Standard Cancer Tests May Not Pick Up Functional Changes In Elderly Cancer Patients

By Kurt Ullman Cancer is a disease of aging. Patients 65 years and older account for 6 in every 10 new cancer cases and 70% of the mortality every year.

Cancer is a disease of aging. Patients 65 years and older account for 6 in every 10 new cancer cases and 70% of the mortality every year.

Studies in both geriatrics and oncology have shown that a person’s functional status is one of the best predictors of overall survival and resource utilization. However, the measures most often used in oncology may not be sensitive enough to give a true picture of functioning in the older adult.

"Traditionally, oncologists do not do a full geriatric assessment on their patients,” said Cathy Schubert, MD, assistant professor of clinical medicine at the Indiana University School of Medicine in Indianapolis. “The measurement tools for oncology are the same, independent of the age of the patient. We are beginning to realize that older adults need a little more of a special touch than a 30 year-old with testicular cancer.”

The Karnofsky performance score (KPS) and Eastern Cooperative Oncology Group (ECOG) performance status tools are a good start in any population with cancer. These are global scales that measure how well a person is able to get around and take care of himself or herself.

While many older adults are able to perform these tasks, it may take them longer or use more of their energy than it does for younger people. Because of this, it does not take much additional stress to impact aspects of living, such as driving or going to the grocery store. KPS and ECOG may not be sufficiently sensitive to pick up on some of these subtle changes.

“The problem is that cancer treatment is very hard on the body, and older people may have less reserves to fall back on,” said Dr. Schubert. “KPS and ECOG work well to assess the functional abilities of a person who is at 100% except for their cancer. But they don’t do as well for the person who may only be starting out at 90% or 95%.”

Homeostenosis is a term Dr. Schubert uses to describe the concern. Compensatory reserves are being used just to maintain homeostasis in many elderly people. Changes relating to aging contribute to a decrease in the magnitude of a challenge that can be tolerated by older people.

“Clinical realities in the world of oncology, as opposed to the geriatric world where I live, is that most oncologists do not have the 3 hours needed to do a complete geriatric assessment,” she said. “What we are struggling with in geriatric oncology is finding what are the absolutely necessary components of a geriatric assessment that should be utilized in the cancer patient. We are not there yet.”

In the interim, Dr. Schubert has some easy and quick tests that can be done to find some of the changes:

  • Get-up-and-go test. Watch the patient get up from a chair, walk 8 meters, and then return to the seat. This assesses strength and balance.
  • Gait speed. Have the patient walk 4 meters and record the time it takes. Gait speed has been correlated with mortality and risk for nursing home placement.
  • Mini-mental exam. Tests for cognition, memory, and orientation.
  • Clock drawing. Have the person draw the face of a clock with the hands at a certain time. Another way to measure cognition and also motor function.
  • Six-item test. Say three words and have the patient repeat them. Ask the patient the month, day, and year. Wait about 3 minutes and ask the patient to repeat the words. This is a good test for orientation and memory.

Another concern seen in geriatric oncology that is not as much of a concern in younger adults and children is the status of the caregiver. Often the spouse or significant other is also of advanced age, with the same homeostenosis concerns as the patient. Supervising medications, making sure appointments are made and kept, as well as taking over additional household duties may sap the physical reserves of the main caregiver. If this person also gets sick or exhausted, there can be major disruptions in treatment that follow.

“All disciplines treating the elderly need to remember that there are often two patients involved,” said Dr. Schubert. “Physicians need to ask about who will take up the slack if the primary caregiver needs help or is unavailable. Not a lot of patients will volunteer this information unprompted.”

Many programs are trying to bridge some of these gaps by forging closer ties between the geriatrics department and cancer pavilion.

“It is hard to answer some of these questions at this time,” said Dr. Schubert. “Geriatric oncology is very much a field in its infancy so there is not a lot of data out there to guide us on what needs to be done. There are a lot of unknowns.”