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Challenges in Cancer Care in Elderly
Zeina Al-Mansour, MD, discusses the unique aspects of cancer care in elderly patients. She shares the latest information on anti-tumor immunity & aging, the importance of assessment of functional status and quality of life consideration and the emerging role comprehensive geriatric assessment in oncology practice.
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Learn more about Zeina Al-Mansour, MD
Zeina Al-Mansour, MD
Zeina Al-Mansour, MD, is an associate professor in UF Health’s Division of Hematology & Oncology in the University of Florida College of Medicine.Learn more about Zeina Al-Mansour, MD
Transcription:
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're discussing challenges in cancer care in the elderly. Joining me is Dr. Zeina Al-Mansour. She's an Associate Professor of Medicine in Malignant Hematology, Bone Marrow Transplant, and Cellular Therapy at UF Health Shands Hospital.
Dr. Al-Mansour, it's a pleasure to have you join us today. Tell us a little bit about the unique aspects of cancer care in elderly patients. What makes this group of patients unique for an oncology practice?
Dr Zeina Al-Mansour: At this point, it's a well-acknowledged fact that age is the most important risk factor for developing cancer. Approximately about 60% of all newly diagnosed malignant tumors happen in elderly patients and about 70% of all cancer deaths occur in patients over the age of 60 and older. For all malignancies, death rate is disproportionately higher in elderly population. And, most likely, this happens for multiple factors. And due to unique considerations that happens in the geriatric age group.
For example, that are medical aspects that are unique to the geriatric population. For example, there is the age-related organ function decline that happen as people grow older, that contribute to higher toxicity with chemotherapy and cancer treatment. There is also the altered natural history of some cancers that happens in aging individuals. There is the concerns of quality of life that older individuals care about probably more than the duration of life. And there's also the psychosocial aspects of caring for an older individual, including the financial burden of cancer care and the access to healthcare physicians and cancer treatment. And on top of that, in the oncology world, we know that most of the clinical trials that establish the standards of care for cancer treatments, the elderly patients are underrepresented in these trials. So these standards of care that we use to treat these individuals do not necessarily represent them when these are standards of care were established.
So for all these seasons, we now consider geriatric oncology a unique field that has to be studied more and investigated more with the clear emphasis on this age group, with all these unique considerations in mind.
Melanie: What great points you just made, Dr. Al-Mansour. It is such a unique group of patients, as you said. And the mechanisms that link age and, say, body weight to cancer, they're incompletely understood, but recent studies provided evidence that anti-tumor immune response is reduced in both conditions, obviously, as we know the aging body, but while responsiveness to immune checkpoint blockade is paradoxically intact. Tell me a little bit about aging and cancer and aging and immunity and how those go together based on what we've learned.
Dr Zeina Al-Mansour: Let me start first by talking a little bit about immunosenescence. Immunosenescence or the aging immune system is defined as the progressive decline of immune function with aging. And this results from multiple observations that we know about the immune system.
First, we know that both the adaptive and the innate immune system both decline as the body ages with the years. And that results in decline in both their T cell function and the B cell function, as well as the cellular immunity. And these observations has led to increased susceptibility of the human body to developing malignancies, infections and also immune diseases that we clearly observe in the elderly population.
The changes in the T cell repertoire and the B cell function that we see in the human body because of increased exposure is through the years to the antigens that results in increased memory cells and decreased naive cells. This we believe is the reason leading to increased susceptibility to malignancies, infections and autoimmune diseases. That leads to decrease in self-tolerance and increased susceptibility to these conditions in elderly individuals.
The unique aspect or the challenge with this is that all or many of the new cancer therapies are now using immune-based techniques to fight malignancies. In other words, we are trying to unleash the immune system to fight the malignancy and combat cancer. So with elderly individuals, the challenge or the question now comes to mind is that with this aging population, that has declined in immune system that comes with the normal aging process, can we really or efficiently unleash their immune system with these new techniques to fight their malignancy in the same way that we're trying to use with younger individuals?
This question has been gaining a lot of interest lately, especially, with the newer cancer treatment that has been approved. As you mentioned, immune checkpoint inhibitor is one of the newer cancer treatment that has gained approval in a wide range of malignancies, including heme malignancies, like lymphomas, for instance, as well as many of the solid tumors, like lung cancers, melanomas. And I believe many of the gastrointestinal malignancies as well are using immune checkpoint inhibitors.
Just to simplify it for the listeners, it tries to promote self-tolerance or you the basics of self-tolerance by reeducating the immune system to help the body of recognize the patient's malignancy as foreign and help the body to fight this malignancy that the patient has. So by doing that, they try to overcome this malignancy or fight this malignancy. That's the whole basic of using immune checkpoint inhibitor.
So in the aging population, the concern was that we cannot use these technologies or these medications. However, there is a newer data that shows with some of the clinical trials that has been able to include some elderly individuals who were fit enough to be included in these clinical trials, they were also able to get some benefits from using these immune-based therapies. I believe the trials were able to include some patients up to the age of 75. And they were able to derive the same benefit that was seen in younger individuals. The thing that is still unclear is were they able to gain quality of life? With the added years of survival that they were able to gain with this cancer treatment, did it come with quality time?
Melanie: Well, doctor, you've mentioned quality of life a few times, and that's a really important aspect for this population. So tell us about the importance of a thorough assessment of functional status and quality of life consideration when treatments are being considered and the emerging role of comprehensive geriatric assessment in oncology practice for other providers and even for primary care providers. Tell them about this geriatric assessment and why it's so important when they're discussing treatments with their patients.
Dr Zeina Al-Mansour: For geriatric patients, they can be vulnerable to treatment toxicities more so than younger individuals, as we said, the decline in their organ function that puts them at higher toxicity. And for these individuals, cancer cure and longevity may not be the primary goal. Oftentimes, their quality of life is a more important goal for them and their independence and being able to continue with their activities of daily living without necessarily being disabled is their primary goal. So that's why being able to fully and totally able to assess their functional status so that you're able to maintain it for them should be a very important goal to maintain throughout their treatment journey.
What we used to use in the past is the ECOG performance status or the Karnofsky performance status, which is a simple measure of what percentage of time the patient basically spends in bed or sedentary. We found that that simple measure is not enough to assess geriatric patients. In exchange of that, we found that the comprehensive geriatric assessment tool, which is a multidisciplinary diagnostic and treatment process. It identifies medical, psychosocial, and functional, domains of an older individual and can identify frailty or prefrailty areas that an older individual may have so that you can develop a coordinated plan for this patient and modify it throughout their treatment process.
We found that if you use something like that during their oncology treatment, you can basically improve their outcome and improve their quality of life and symptom contro rather than just using a simple measure of how sedentary they are or how much time they spend in bed. And this is gaining popularity and has been validated in multiple settings in oncology and in other fields of medicine. I come from the cellular therapy field of oncology and bone marrow transplant. And it has been used successfully in this population. And it's showing to be a very promising approach in improving the outcome of elderly individuals undergoing this very aggressive approach of cancer treatment.
Melanie: Such an interesting field that you're in, Dr. Al-Mansour. As we wrap up and we're talking about really consideration when we're discussing treatments for elderly patients with cancer, you mentioned it briefly about the multidisciplinary approach. Tell us about that, how that really affects treatment outcomes for better outcomes and what you'd like other providers to know about referral to UF Health Shands Hospital.
Dr Zeina Al-Mansour: What I want everybody to always remember that older individuals are a unique group. They can have very promising outcomes in terms of their geriatric cancer treatment. They can be treated and they can be cured from many of their cancers if they are detected early and if they are cared for very thoroughly. Their treatment has to be very multidisciplinary with thorough care and review of their medications, of their physical status and nutrition and chemotherapy plan at multiple areas and multiple stages of their treatment. Their outcomes can be very promising if it is done in the right way. And here at Shands, we are seeing a lot of elderly individuals and I believe their outcomes are promising and they are being cared of according to all the up-to-date standards.
Melanie: Thank you so much, Dr. Al-Mansour. What an interesting topic in such a burgeoning field, really, anything having to do with the elderly, but cancer care and specifically, and quality of life and geriatric assessments. Thank you so much for discussing all of that.
To refer your patient or to listen to more podcasts from our experts, please visit UFHealth.org/medmatters for more information. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.
The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're discussing challenges in cancer care in the elderly. Joining me is Dr. Zeina Al-Mansour. She's an Associate Professor of Medicine in Malignant Hematology, Bone Marrow Transplant, and Cellular Therapy at UF Health Shands Hospital.
Dr. Al-Mansour, it's a pleasure to have you join us today. Tell us a little bit about the unique aspects of cancer care in elderly patients. What makes this group of patients unique for an oncology practice?
Dr Zeina Al-Mansour: At this point, it's a well-acknowledged fact that age is the most important risk factor for developing cancer. Approximately about 60% of all newly diagnosed malignant tumors happen in elderly patients and about 70% of all cancer deaths occur in patients over the age of 60 and older. For all malignancies, death rate is disproportionately higher in elderly population. And, most likely, this happens for multiple factors. And due to unique considerations that happens in the geriatric age group.
For example, that are medical aspects that are unique to the geriatric population. For example, there is the age-related organ function decline that happen as people grow older, that contribute to higher toxicity with chemotherapy and cancer treatment. There is also the altered natural history of some cancers that happens in aging individuals. There is the concerns of quality of life that older individuals care about probably more than the duration of life. And there's also the psychosocial aspects of caring for an older individual, including the financial burden of cancer care and the access to healthcare physicians and cancer treatment. And on top of that, in the oncology world, we know that most of the clinical trials that establish the standards of care for cancer treatments, the elderly patients are underrepresented in these trials. So these standards of care that we use to treat these individuals do not necessarily represent them when these are standards of care were established.
So for all these seasons, we now consider geriatric oncology a unique field that has to be studied more and investigated more with the clear emphasis on this age group, with all these unique considerations in mind.
Melanie: What great points you just made, Dr. Al-Mansour. It is such a unique group of patients, as you said. And the mechanisms that link age and, say, body weight to cancer, they're incompletely understood, but recent studies provided evidence that anti-tumor immune response is reduced in both conditions, obviously, as we know the aging body, but while responsiveness to immune checkpoint blockade is paradoxically intact. Tell me a little bit about aging and cancer and aging and immunity and how those go together based on what we've learned.
Dr Zeina Al-Mansour: Let me start first by talking a little bit about immunosenescence. Immunosenescence or the aging immune system is defined as the progressive decline of immune function with aging. And this results from multiple observations that we know about the immune system.
First, we know that both the adaptive and the innate immune system both decline as the body ages with the years. And that results in decline in both their T cell function and the B cell function, as well as the cellular immunity. And these observations has led to increased susceptibility of the human body to developing malignancies, infections and also immune diseases that we clearly observe in the elderly population.
The changes in the T cell repertoire and the B cell function that we see in the human body because of increased exposure is through the years to the antigens that results in increased memory cells and decreased naive cells. This we believe is the reason leading to increased susceptibility to malignancies, infections and autoimmune diseases. That leads to decrease in self-tolerance and increased susceptibility to these conditions in elderly individuals.
The unique aspect or the challenge with this is that all or many of the new cancer therapies are now using immune-based techniques to fight malignancies. In other words, we are trying to unleash the immune system to fight the malignancy and combat cancer. So with elderly individuals, the challenge or the question now comes to mind is that with this aging population, that has declined in immune system that comes with the normal aging process, can we really or efficiently unleash their immune system with these new techniques to fight their malignancy in the same way that we're trying to use with younger individuals?
This question has been gaining a lot of interest lately, especially, with the newer cancer treatment that has been approved. As you mentioned, immune checkpoint inhibitor is one of the newer cancer treatment that has gained approval in a wide range of malignancies, including heme malignancies, like lymphomas, for instance, as well as many of the solid tumors, like lung cancers, melanomas. And I believe many of the gastrointestinal malignancies as well are using immune checkpoint inhibitors.
Just to simplify it for the listeners, it tries to promote self-tolerance or you the basics of self-tolerance by reeducating the immune system to help the body of recognize the patient's malignancy as foreign and help the body to fight this malignancy that the patient has. So by doing that, they try to overcome this malignancy or fight this malignancy. That's the whole basic of using immune checkpoint inhibitor.
So in the aging population, the concern was that we cannot use these technologies or these medications. However, there is a newer data that shows with some of the clinical trials that has been able to include some elderly individuals who were fit enough to be included in these clinical trials, they were also able to get some benefits from using these immune-based therapies. I believe the trials were able to include some patients up to the age of 75. And they were able to derive the same benefit that was seen in younger individuals. The thing that is still unclear is were they able to gain quality of life? With the added years of survival that they were able to gain with this cancer treatment, did it come with quality time?
Melanie: Well, doctor, you've mentioned quality of life a few times, and that's a really important aspect for this population. So tell us about the importance of a thorough assessment of functional status and quality of life consideration when treatments are being considered and the emerging role of comprehensive geriatric assessment in oncology practice for other providers and even for primary care providers. Tell them about this geriatric assessment and why it's so important when they're discussing treatments with their patients.
Dr Zeina Al-Mansour: For geriatric patients, they can be vulnerable to treatment toxicities more so than younger individuals, as we said, the decline in their organ function that puts them at higher toxicity. And for these individuals, cancer cure and longevity may not be the primary goal. Oftentimes, their quality of life is a more important goal for them and their independence and being able to continue with their activities of daily living without necessarily being disabled is their primary goal. So that's why being able to fully and totally able to assess their functional status so that you're able to maintain it for them should be a very important goal to maintain throughout their treatment journey.
What we used to use in the past is the ECOG performance status or the Karnofsky performance status, which is a simple measure of what percentage of time the patient basically spends in bed or sedentary. We found that that simple measure is not enough to assess geriatric patients. In exchange of that, we found that the comprehensive geriatric assessment tool, which is a multidisciplinary diagnostic and treatment process. It identifies medical, psychosocial, and functional, domains of an older individual and can identify frailty or prefrailty areas that an older individual may have so that you can develop a coordinated plan for this patient and modify it throughout their treatment process.
We found that if you use something like that during their oncology treatment, you can basically improve their outcome and improve their quality of life and symptom contro rather than just using a simple measure of how sedentary they are or how much time they spend in bed. And this is gaining popularity and has been validated in multiple settings in oncology and in other fields of medicine. I come from the cellular therapy field of oncology and bone marrow transplant. And it has been used successfully in this population. And it's showing to be a very promising approach in improving the outcome of elderly individuals undergoing this very aggressive approach of cancer treatment.
Melanie: Such an interesting field that you're in, Dr. Al-Mansour. As we wrap up and we're talking about really consideration when we're discussing treatments for elderly patients with cancer, you mentioned it briefly about the multidisciplinary approach. Tell us about that, how that really affects treatment outcomes for better outcomes and what you'd like other providers to know about referral to UF Health Shands Hospital.
Dr Zeina Al-Mansour: What I want everybody to always remember that older individuals are a unique group. They can have very promising outcomes in terms of their geriatric cancer treatment. They can be treated and they can be cured from many of their cancers if they are detected early and if they are cared for very thoroughly. Their treatment has to be very multidisciplinary with thorough care and review of their medications, of their physical status and nutrition and chemotherapy plan at multiple areas and multiple stages of their treatment. Their outcomes can be very promising if it is done in the right way. And here at Shands, we are seeing a lot of elderly individuals and I believe their outcomes are promising and they are being cared of according to all the up-to-date standards.
Melanie: Thank you so much, Dr. Al-Mansour. What an interesting topic in such a burgeoning field, really, anything having to do with the elderly, but cancer care and specifically, and quality of life and geriatric assessments. Thank you so much for discussing all of that.
To refer your patient or to listen to more podcasts from our experts, please visit UFHealth.org/medmatters for more information. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.