In the past year, three clinical trials have unequivocally demonstrated what those who deal with cancer in older people have known for some time: that geriatric evaluation and support from a geriatrician improve significantly – now we can say statistically significant – the path of care and the quality of life of elderly patients. Specifically: severe adverse effects decrease, increase adherence to therapy and allow the identification of people to be treated less aggressively from the very beginning.
To take stock of the new knowledge of geriatric oncology, the advanced course of the International Society of Geriatric Oncology (Siog) is currently being held. About thirty young doctors, including oncologists and geriatricians, gathered in Treviso from all continents to learn from very high profile experts in the field of geriatrics and oncology how to treat cancer, any type of cancer, when the disease strikes the most fragile. Which happens often.
Cancer in the over 70s in Italy
In our country, more than half of cancer diagnoses concern people over 70, 39% of those living with a cancer diagnosis (almost 900,000 people) are between 60 and 74 years old and 34% (over 750,000 people) are over 75. In short, we are talking about many patients, and with special needs. As in past editions, lectures on geriatrics for oncologists and oncology for geriatricians are held, and clinical cases are discussed together, with particular attention to polypharmacy, comorbidities and frailties.
Older people are different from adults and different from each other
An elderly cancer patient may be frail, that is, have associated pathologies – from diabetes to hypertension, osteoporosis – may have decreased function, problems in communication or logistics. “Geriatricians know how to identify and deal with these problems, medical oncologists much less”, says Silvio Monfardini, creator of the initiative with geriatrician Roberto Bernabei, former director in past editions and today on the scientific committee of the event: “The geriatrician should always enter into the care of the elderly cancer patient, except in cases of elderly patients who are actually fit, as they say in medical language, ie patients with health characteristics that are similar to those of younger adults “.
But geriatricians aren’t in hospitals
It often happens that oncologists would like to have a geriatrician to deal with. “But – continues Monfardini – there are not many hospital geriatric divisions along the Peninsula. In some regions they are completely missing. There are geriatricians in the area, sure, but fewer in hospitals, and it is in hospitals that decisions are made for those with cancer. Geriatrics is a bit of medicine’s Cinderella. And it is a shame because for an elderly patient it is important, indeed it is necessary, the contact, the empathy, the time that is dedicated to him to understand not only what pathologies he suffers from. We need a background of information that does not concern strictly clinical aspects, but which plays an important role in guaranteeing the most suitable treatments “.
The Gain, Gap 70+ and Jericho Studies
To prove this with numbers, as anticipated, are three studies discussed yesterday during the event. “These are the most important innovations in geriatric oncology, also because they are randomized trials, therefore more solid than observational studies”, underlines Andrea Luciani, Director of the Department of Oncological Pathways at the Treviglio Hospital, ASST Bergamo Ovest. The first, the GAIN study, was conducted on over 600 patients with different types of solid tumors. One third received traditional management, and the other two thirds integrated management, where the geriatrician supported the oncologist. “The interventions evaluated and implemented in the experimental arm were the most diverse”, explains Luciani: “They concerned the comorbidities, the psychological, cognitive, social state and so on. The results, published in Jama Oncology, clearly show a reduction in the risk of chemotherapy toxicity of grade 3 or higher ”. The second study, GAP 70+, enrolled an additional 733 patients. Again, the solid tumors were different, and a small percentage of cases also involved lymphomas. “The interesting data, published in the Lancet, is that the geriatrician’s assessment made it possible to identify from the beginning a group of patients to be treated with a reduced dose”, says the oncologist: “This allowed us to maintain the deadlines set for cycles of therapy. In patients treated with a standard approach, however, it was necessary to reduce the dosage in the first three months. The take-home message is this: the geriatrician’s intervention has changed clinical practice ”. The latest study is GERICO, published in the British Journal of Cancer. In this case 153 vulnerable patients with primary or metastatic colon cancer were involved. In the experimental arm, various interventions have been implemented, from nutritional ones to those concerning physical exercise. “There was a statistically significant reduction in the risk of toxicity and an increase in the likelihood of receiving chemotherapy for all planned cycles, in the foreseen doses and on schedule”, says the expert: “This is an important goal. , because we already know from other studies that if the elderly patient completes the treatment correctly, he has the same benefits as the younger patient “.
Today there is more awareness
But is the approach of the elderly cancer patient changing in everyday medicine? “We have finally gotten used to the idea that comprehensive evaluations are needed for the elderly with cancer”, replies Monfardini. “Then whether these assessments are made or not is a matter of time, but today this awareness exists in doctors and, where it has been possible, ad hoc tools have been introduced. Our courses have such an international character precisely to exchange experiences, as well as skills. The elderly, more than other patients, must have the right to a holistic approach ”, he concludes:“ The drug against cancer, which is fundamental and necessary, alone is not enough ”.