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Oncologists, Geriatricians Team Up To Close Research Gaps on Cancer Care
by William Kanapaux
Geriatric Times May/June 2004 Vol. V Issue 3
Older Americans suffer a disproportionate burden from cancer, a situation that will become more apparent in the years ahead as the U.S. population continues to age.
According to the National Cancer Institute (NCI), nearly 60% of all newly diagnosed malignant tumors are in people aged 65 and older, and these older patients account for 70% of all cancer deaths. The age-adjusted rate of cancer in people 65 and older is 10 times greater than the rate for younger people, and the age-adjusted mortality rate is more than 16 times higher.
However, a significant knowledge gap on cancer in older patients exists, making geriatric oncology a critical area of research.
Rosemary Yancik, Ph.D., told Geriatric Times, "The statistics show that older persons bear a disproportionate burden of cancer, and because we have a demographic transition, it's very important that we start addressing this issue.
"We're having more and more cancer survivors, but there'll be more and more people who are aging and more vulnerable to cancer," added Yancik, who is health scientist administrator in the Geriatrics and Clinical Gerontology Program at National Institute on Aging (NIA).
In October 2003, the NCI and NIA launched a five-year initiative designed to establish a stronger research focus on the relationship between aging and cancer. The $25 million program awarded first-year grants totaling $5 million to each of eight research centers, based on research goals established at a joint NCI/NIA workshop in 2001. (A report on the 2001 workshop can be found at <http://nia.nih.gov/health/nianci/>--Ed.) The workshop's report on integrating aging and cancer research stated:
Data that indicate what happens when cancer is superimposed on the pre-existing health problems of older patients are few. The varying health status and the physical and physiological substrates of the older individual need to be incorporated into mainstream clinical research.
The Table shows the seven areas the joint workshop identified for further research.
The NIA/NCI project is designed to promote research at the complex interface of aging and cancer and embraces a broad scientific spectrum, according to Yancik. Each of the eight cancer centers has a research team codirected by a specialist in geriatrics and a specialist in oncology.
The goal is to establish a permanent structure for ongoing research in aging and cancer, Yancik said. Each center will then receive its own research grants from the National Institutes of Health and other funding bodies so that it can develop a stable program.
The request for applications that ultimately funded the eight programs within existing cancer centers emphasized three of the seven themes identified at the 2001 workshop: treatment efficacy and tolerance, the effects of comorbidity, and the biology of aging and cancer. Each applicant had to include at least one of the three areas in its proposal.
The NCI and NIA in 2002 also launched a three-year funding initiative directed at a broad base of researchers in the scientific community at large in order to further expand the knowledge base on age-related aspects of cancer in older patients. The initiatives are receiving support from a complementary fellowship program first announced in 2001 by the American Society of Clinical Oncology (ASCO), which has more than 20,000 professional members.
The American Society of Clinical Oncology received a $3 million grant from the John A. Hartford Foundation to administer a geriatrics/oncology training program that has awarded 10 major medical centers around the country up to $225,000 for a three-year fellowship program that offers trainees the opportunity for American Board of Internal Medicine Certification in medical oncology.
The goal is to foster the development of more training programs in geriatrics and oncology, produce academicians to teach about geriatric issues in medical oncology, and influence future research efforts.
John M. Bennett, M.D., principal investigator for ASCO's training grants and professor at the University of Rochester James P. Wilmot Cancer Center, told GT that the fellowship program is mostly attracting trainees from geriatric medicine who want to move into medical oncology. The program is also attracting individuals whose main interest is oncology. In some instances, fellows are opting for a fourth year in order to receive geriatric/hematology training.
Critical Gaps
Three main areas of concern currently exist in geriatric oncology care, Bennett said.
The first is the issue of conducting a comprehensive assessment for older patients. This may be difficult to accomplish in a busy oncology practice where a lot of patients are screened to determine whether they should be placed in clinical trials or receive a particular treatment.
"It's quite clear that a comprehensive geriatric assessment is not something that can be done in every practice, even in academic centers, because it can take hours," Bennett explained. "It's just too time-consuming and isn't cost-effective."
The standard, quick performance-status evaluations that medical oncologists use are not as accurate in predicting outcomes in patients who are 70 years or older, according to Bennett. However, instruments are being developed for rapid geriatric assessments that can be done within 20 to 30 minutes.
The second issue is the need to address the biases of internists, surgeons and family practitioners that can result in the failure to refer older patients in a timely manner for preventive measures such as mammograms for breast cancer and stool guaiacs or sigmoidoscopy for colon cancer.
"The prevailing attitude seems to be, 'Well, they're going to die from something else, so why bother?'" Bennett said.
But it's clear, he explained, that as better preventive tools are developed for managing conditions such as cardiovascular disease, stroke and hypertension, older individuals are living longer and with a better quality of life. That makes them candidates for the same types of medical approaches that would be offered to a 50-year-old who is newly diagnosed with cancer.
The third area of concern is that older individuals have been denied the opportunity to participate in formal clinical trials that address important issues in cancer treatment. Consequently, when a paper gets published on a new drug program for lung cancer or leukemia, "It's more often applicable for individuals under age 60, and we have no idea about how useful it would be in the older population," stated Bennett. There are a few exceptions, such as in lymphoma or early-stage breast cancer studies, "but by and large there is a tendency to exclude older patients from participation in clinical trials."
Part of this problem results from comorbidities seen almost exclusively in older patients that do not make them ideal candidates for research, such as impaired kidney function, pulmonary and cardiovascular diseases, economic troubles, and dementia and Alzheimer's disease. "Nevertheless, we still believe that there are individuals out there who would be suitable were they made aware or were their physicians made aware that there are trials open for which they are candidates," Bennett explained.
Need for Programs
About 20 fellows currently participate in ASCO's 10 fellowship programs, according to Bennett. However, potentially more than 100 such programs could exist in the United States.
"The hope is that this program will be succeeded by other programs that will be sponsored primarily by the NCI and NIA," he said. "I don't think we can continue to depend on the good will and the funding from the Hartford Foundation or other private organizations to keep these programs going."
The American Society of Clinical Oncology has also provided funding for junior faculty and career development awards in the area of geriatric oncology and has developed a major syllabus on cancer care in the older population that serves as a self-teaching guide. All of this has added up to an increasing presence of geriatric oncology at ASCO's annual meetings.
The issues oncologists are addressing also need to be addressed by a number of subspecialties because older patients often have a number of medical problems.
"The more serious the comorbidity, the more difficult it is to manage the patient," Bennett reported. That's why groups such as the Endocrine Society are attaching a geriatric component to their training programs. "Eventually, everyone trained in a medical subspecialty will have skills in geriatrics," he said. However, it will take at least 10 years for that approach to have an effect on addressing current knowledge gaps.
"We need to start now, because if we wait, we'll be faced with an insurmountable problem, and that's why these initiatives have begun," Bennett said.
