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GUEST EDITORIAL |
Clinical Research Branch, National Institute on Aging, Baltimore, Maryland.
Address correspondence to William Ershler, MD, Clinical Research Branch, National Institute on Aging, Harbor Hospital, NM 526, 3100 South Hanover St., Baltimore, MD 21225. E-mail: wershler{at}iasia.org
GERONTOLOGISTS and geriatricians are aware of the common occurrence of cancer in older people. In fact, we know that age is the single greatest risk factor for cancer (1,2). The 13% of the U.S. population that is older than 65 years comprise approximately 60% of all cancer cases and sustain 70% of cancer-related deaths (3). Questions regarding the biology of neoplasia and its relationship to the processes of aging are increasingly being addressed, and first rate investigators have turned their attention to the commonalities of carcinogenesis, proliferation, apoptosis, and cellular senescence [for review, please see (4–7)]. Yet, translational research remains dormant, and the few clinical investigations to date have skirted the major and most difficult questions. It is telling that the ratio of review articles on cancer in elderly people far exceeds the number of primary research papers. This is not to say there have been no gains in geriatric oncology, but most in the field would agree that we have barely touched the surface. We have learned that older, otherwise "fit" patients tolerate cancer treatment, including chemotherapy, as well, or nearly as well as younger patients (8,9). And, if they receive full doses for many of the most common cancers, their response rates are as good, or nearly as good as younger patients (10). This is good news, of course, but relevant only to that small segment of the elderly cancer population considered by quite rudimentary or arbitrary criteria to be "fit."
Yet, cancer more typically occurs in older patients who fail to meet criteria for "fit." More likely, older cancer patients present with coexisting diseases, functional impairments, geriatric syndromes, and demonstrable impairment of critical organs. What have clinical trials to date told us about optimal management for these patients? We suggest, not much. Granted, this is a difficult task, and we, as seasoned investigators in this domain, are as much at fault as any, but it is time we acknowledge that our accomplishments have been too few and the progress (in geriatric oncology) too slow to meet the challenge in coming decades. The average age for all cancer patients in the United States is currently 70 years, and this will climb to 75 years or older by 2030. How are we to get started approaching the real issues, and what are realistic expectations?
For starters, we propose an expanded research agenda to include the following questions:
In this age in which physicians aspire to practice evidence-based medicine, the bulk of such evidence in oncology is based upon trials conducted in young patients. The fact remains that we have virtually no trial-derived evidence to support any approach for over 50% of cancer patients. We need to do better: Our feet are to the fire!
References
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