A lot of this was summarized well by David Minster in JCO published way back in 2013 and a decade later, I still refer to this same article to this day! This article is 3rd in a series of blog articles on this topic.
Treating geriatric patients is often a difficult task. There are so many factors that go into the equation of whether we should treat to cure or control the disease with potential risky treatments, or should we pursue a comfort care approach with treating the symptoms and focusing on quality of life first. Doing both can be a fine balance in the elderly. We may treat with systemic therapy for a patient with a reasonable performance status who maintains all activities of daily living BUT then when we cause a significant life-threatening harm by putting the patient in the hospital with treatment related adverse effects… EVERYONE including the nurses, staff, colleagues will be saying to me…. “What did you do to Grandma?!”
As a medical physician, I have seen firsthand the difficult balancing act between being aggressive and being careful in the field of geriatric oncology. It is a fine line to walk – on the one hand, we know that elderly folks are often underdiagnosed, under-staged, and undertreated, and that these suboptimal treatments can lead to suboptimal results and limited life expectancy. But on the other hand, we also know that the elderly folks often have other comorbidities that make aggressive treatment more challenging.
It is clear that for the fit elderly, we should treat them as we would for younger patients. They can generally tolerate therapy as well and will have similar outcomes to their younger counterparts. I have patients in their 90s who are in complete remission from metastatic melanoma after checkpoint inhibitors. In fact, a well-known former president Jimmy Carter was treated with Keytruda (2015) for his metastatic melanoma to the liver and brain 8 years ago and had apparently achieved remission off all treatments. Only recently (2023), he just went into home hospice at the age of 98 although it is not clear to me that he was dying from metastatic melanoma as opposed to other medical issues with his recent falls.
I am sure it is not a surprise for any of us that NONE of us are getting out of this thing we call life… alive. Eventually, we all become morbid, frail, deconditioned, or too sick to undergo any life prolonging treatments. And for the frail elderly, palliative treatment may be the best option, to help manage symptoms and improve quality of life. The real challenge is with the majority of elderly patients who fall somewhere in between. These patients may have some comorbidities, but are still relatively healthy overall. In these cases, we need to have open and honest conversations with the patient and their family about their goals of care, and what they hope to achieve with treatment.
Another patient I saw several months ago was 96-year-old with recurrent unresectable rectal cancer to the pelvis. He could not undergo aggressive surgical resection and he already had prior chemoradiotherapy with intention to knock the tumor out just a year prior. His only option was palliative chemotherapy to help slow the disease down and perhaps keep it at bay longer as long as he was not sick from the treatment. I feel extremely comfortable with giving 5FU chemotherapy to most elderly patients, and normally patients can do reasonable well with infusional treatment. But for this patient, I think this simple treatment almost did him in. We were able to admit him quickly to the hospital and treat him with fluids, anti-diarrheals, and pain control. Eventually he left the hospital and came back to clinic asking me for more treatment? I told him that treating him with more systemic therapy needs to make sense for the patient, the family who are caring for him, my staff who will be giving treatment in the infusional center, and myself as the treating physician. My staff will not be happy with me if I send someone upstairs who cannot even get out of chair or look like they are going to code on them during the treatment. So far, everyone but the patient was unhappy with the recent events. After an honest conversation, he and his family were agreeable for comfort care with home hospice.
It is important to remember that what is “best” for a younger patient may not always be what is best for an elderly patient. We need to take into account the patient’s overall health, as well as their wishes and desires for treatment. While patients generally want the best outcome with the least toxicity, it is important to weigh the benefits and risks of each treatment option. It is honestly a balancing act: On one side, we have the potential benefits of aggressive treatment – cure or improved survival. On the other side, we have the potential risks and toxicities of that treatment. We need to find the right balance between these two sides, based on the individual patient and their unique circumstances.
Ultimately, the decision about what treatment to pursue should be a collaborative one, made in partnership with the patient and their family. We need to approach each patient as an individual, with unique goals and desires, and work together to find the best path forward. It is not about what we did to Grandma – it is about what we did with her, in partnership, to help her achieve the best possible outcome. We need to treat the elderly with the same level of care and respect that we would want for our own loved ones and work together to find the right balance between being aggressive and being careful.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. Currently practicing at the renowned Orlando Health Cancer Institute, he brings a wealth of expertise to the complex and challenging world of oncology.
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