cancer Research
President-Elect of the International Society of Geriatric Oncology (SIOG)
Co-Chair of the European Cancer Organization Inequalities Focused Topic Network
BECA Public hearing on
11th January 2021
Increasing burden of cancer in older individuals
Distribution of the European population by age and sex1 Combined incidence of all cancers2
2017 and 2050 US, 1975-2011
1. United Nations. (2017). World Population Prospects. Available at: https://population.un.org/wpp/Publications/Files/WPP2017_DataBooklet.pdf. Accessed: October 2020.
2. Bluethmann SM et al, Cancer Epidemiol Biomarkers Prev, 2016
Cancer incidence and mortality according to age
Gaps of knowledge in geriatric oncology
Proportion of patients ≥65 years enrolled in SWOG trials vs US cancer Age distribution for patients enrolled onto NCI adult cooperative
patient population1 group Phase II and III treatment trials (all diseases)2
according to the type of cancer 2001–2011
1. Hutchins L, et al. N Engl J Med 1999;341:2061–7
2. Hurria A, et al. J Clin Oncol 2014;32:2587–94.
Treatment variation
Proportion of patients receiving various treatment options by stage of disease
EURECCA Breast Cancer Group analysis, 2000-2013
Derks M et al, Br J Cancer, 2018
Older adults are heterogeneous
FIT FRAIL
Life
expectancy
Comorbidities
Functional
status
Polypharmacy
Organ reserve
Toxicities risk
Focus on
survival
Focus on
quality of life
Under- versus over-treatment
Undertreatment
• Use of less intensive treatment in fit older
adults who would otherwise derive a greater net
benefit from more intensive treatment
• Not providing nononcologic interventions to
deficits in geriatric domains regardless of what
therapy is chosen
Overtreatment
• Treatment of cancer in an older patient that
would not likely lead to symptoms in the
remaining lifetime
• Intensive treatment in a vulnerable older
patient in whom there would be a greater net
benefit from less intensive therapy
DuMontier C et al, J Clin Oncol, 2020
Complexity of managing cancer in older adults
Comorbidities Psychological distress
• Cardiovascular • Depression
• Diabetes mellitus • Anxiety
• Cancer
Reduced organ function Polypharmacy
• Bone • Kidneys • Interactions
marrow • Liver • Errors
• Heart • Reduced compliance
Increased risk of Nutritional problems
toxicities/complications
• Obesity
• Chemotherapy • Malnutrition
• Surgery • Weight loss
• Radiotherapy
Lack of social support Cognitive impairment
Impaired function
• ADL
Quality of life • IADL
Soto-Perez-de-Celis E, et al. Lancet Oncol 2018;19:e305–16
Battisti NML & Extermann M. (2017). Multidisciplinary management, including chemotherapy of solid tumours (lung, breast, and colon). In: Michel J-P, Beattie BL, Martin FC and Walston J (eds). Oxford
Textbook of Geriatric Medicine. 3rd edn. Oxford University Press.
Ageing-related concerns in geriatric oncology
Function • How will treatment affect independence?
Physical performance • Will I fall more while on treatment?
Comorbidities • How will treatment affect my other medical problems?
How will I
Cognition • Will my mother be more confused with treatment? tolerate the
treatment?
Psychological status • Can I improve my mood?
Nutrition • I do not feel like making meals. How can I increase my intake?
• What are the resources available for my mother so that she can
Social support stay in her home?
Mohile S. et al, J Natl Compr Canc Netw, 2015Benefits of integrated oncogeriatric care
Predicting complications and side effects from treatment
Medical
oncologist Predicting functional decline during treatment
Radiation
Primary care
oncologist
Estimating survival
Supportive Assisting in cancer treatment decisions
Surgeon
care
Detecting problems not found by routine history and physical
examination in the initial evaluation
Identifying and treating new problems during follow-up care
Psychologist Patient Geriatrician Improving mental health and well-being
Improving pain control
Reducing severe chemotherapy toxicity
Social
Nurse
worker
Reducing unplanned hospitalisations
Physiotherapi Increasing completion of advanced directives
st Dietician
/OT Shortening post-operative inpatient and ICU admissions
Pharmacist
Improving quality of life
Wildiers H, et al, J Clin Oncol, 2014
Decoster L et al, Ann Oncol, 2015
Mohile SG et al, J Clin Oncol, 2018‘Geriatricising’ clinical trials
• Expand eligibility criteria • Quality of life
• Allocate treatment according to fitness • Physical function
• Increase retention of enrolled • Tolerability
individuals
Enrol
Select relevant
vulnerable and
endpoints for
frail older
older adults
patients
Include
• Extended trials Utilise novel • Toxicity prediction
geriatric
trial designs
• Pragmatic trials assessment • Treatment allocation
and strategies
tools
• Prospective cohorts • Longitudinal follow-up
Soto-Perez-De-Celis E and Lichtman SM, Expert Opin Investig Drugs, 2017.Models of care in geriatric oncology
Geriatric
screening Consultative
• Oncologist refers patient to
Negative Positive geriatrician
Oncology Oncology
Shared care
work-up/set-up work-up/set-up
• Collaboration oncologist-
geriatrician
Geriatric
work-up/set-up
Comprehensive
INTEGRATED • Geriatric oncologist is the
TREATMENT
PLAN
TREATMENT
PLAN
treating oncologist
Battisti NML and Dotan E. (2020) Integrating Geriatric Oncology into Clinical Pathways and Guidelines. In: Extermann M. (eds) Geriatric Oncology. Springer, Cham. https://doi.org/10.1007/978-3-319-
57415-8_18.Joining forces to improve outcomes for older
adults with cancer
International Society of Geriatric Oncology (SIOG)
European Cancer Organisation
Cancer and Aging Research Group (CARG)
European Organisation for Research and Treatment of
Cancer (EORTC) Elderly Task Force
Journal of Geriatric OncologySIOG Top Priorities for the global advancement of
care for older adults with cancer
Education Clinical practice Research Collaborations and partnerships
• Integrate geriatric oncology • Develop and implement • Improve the relevance of • Develop and strengthen links
into medical, nursing and models to provide optimal clinical trials to older adults between SIOG and the
allied health professionals care for older adults with with cancer geriatric oncology
schools and residency cancer workforce, international
training programmes and • Evaluate the benefits of specialised agencies, global
promote involvement of • Develop guidelines for the geriatric assessment- and regional professional
trainees in research optimal treatment of older allocated treatments and organisations, policy
adults with cancer geriatric comanagement in makers, and patient
• Provide educational material improving treatment outcomes advocacy groups
and organise formal • Establish centres of for older adults with cancer
educational activities excellence in geriatric • Promote the inclusion of
focused on geriatric oncology for delivering clinical • Use personalised medicine specific provisions for
oncology for practising health care, conducting clinical and technologies to enhance delivering high-quality,
care professionals translational research, and cancer understanding and evidence-based care for older
providing educational management of older adults adults in national cancer
• Educate the general public opportunities control plans
about the relevance of
providing age-appropriate care • Create global funding
for older adults with cancer mechanisms aimed at
fostering professional
development of the geriatric
oncology workforce and
promoting research on the
interface of cancer and ageing
Extermann M et al, Lancet Oncol, 20203 ways the EU can help banish age discrimination in
cancer care
Improve access to healthcare Recognise and respond to
1 professionals trained in 3 the comorbidity challenge
geriatric oncology • Improve data collection and
• Support initiatives that help to embed
geriatric training for cancer
2 reporting on the interface
cancer/comorbidities, including
clinicians and oncology training for cancer registries, European Health
geriatricians within healthcare Data Space and within regulatory
professional curricula e.g. Minimum Ensure inclusion databases - e.g. market
Training Requirements within the authorisation, post-authorisation and
of older patients in pharmacovigilance activities
Professional Qualifications Directive,
EU4Health clinical trials
• Ensure research on
• Take action on workforce comorbidities are a
• Initiate a Commission-sponsored study core part of the EU
shortages through DG Jobs
into the EU regulatory environment for Cancer Mission,
mechanisms on addressing
clinical trials, and, specifically, how greater Horizon Europe &
EU skills shortages,
participation of older patients in trials might EU4Health
including geriatric oncology
be achieved programmes
skills shortageSome further reading Extermann M et al, Lancet Oncol, 2020
Thank you!
National Cancer Institute & San Paolo Hospital, Milan,
Italy
The Royal Marsden, Sutton, UK
twitter: @nicolobattisti nicolo.battisti@gmail.com
#gerionc nicolo.battisti@rmh.nhs.uk
#gerihem
H. Lee Moffitt Cancer Center, Tampa, FL, USAYou can also read
