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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 1  |  Page : 2-8

Challenges and determinants in the management of the older patients with cancer – Report from a low- and middle-income country


1 Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India; Department of Internal Medicine, Hospital for Advanced Medicine and Surgery, Kathmandu, Nepal
2 Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
4 KIMS Cancer Centre, KIIT University, Bhubaneswar, Odisha, India

Date of Submission15-Feb-2021
Date of Decision03-Aug-2021
Date of Acceptance10-Jul-2021
Date of Web Publication17-Aug-2021

Correspondence Address:
Dr. Joyita Banerjee
Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_3_21

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  Abstract 


Introduction: Cancer is a malady of old age. Older people lose autonomy and independence due to age-associated functional decline and adverse consequences of comorbidity. The impact of these variables has an effect on treatment decisions in older cancer patients. Methods: In an observational study, 290 cancer patients aged 60 years or more were evaluated before the initiation of the treatment. They were subjected to a geriatric assessment by various validated assessment tools. Management decisions were as per the prevailing hospital practice. Results: The median age at the diagnosis was 65 years and two-third were males. Lung cancer was the most common (49.3%) diagnosis. The major comorbidities seen were hypertension (34.14%), diabetes (20.34%), and COPD (15%). Depression (57%), cognitive impairment (37%), malnourishment (34%), and vision problem (20%) were common age-related issues observed. Seventy-one percent were dependent in one or more domains of activities of daily living. Eighty-one percent had Eastern Cooperative Oncology Group status score between 0 and 2 (thereby eligible for treatment). In multivariable analysis, good functional status (P < 0.001) and performance status by Karnofsky's Performance Status Scale (P < 0.001) were associated with receiving treatment. Conclusion: Improvement in pretreatment functional status by initial geriatric assessment and requisite interventions may improve the access to and consideration of older cancer patients for standard treatment and care in oncology clinics.

Keywords: Comorbidity, functional status, geriatric oncology, performance status, treatment


How to cite this article:
Kandel R, Banerjee J, Saravanan M, Chatterjee P, Chakrawarty A, Dwivedi S N, Mohanti BK, Dey AB. Challenges and determinants in the management of the older patients with cancer – Report from a low- and middle-income country. J Indian Acad Geriatr 2021;17:2-8

How to cite this URL:
Kandel R, Banerjee J, Saravanan M, Chatterjee P, Chakrawarty A, Dwivedi S N, Mohanti BK, Dey AB. Challenges and determinants in the management of the older patients with cancer – Report from a low- and middle-income country. J Indian Acad Geriatr [serial online] 2021 [cited 2021 Oct 24];17:2-8. Available from: http://www.jiag.com/text.asp?2021/17/1/2/323941




  Introduction Top


Increasing age is a major risk for developing cancer. With an unprecedented rise in the aging population, the incidence of cancer is also showing an upward trend. Patients aged over 65 years have an 11-fold increase in cancer incidence and a 16-fold increase in cancer mortality compared to younger participants.[1] In aging adults' functional status which is a measure of the ability of an individual to physically perform important tasks in maintaining independence, declines progressively.[2] This renders older individuals vulnerable to environmental stress and incapable of living independently functionally and socially. Thus, a functional status assessment is of paramount importance and should be a vital part of initial assessment of older patients diagnosed with cancer. In geriatric practice, substantial stress is placed on assessment designed to capture the functional status of an older adult which may be a ramification of comorbidities, physical abilities and disabilities, and health system response. In traditional oncology practice, performance status of cancer patients is usually assessed by age neutral, subjective scales such as Karnofsky Performance Status (KPS) Scale or Eastern Cooperative Oncology Group (ECOG) Scale.[3],[4] These scales, however, may not capture the intricacies of functional status in advancing years.[5]

Geriatric oncology is an evolving discipline globally and in a very nascent stage in developing, low- and middle-income countries (LMICs) like India, which have started experiencing the impact of population aging only recently. Health systems in these regions are stressed under the dual load of communicable and noncommunicable diseases, and geriatric care is still not high on the list of priorities for care. In this scenario, the management of cancer in old age in these developing countries can be challenging. There is a need to improve the ability to accurately assess patient fitness for cancer treatments so that older patients with cancer do not end up being over or under treated and receive care which will be beneficial for them. Better selection of patients for specific therapeutic approaches will help in finer outcomes and improve the quality of life (QoL) during cancer treatment. This, in turn will help reduce the burden on the strained health-care machinery in LMICs both logistically and financially.

In the present study, a detailed geriatric assessment has been done on older patients newly diagnosed with cancer. The main aim was to examine the impact of variables such as functional status, performance status, and comorbidity on management decision-making and actual therapy received.


  Methods Top


In a prospective, observational study, 290 treatment naïve patients with histopathologically proven diagnosis of cancer and aged 60 years or more were recruited from geriatric medicine services of a tertiary care hospital in India. Seriously ill and dying patients were excluded from the study. Ethical clearance was taken from the Institutional Ethics Committee. After obtaining informed consent, the eligible patients were subjected to elicitation of detailed history and physical examination. Additional evaluation included assessment of nutritional status by Mini-Nutritional Assessment Scale (MNA, Nestle Nutrition Institute),[6] mood by 15-point Geriatric Depression Scale (GDS);[7] cognitive status by Hindi version of the Mini Mental Status Examination (HMSE),[8] and socioeconomic status by Modified Kuppuswami scale.[9] The presence of geriatric syndromes was elicited with a history of falls, bladder and bowel incontinence, depression or disabilities such as hearing or visual impairment. A history of urinary incontinence and falls in the previous 6 months were taken. A fall was defined as an unintentional event resulting in a laying position on the floor, the ground or other lower level[10] and urinary incontinence, defined as a self-reported presence of involuntary urine loss.[11] The ten-item Barthel's basic activities of daily living (BADL) and the eight-item Lawton and Brody's instrumental activities of daily living (IADL) were used to assess the functional status of the patients. Dependence in carrying out any one or more of the ten or eight items in the above scales was considered as dependence of the patient in ADL or IADL, respectively.[12],[13] The performance status of the patient was assessed by the 100-point KPS scale and the 5-point ECOG scale.[3],[4] The subjects were assessed for all other health issues in addition to cancer for which they were receiving some form of treatment and health problems of the past (quiescent morbidity) which may have an impact on treatment planning by detailed history taking and review of medical documents. After complete assessment, patients were referred to the multidisciplinary oncology service of the hospital. A note was made of the treatment received by the participants.

To observe the association between various patient disease-related factors and the modality of treatment received, the participants were divided into two groups depending on the treatment modality received for the purpose of analysis. All participants receiving “curative and adjunctive treatment” were clubbed as “receiving curative form of treatment” category; and the remaining “palliative care,” “didn't receive treatment” and “death before initiation of therapy” were clubbed as “didn't receive curative form of treatment” category.

Statistical analysis

A descriptive analysis of the baseline demographic and socioeconomic characteristics and issues related to aging was performed. Data were analyzed using the SPSS statistics, version 19 (IBM, Chicago, IL, USA). All statistical tests were two-sided, and P < 0.05 was considered statistically significant. Univariate and multivariable analysis was done to see the relation between various patient-related factors and their relation to receiving curative form of treatment.


  Results Top


Baseline characteristics of the participants of the study are provided in [Table 1]. Eighty-eight percent of the participants were in the age group of 60–74 years, and the rest 12% were above the age of 75 years. The median age at the diagnosis was 65 years (mean 66.8 ± 6.48 years). Two-thirds of the patients were males.
Table 1: Baseline characteristics of the study participants (n=290)

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Specific clinical variables associated with old age and functional status of the participants are provided in [Table 2]. History of urinary incontinence and falls were positive among 27% and 17% of the patients, respectively. Twenty percent and 17.2% of patients had difficulty in vision and hearing, respectively. 34.4% were malnourished. 37% of the patients were cognitively impaired (HMSE score: <24) and more than half of the patients (57.2%) had GDS score more than 5, suggesting the presence of depression. Independence in ADL was reported by only 71 (24.5%) patients, whereas 98 (33.8%) were dependent in BADL and IADL. The rest 121 patients had impaired IADL.
Table 2: Geriatric specific characteristics of the study participants (n=290)

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The top five comorbidities were hypertension (34%), diabetes mellitus (21%), chronic obstructive pulmonary disease (15%), chronic kidney disease (14%), and osteoarthritis (11.7%). Twenty patients (6.9%) were receiving antitubercular therapy either empirically or with proven tuberculosis. Multi-morbidity, that is more than one morbidity, was present in 16.5% of the patients [Figure 1]a.
Figure 1: (a) Comorbidities (b) Cancer type by site. (a) The common comorbidities seen in the study participants. Hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and osteoarthritis are the five common comorbidities. (b) Lung cancer was the most common cancer seen followed by non-Hodgkin's lymphoma and gall bladder carcinoma

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Lung cancer constituted the bulk (49.3%) of cancer diagnosis, followed by hepato-cellular carcinoma (8.6%), Non-Hodgkin lymphoma (5.9%), carcinoma of stomach (5.5%), carcinoma of the gall bladder (4.5%), and carcinoma of the ovary (4.1%). Cancer of unknown primary constituted 2.8% of the total patients [Figure 1]b. Majority of the patients had advanced disease at the diagnosis. Over 60% of patients had Stage IV disease followed by 37.2% in Stage III. Six patients were in Stage II and one in Stage 1. KPS score was between 80 and 100, indicating good performance status in 48.6% of patients and <50 indicating poor performance status in 19.3% of patients. Ten (3.45%) patients had ECOG score of 0, whereas the score was 1, 2, 3, and 4 among 46.2%, 31.7%, 15.9%, and 2.8% of patients, respectively, increasing scores indicating gradually worsening performance status.

One hundred and forty-nine (51.4%) of the patients received curative form of treatment (43.3% received curative and 2.07% received adjunctive treatment) while 141 patients (48.6%) did not receive curative form of treatment (34.1% received palliative care, 11.3% did not receive any form of treatment, and 3.1% died before receiving any treatment). 73.8% of the patients with independent IADL status received the treatment compared to 42.23% of those with dependency. Similarly, functionality assessed by status of both ADL and IADL had significant association with curative modality of treatment (P < 0.001). 78.9% of the patients with both normal ADL and IADL received curative form of treatment compared to only 18.3% with impairments. Sixty-seven percent of the patients described as normal by MNA received the curative form of treatment, whereas only 31% of the patients described as malnourished received the curative form of treatment. PS (P < 0.001) and ECOG (P < 0.001) had statistically significant association with the reception of curative modality of treatment. 77.3% of the patients with KPS score between 80 and 100 received curative forms of treatment compared to 34.4% of the patients with KPS between 50 and 70 and 14.2% of the patients with KPS score <50 received the curative form of the treatment.

Similarly, ECOG score had statistically significant association with the reception of curative form of treatment (P < 0.001). The proportion of patients receiving curative form of treatment decreased significantly as the ECOG score increased from 0% to 4. 80% of the patients with ECOG score equal to zero received curative form of treatment, whereas only 12.5% with ECOG score 4, received treatment. In the univariable analysis [Table 3], socioeconomic status, ADL, IADL, malnutrition, and the performance status scores by KPS and ECOG were significantly associated with treatment received. In the multivariable analysis [Table 3], functional status (95% confidence interval [CI]: 0.166–0.615, odds ratio [OR]: 0.315, P = 0.001) and KPS (95% CI: 66.664–70.990, P < 0.001) were independently associated with treatment received.
Table 3: Factors associated with treatment modality using univariate and multivariable cox-regression analysis

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  Discussion Top


Older adults with a diagnosis of malignancy present with multiple other health and age-related issues which requires attention of the health-care provider. The study sample comprised of mainly young old with a mean age of 66.8 ± 6.48 years. Failing health and functional impairment with increasing age, dependence on caregivers might be reasons which hinder their access to health care. Sixty-seven percent of the study participants were male which a common occurrence in our setting is. In India and other LMICs, there is a strong gender bias in health-seeking behaviors as well as accessibility to health care.[14] Lung cancer made up the majority of cases. Lung cancer has a strong link to tobacco consumption which is predominantly seen in males globally. This might also be a reason of male predominance in the study sample. Almost 68% of the participants had a history of chronic smoking. Most cases presented in later stages of the disease, which shows a lack of awareness among older adults regarding the early signs and symptoms. Moreover, many early symptoms of malignancy overlap with those common in aging such as weight loss, weakness, fatigue, and loss of appetite, thus adding to the confusion and delay in seeking medical help.

About 75% of the study participants belonged to the lower middle and lower socioeconomic class. Prior studies have shown that socioeconomic status influences cancer risk factors such as tobacco use, poor nutrition, physical inactivity, and obesity and psychological effects such as dementia or depression.[15] Lower socioeconomic status also has a detrimental influence in access to appropriate early detection, treatment, and palliative care.[15] Seventy-three percent of participants were staying with their families as is characteristic in our part of the world. Thus, while low socioeconomic status was a major social deterrent in health-seeking trends, strong family system was a significant source of social support in our study participants. Lung cancer constituted about 50% of the malignancies seen followed by hepatorenal and hematological malignancy. Lung cancer is one of the leading malignancies in older males in India.[16] Hypertension, diabetes mellitus, and COPD were the predominant comorbidities followed by CKD and osteoarthritis. This corroborates with global data on comorbidities in older adults with cancer.[17] Forty-two percent were dependent in their IADLs and 34% had both ADL and IADL impairment. Similar results were reported in a systemic meta-analysis done by Neo et al. where they reported about one-third of adults with cancer require assistance to perform basic ADLs and about one-half require assistance to perform instrumental ADLs.[18] Depression was found in more than half (57%) of the participants. In older adults with cancer, depression has been reported in the range from 3% to 31%.[19] Several symptoms of depression in older adults overlap with those of malignancy such as sleep disturbances, decreased interest in sexual activity, and lack of energy. Because of these overlapping symptoms and issues, identifying depression in older patients with cancer is challenging and is often under reported and undertreated.[20] Cognitive impairment was found in 36% of participants. Cognitive impairment frequently goes unnoticed in older adults and has an effect on both QoL as well as survival.[21] It has been estimated that overall, 30% of cancer patients have detectable cognitive impairment before treatment.[21] Risk of malnutrition was seen in 38% and 34% of patients had frank malnutrition in this study. The prevalence of malnutrition among patients with cancer has been reported to range between 32% and 66%.[22] Malnutrition is a frequently observed complication in patients with cancer due to various reasons such as anorexia, nausea, vomiting, and cancer cachexia and can negatively affect the outcome of treatments. Early identification and timely interventions of malnutrition or its risk can potentially reverse the process before cancer cachexia sets in.[23] Almost 50% of participants had low body mass index (BMI). BMI has a major impact on muscle strength, physical function, as well as mortality in older people.[24],[25] Seventeen percent had a history of fall in the previous 6 months. It has been reported that falls are more common in older adults with cancer than the general population and have a serious implication on the functional status, QoL, course of disease, and survival.[26] Therefore, it is imperative to screen, assess the risk of falls, and manage them before initiation of anticancer therapy. Twenty percent had visual and 17% had hearing problems. Hearing and visual impairments are common among community-dwelling older adults and are associated with psychological, functional, and cognitive deficit.[27] Fifty-one percent of the participants received curative treatment. Forty-nine percent received curative and 2% adjunctive treatment. Thirty-four percent participants received palliative care in some form. Forty-eight percent of participants had KPS scores of 80–100 showing good performance and 32% had scores between 50 and 70 showing deficits in performance status. Similarly, 46% scored 1in the ECOG performance score (which is equivalent to scores of 80–100 in KPS) followed by 31% who Scored 2. ECOG status score between 0 and 2 (thereby eligible for treatment) was found in 81% of patients. However, only 51% of older cancer patients received curative form of treatment. In comparison, those independent in their IADLs and ADLs received significantly more curative treatment than those who were dependent. Although the performance status scales (KPS and ECOG) are well validated and routinely used scales in oncology, literature suggests the use of more robust assessment techniques like the geriatric specific functional status scales for better management and increased eligibility to treatment for older cancer patients.[28] In multivariable analysis, good functional status and KPS scores were independently associated with receipt of curative treatment. Significantly greater number of patients who were independent in the domains of basic as well as IADL (i.e., functionally able) received the curative form of treatment compared to those who were dependent. A majority of the older patients with poor functional status did not receive the curative form of treatment although they received palliative care.

The study throws light on the importance of a pretreatment robust functional status evaluation in older adults as it might have an effect on treatment decision-making. Many a times, functional impairment might be due to reversible causes which can be rectified before start of anti-cancer therapy. Functional status in older adults is often influenced by other domains and reversible conditions such as cognitive impairment, depression, comorbid conditions, and nutritional deficits.[28] It has been recorded in earlier studies that functional status has a major impact on QoL and mortality in older adults with cancer.[29]

In India and other LMICs, the discipline of geriatric oncology is still in its budding stages. There is an urgent requirement to incorporate geriatric assessments in oncology services to optimize care. International bodies like the International Society of Geriatric Oncology and National Cancer Care Network advocate conducting a Comprehensive Geriatric Assessment for all older cancer patients.[30],[31] A CGA is time-consuming and not feasible in busy oncology services in the LMICs with skewed doctor patient ratios. Many screening tools are being used mainly in the developed nations for preliminary screening and assessment but are not compatible with countries such as India with great cultural heterogeneity.[32] A validated screening tool developed recently for LMICs is the SCOPE-C, Version 1 tool which incorporates most of the relevant domains of assessment for older adults as suggested by a CGA.[33] This tool also stresses more on the functional domain in its score structure and is complemented by other relevant domains such as mood, affect, nutrition, comorbidity, poly-pharmacy, geriatric syndromes, and social support.


  Conclusion Top


A failing functional status may be a major cause of not qualifying for receipt of standard treatment in older adults with cancer. A pretreatment comprehensive assessment of functional status and relevant domains affecting it can highlight reversible causes for discrepancies and a potential for interventions to correct them. This may lead to older patients with cancer being eligible for different modalities of treatment thus enhancing their QoL and survival.

Acknowledgment

The authors would like to thanks all the study participants. The authors acknowledge the National Program for Health Care of the Elderly and the Institute fellowship of the All India Institute of Medical Sciences, New Delhi, for providing fellowship to Joyita Banerjee for her doctoral research and Ramesh Kandel for his MD dissertation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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