What special considerations are required to minimise risk when providing cancer therapy to older adults?

From Cancer Guidelines Wiki

Introduction

A number of sub-populations receiving cancer therapy may be at higher risk of errors due to factors such as age, place of residence, treatment location, cultural background, ethnic origin, psychosocial and other social factors.

This section highlights recommendations for older adults. This section is not exhaustive and facilities should consider how medication safety can be optimised and errors reduced according to the population that is treated or who may present to the facility for management of treatment effects.

Individual sections on dose calculations, prescribing, dispensing and administration also provide information and recommendations on cancer therapy and roles of healthcare professionals for older adults.


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Evidence Summary

Aging is the most significant risk factor for the development of cancer with 57% of new cancer diagnoses in Australia occurring after the age of 65 years. Cancer and its treatment can affect the overall life expectancy, the active life expectancy and functioning of older individuals.[1]

Extreme caution and an individual tailored approach is required to treat this cohort of patients.[2] Although several studies have demonstrated that older adults gain as much benefit from chemotherapy as younger patients, the risk of toxicity increases with age.[3] Elderly patients have age-related changes in pharmacodynamics and pharmacokinetic disposition of chemotherapy medication and related therapy. Elderly patients with cancer are more likely to be frail and on polypharmacy. One study has found a substantial impact of potential drug interactions on the risk of non-haematological toxicities in older cancer patients.[4]

Evidence-based decision making in older adults is limited due to the under-representation of elderly patients in large clinical trials. However, a number of recent studies have advocated for specific assessment of older patients to take into account parameters including co-morbidities, performance status, social issues, medication and the presence of geriatric syndromes such as falls, cognitive impairment and depression.[5]

Numerous tools have been developed to evaluate an older individual’s ability to receive and tolerate cancer treatment. The International Society of Geriatric Oncology suggests that a geriatric assessment can be valuable to detect functional impairment not otherwise identified in routine history taking or physical examination and provides the ability to predict severe treatment-related toxicity and influence treatment choice and intensity.[6] The comprehensive geriatric assessment (CGA) evaluates an individual’s functional status, comorbid medical conditions, cognition, nutritional status, mental health status, fatigue, social support, presence of geriatric syndromes and incorporates a review of the patient’s medication.[7] Tools to predict chemotherapy toxicity in older adults have been used and validated.[7][8] These have clearly identified parameters assessed or measured during an evaluation which can contribute to the prediction of severe chemotherapy-related complications.


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Recommendations

Consensus-based recommendationQuestion mark transparent.png

A comprehensive assessment using a specific tool should be performed prior to the initiation of systemic chemotherapy in the older person. Validated chemotherapy toxicity prediction tools such as the Cancer and Aging Research Group (CARG) toxicity tool (Cancer and Aging Research Group) and the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) toxicity tool (Moffitt Cancer Center) are recommended (Hurria et al, 2011; Extermann et al, 2012).


A comprehensive medication history taken by a suitable healthcare professional (preferably a pharmacist) (Lichtman et al, 2014; Carrington et al, 2010) should be incorporated into the evaluation of the older cancer patient. Assessment of actual and potential medication interactions, medication-disease interactions, suitability of medication/rationalisation and opportunities for de-prescribing where clinically appropriate should occur.

(Cancer and Aging Research Group, 2016)[9] ;(Moffitt Cancer Center, 2016)[10] ;(Hurria et al, 2011)[8] ;(Extermann et al, 2012)[7] ;(Lichtman et al, 2014)[1] ;(Carrington et al, 2010)[11]


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References

  1. 1.0 1.1 Lichtman SM, Hurria A, Jacobsen PB. Geriatric oncology: an overview. J Clin Oncol 2014 Aug 20;32(24):2521-2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25513235.
  2. Kim J, Hurria A. Determining chemotherapy tolerance in older patients with cancer. J Natl Compr Canc Netw 2013 Dec 1;11(12):1494-502 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24335684.
  3. Gajra A, Klepin HD, Feng T, Tew WP, Mohile SG, Owusu C, et al. Predictors of chemotherapy dose reduction at first cycle in patients age 65 years and older with solid tumors. J Geriatr Oncol 2015 Mar;6(2):133-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25666905.
  4. Popa MA, Wallace KJ, Brunello A, Extermann M, Balducci L. Potential drug interactions and chemotoxicity in older patients with cancer receiving chemotherapy. J Geriatr Oncol 2014 Jul;5(3):307-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24821377.
  5. Lakhanpal R, Yoong J, Joshi S, Yip D, Mileshkin L, Marx GM, et al. Geriatric assessment of older patients with cancer in Australia--a multicentre audit. J Geriatr Oncol 2015 May;6(3):185-93 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25813881.
  6. Wildiers H, Heeren P, Puts M, Topinkova E, Janssen-Heijnen ML, Extermann M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 2014 Aug 20;32(24):2595-603 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25071125.
  7. 7.0 7.1 7.2 Extermann 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 Jul 1;118(13):3377-86 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22072065.
  8. 8.0 8.1 Hurria A, Togawa K, Mohile SG, Owusu C, Klepin HD, Gross CP, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol 2011 Sep 1;29(25):3457-65 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21810685.
  9. Cancer and Aging Research Group (CARG). Chemotherapy Toxicity Calculator. [homepage on the internet]; 2017 Nov 19 [cited 2016 Jul]. Available from: http://www.mycarg.org/Chemo_Toxicity_Calculator.
  10. Moffitt Cancer Center. Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH). [homepage on the internet]; 2017 Nov 19 [cited 2016 Jul]. Available from: https://www.moffitt.org/eforms/crashscoreform.
  11. Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010 Sep;6(3):220-37 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20887505.

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