Flashcards in Cancer Deck (37):
T/F: 60% of all cancers occur in those age 65+ yo.
Why is aging a factor of cancer incidence?
- DNA repair mechanism
- Telomeres shortening (Dec. control of cell proliferation)
- Inc. resistance to apoptosis
- Age-related physiologic changes
- Dec. tissue intergrity
Why is carinogenesis a factor of cancer incidence?
- Immune surveillance
- Susceptibility to carcinogens
- Genetic instability (Oncogene Activation; Tumor Suppressor Gene Mutation)
- Dec. clearance of damaged cells
- Altered tissue microenvironment
- Dec. barriers to tumor invasion
Progression of Cancer over time.
1. Initiation - Accumulated genetic alterations
2. Promotion - Clonal expansion, Premalignant lesion
3. Malignant Transformation
4. Progression: Clinical Cancer (Tissue invasion/Metastases)
What can cause the initiation and promotion of cancer to occur?
- Ionizing Radiation
- Spontaneous Mutations
Why are Cancer Death Rates High in the Elderly?
1. Medical Issues
2. Age Bias
3. Healthcare Access Issues
What medical issues can cause cancer death rated to rise?
- Limiting Standard Treatment Options
- Age-related changes in physiology
- Co-existing chronic medical conditions
What age biases can cause cancer death rated to rise?
- Reduced participation in cancer screening programs (delayed dx)
- Under representation in clinical trials (efficacy of treatment)
Age dependent principles in cancer patients.
- Age-related changes in physiology complicated the treatment
- Cancer occurs in the setting of multiple chronic conditions in older patients
- Medical decision making styles differ between young and old
- Preferences for treatment outcomes change with age
- Physical and cognitive function are major concerns in maintaining independence.
- Competing risks may obviate treatment
Age-Related Physiologic Changes in the Kidneys
- Age related loss of nephrons
- Dec GFR about 1 mL/min/year after age 40
-Tubular and interstitial changes.
What common drugs are effected by the age-related physiologic changes in the kidneys?
Age-Related Physiologic Changes in the Gastric
- Dec. Acid
- Dec. Digestive Enzymes
What common drugs are effected by the age-related physiologic changes in the gastric?
Age-Related Physiologic Changes in the Liver
- Dec. liver volume and blood flow about 1% per year
- Dec. Hepatic Metabolism and clearance of drugs
What common drugs are effected by the age-related physiologic changes in the Liver?
- Comorbidity and Cytochrome System
Age-Related Physiologic Changes in the Immune System
- Dec. bone marrow reserve
- Macrophages: dec. phagocytic activity, oxidative burst and MHC class II expression
- NK cells: Dec. cytotoxicity, cytokine/chemokine production, and proliferative response to IL2
- Inc. serum levels of the IL6, IL-1 Beta, TNF-alpha
What do treatment preferences for older patients in cancer depend on?
- Burden of treatment
- Possible outcomes
- Likelihood of outcomes
**Changes with age and progression of disease**
T/F: Many older patients would choose against survival for outcomes of physical or cognitive impairment.
T/F: Older persons with multiple morbidities cannot understand concept of competing outcomes and prioritize outcomes to guide decisions
False, they can understand the concept.
Common Challenges of Effective Cancer Treatment for Older Patients
- Common comorbidities may limit therapeutic options
- Age-related physiologic changes may impact toxicities
- Dec. reserve may delay recovery of functional status
- Prognostic Indices not validated in older patients
- Optimal tx for elders not known (clinical trial exclusions)
Approach Challenges of Effective Cancer Treatment for Older Patients
- Careful medical evaluation of comorbidities and physiologic status
- Proactive approach to prevent potential complications
- Early involvement of cancer rehabilitation team
- Cautious Prognostication
- Clinical research protocols designed for older patients
What are the primary treatment modalities?
- Chemotherapy (includes hormonal therapy and biological agents)
- Radiation Therapy
What is the best opportunity for cure or control (initial therapy)?
- Surgery or radiation therapy for control of primary tumor, usually with histologic assessment of adjacent/regional lymph nodes
- Radiotherapy or chemotherapy for spread to adjacent/regional lymph nodes
- Chemotherapy for systemic (metastatic) disease
- Focal radiation therapy for symptomatic lesions
T/F: Initial chemotherapy cycle often more difficult than later cycles
Ask the patient their goals of treatment.
- Long-term disease control and prolongation of life
- Palliative/Supportive care (control symptoms, optimize function)
- Hospice/EOL care (comfort)
T/F: Chronological age alone is reliable guide for planning treatment or predicting outcome.
- Effects of aging vary among individual patients
- Rates of loss of functional reserves vary from organ to organ in any single individual
What is important to assess in the treatment planning of a patient? Why?
- Physiologic Age
- Functional Status
- A better estimate of QoL, life expectancy, and ability to tolerate cancer treatment
- Components: Co-morbidity, physio function, and functional status.
Surgical Treatment Issues
- Surgery as most effective therapy for local control of many malignancies
- Most elective surgeries associated with relatively low mortality risk
- New less invasive procedures with less morbidity (i.e. Laparoscopic procedures; Robotic technology)
- Surgical risk factors for elderly
What are surgical risk factors for the elderly?
- Emergency surgery or prolonged surgery
- Co-existing disease (especially atherosclerosis, COPD, and diabetes mellitus)
- Poor nutritional status (wound healing, infections)
- Poor functional status
Radiation Therapy Treatment Issues
- Safe and effective curative and palliative therapy for localized cancer
-- Relatively little functional impairment compared to surgery and chemotherapy
- Short course RT very safe and convenient (especially for sick patients)
Chemotherapy Treatment Issues
- Increased susceptibility to drug toxicity
- Dec. functional reserves
- Co-existing dz
- Altered metabolism and distribution of drugs
- Decreased treatment effectiveness due to dose reductions related to drug toxicities
What are common drug toxicities?
- Neutopenia and sepsis
- Thrombocytopenia and bleeding
- Anemia → fatigue, cardiopulmonary decompensation
- Vomiting/diarrhea → dehydration, anorexia and malnutrition
- Renal impairment
________ is a predictor of poor outcomes. Such as:
- Morbidity (inc. falls, ADL, disability, hospitalizations)
- Mortality (5-year mortality)
- Surgical Outcomes (independent predictor of post-op complications, LOS, and discharge to skilled nursing or assisted living facilities)
- Chemotherapy (Inc. probablity of not completing treatment, inc. mortality with chemotherapy)
- Age 85+
- ADL Dependence > 1
- Co-morbid conditions 3+
- Geriatric syndromes > 1
- Unintentional Weight loss
- Significant Muscular Weakness and Fatigue
"Fried" Frailty Index
- Unintentional Weight Loss
- Slow walking Speed
- Subjective exhaustion
- Low grip strength
- Low levels of physical activity
If the patient is frail, what should we consider for treatment?