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Part 1 Key principles in geriatric oncology

Chapter 1 Geriatric assessment for the older adult with cancer

A. The aging population in the United States and worldwide

B. The association between cancer and aging

C. Assessment of older adults with cancer: Integrating geriatric principles in oncology care

C.1. The role of functional status

C.2. Comorbidity

C.3. Cognition

C.4. Nutritional status

C.5. Psychological state and social support

C.6. Performing a geriatric assessment in oncology practice

D. Age-related changes in physiology

D.1. Age and organ function

D.2. Age and bone marrow

D.3. Inflammation, coagulation, and physiologic dysregulation in older adults

D.4. Inflammation, coagulation, and physiologic dysregulation in patients with cancer

E. Conclusion

Endnote

References

Chapter 2 Pharmacology and unique side effects of chemotherapy in older adults

A. Introduction

B. General pharmacological issues related to chemotherapy in elderly cancer patients

C. Pharmacology and side effects of specific anticancer drugs in elderly individuals

C.1. Alkylating agents

C.2. Platinum compounds

C.3. Taxanes

C.4. Topoisomerase interactive agents

C.5. Antimetabolites

C.6. Antitumor antibiotics

D. General side effects of chemotherapy in older adults with cancer

D.1. Myelosuppression

D.2. Mucositis

E. Practical recommendations

F. Future perspectives

References

Chapter 3 Pharmacology and unique side effects of hormonal therapy in older adults

A. Tamoxifen

A.1. Pharmacology and metabolism

B. Tamoxifen side effects

B.1. Thromboembolic disease

B.2. Endometrial carcinoma

B.3. Cognitive function

B.4. Other

C. Aromatase inhibitors

C.1. Pharmacology and metabolism

D. Aromatase inhibitor side effects

D.1. Bone loss

D.2. Treatment options for bone loss

D.3. Joint pain and stiffness

D.4. Lipid profile and cardiovascular risk

D.5. Atrophic vaginitis

D.6. Cognitive function

E. Conclusions and future directions

References

Chapter 4 Drug utilization, adherence, and unique side effects of targeted therapy in older adults

A. Introduction

B. Physiologic changes with aging

B.1. Polypharmacy

B.2. Nonadherence

C. Specific targeted therapies

C.1. Endocrine therapy

C.2. Tamoxifen

C.3. Aromatase inhibitors

D. Monoclonal antibodies

D.1. Bevacizumab

D.2. Trastuzumab

D.3. Cetuximab

D.4. Rituximab

E. Signal transduction inhibitors

E.1. Imatinib

E.2. Erlotinib

E.3. Sorafenib and sunitinib

E.4. Lapatinib

F. Conclusions

References

Chapter 5 Principles of surgical oncology in older adults

A. Defining the targets

B. Breast cancer

C. Colorectal cancer

D. Hepatic, pancreatic, and biliary surgery

E. Upper gastrointestinal surgery

F. Thoracic surgery

G. Head and neck cancer surgery

H. Conclusions

References

Chapter 6 Principles of radiation oncology in older adults

A. Introduction

B. General considerations

C. Breast cancer

C.1. Ductal carcinoma in situ

C.2. Early invasive breast cancer

C.3. Locally advanced breast cancer

C.4. Radiation dose

C.5. Treatment toxicity

D. Prostate cancer

D.1. Low and intermediate risk

D.2. High risk

Hormone therapy alone versus hormone therapy and radiation

Radiation therapy alone versus radiation therapy plus hormone therapy

D.3. Dose escalation and age

D.4. Radiation toxicity

E. Lung cancer

E.1. Medically inoperable, stage I, non-small-cell lung cancer

Dose

Stereotactic radiosurgery

E.2. Stage III (locally advanced) non-small-cell lung cancer

Sequential chemoradiotherapy

Concurrent chemoradiotherapy

Trimodality therapy

Dose

Radioprotectors

Staging

E.3. Small-cell lung carcinoma

E.4. Palliation of intrathoracic symptoms

F. Glioblastoma multiforme

G. Non-Hodgkins lymphoma

H. Summary

References

Part 2 Management of solid tumors in older adults

Chapter 7 Management of breast cancer in older adults

A. Introduction

B. Approach to management: Weighing risks and benefits

C. Determining mortality and relapse risk: Standard pathologic prognostic and predictive indicators

C.1. Tumor gene expression analysis

C.2. Statistical modeling to ascertain relapse risk

D. Management introduction

E. Surgery

E.1. Surgery and risk assessment

E.2. Axillary management

F. Radiation therapy

G. Hypofractionated radiation therapy

G.1. Partial breast irradiation

G.2. Omitting radiation in patients treated with hormonal therapy

H. Systemic therapy by stage

H.1. Ductal carcinoma in situ

I. Early stage

I.1. Hormonal therapy

I.2. Chemotherapy

I.3. Determinants of increased benefit from chemotherapy

J. Tools to assess benefits and toxicity from chemotherapy

K. Available chemotherapy regimens

L. Metastatic disease

L.1. Endocrine Therapy

L.2. Chemotherapy

M. Choice of chemotherapeutic regimen

M.1. Targeted agents

N. Other supportive therapies for metastatic breast cancer

N.1. Bisphosphonates

O. The frail elderly patient

References

Chapter 8 Management of lung cancer in older adults

A. Introduction

B. Non-small-cell lung cancer (NSCLC)

C. Advanced-stage NSCLC

D. Systemic chemotherapy: Monotherapy

E. Combination chemotherapy

F. Second-line therapy

G. Early-stage NSCLC: Surgically resectable patients

H. Combined-modality therapy

I. Small-cell lung cancer (SCLC)

J. Extensive-stage SCLC

K. Salvage therapy

L. Limited-stage SCLC

M. Prophylactic cranial irradiation

N. Future perspectives

References

Chapter 9 Management of head and neck cancer in older adults

A. Introduction/incidence

B. Goals of multimodality treatment

C. Workup

D. Etiology and molecular markers

E. Combined modality treatment

F. Induction chemotherapy

G. Metastatic disease/recurrent

H. Locoregional nonmetastatic recurrence

I. Targeted therapy in squamous cell carcinoma of the head and neck

J. Quality-of-life toxicity outcomes

K. Conclusion

References

Chapter 10 Management of esophageal and gastric cancer in older adults

A. Esophageal cancer

A.1. Epidemiology

A.2. Pathology

A.3. Risk factors

A.4. Evaluation and staging

A.5. Treatment-localized disease

Primary surgery

Primary radiation therapy

Primary chemoradiation

Preoperative and perioperative chemotherapy

Preoperative CRT

A.6. Treatment-metastatic disease

A.7. Treatment-palliative measures

A.8. Treatment conclusion

B. Gastric cancer

B.1. Epidemiology

B.2. Pathology

B.3. Risk factors

B.4. Evaluation and staging

B.5. Treatment-localized disease

Primary surgery

Perioperative therapy

Adjuvant therapy

Perioperative chemotherapy or CRT

B.6. Treatment-advanced disease

B.7. Treatment-palliative care

B.8. Treatment conclusion

References

Chapter 11 Management of colon and rectal cancer in older adults

A. Introduction

B. Epidemiology of colorectal cancer in the older patient

C. Selection of elderly colorectal cancer patients for screening and treatment

D. Screening for colorectal cancer in the elderly patient

E. Surgery for colorectal cancer in the elderly patient

F. Radiotherapy for rectal cancer in the elderly patient

G. Chemotherapy for the older patient with colorectal cancer

G.1. Adjuvant chemotherapy for colorectal cancer

G.2. Chemotherapy for metastatic colorectal cancer

H. Conclusion

References

Chapter 12 Management of renal and bladder cancer in older adults

A. Introduction

B. Bladder cancer

B.1. Superficial bladder cancer

B.2. Invasive bladder cancer

Radical cystectomy

Bladder preservation

B.3. Chemotherapy

C. Kidney cancer

C.1. Localized kidney cancer

C.2. Metastatic kidney cancer

References

Chapter 13 Management of prostate cancer in older adults

A. Epidemiology

B. Etiology

C. Prevention

D. Screening, diagnosis, and risk stratification

D.1. Screening

D.2. Diagnosis

D.3. Risk stratification

D.4. Stage migration and natural history of prostate cancer

E. Treatment

F. Localized disease

F.1. Radical prostatectomy

Radiotherapy

Active surveillance

G. Locally advanced disease

H. Advanced disease

H.1. Hormonal therapy or androgen-deprivation therapy (ADT)

H.2. Second-line hormonal therapy

H.3. Castrate-resistant prostate cancer

Chemotherapy

I. Supportive care

J. Conclusions

References

Chapter 14 Management of ovarian and endometrial cancer in older adults

A. Introduction

B. Ovarian cancer

B.1. Risk factors

B.2. Diagnosis

B.3. Prognostic factors

B.4. Surgery

B.5. Chemotherapy

First line

B.6. Intraperitoneal chemotherapy

Second line

B.7. Geriatric assessment

B.8. Quality of life and survivorship

End of life

C. Endometrial cancer

C.1. Diagnosis and prognostic features

C.2. Surgery

C.3. Radiation

C.4. Chemotherapy

C.5. Quality of life and survivorship

C.6. Lifestyle

D. Conclusion

References

Part 3 Management of hematologic malignancies in older adults

Chapter 15 Management of myelodysplasia in older adults

A. Introduction

B. Epidemiology

C. Diagnosis

D. Classification

E. Prognosis

F. Treatment

F.1. Supportive care

F.2. Chemotherapy

F.3. Biologic therapy

G. Unresolved issues for the aging patient

H. Future directions

I. Conclusions

References

Chapter 16 Management of chronic leukemia in older adults

A. Chronic myelogenous leukemia

A.1. Clinical features and epidemiology

A.2. Molecular biology

A.3. Diagnosis

A.4. Treatment

A.5. Imatinib mesylate in chronic phase disease

A.6. Imatinib in advanced disease

A.7. Resistance and second-generation tyrosine kinase inhibitors

A.8. Dasatinib

A.9. Nilotinib

A.10. Interferons

A.11. Reduced-intensity stem cell transplantation

A.12. Conclusions

B. Chronic lymphocytic leukemia in older adults

B.1. Introduction

B.2. Diagnosis

B.3. Staging and prognosis

B.4. Treatment Considerations

Decision regarding treatment initiation

Initial treatment

Treatment of relapsed disease

B.5. Conclusions

References

Chapter 17 Management of acute myeloid leukemia in older adults

A. Introduction

B. Host-related factors and biological features of acute myeloid leukemia (AML) in the elderly

C. Decision making and quality of life in elderly AML patients

D. Therapeutic options for elderly AML patients

D.1. Palliative therapy and best supportive care

D.2. Attenuated chemotherapy

D.3. Standard intensive induction therapy and role of postremission therapy

D.4. Role of gemtuzumab ozogamicin (Mylotarg)

D.5. Role of hematopoietic stem cell transplantation

E. New and emerging therapeutic modalities for treatment of AML in the elderly

E.1. Novel chemotherapeutic agents

E.2. Farnesyltransferase inhibitors

E.3. FLT3 inhibitors

E.4. Differentiation therapy

E.5. Other agents

F. Hematopoietic growth factors in elderly AML

G. Summary and conclusions for future directions

References

Chapter 18 Hematopoietic cell transplantation in older adults

A. Introduction

B. Epidemiology of hematologic diseases in the elderly

C. Autologous and allogeneic hematopoietic cell transplantation (HCT)

D. The current era: Increased utilization of HCT in older adults

E. Applying HCT to older adults

F. Transplant tolerability

F.1. Reduced-intensity conditioning

F.2. Nonconditioning factors

F.3. Donors

G. Outcomes

G.1. Autologous hematopoietic cell transplantation

H. Allogeneic hematopoietic cell transplantation

I. Tolerance to HCT

I.1. Age

I.2. Comorbidity

I.3. Functional assessment

I.4. Biomarkers

J. Recommendations

K. Conclusion

References

Chapter 19 Management of non-Hodgkin's lymphoma in older adults

A. Incidence

B. Impact of aging

C. Epidemiology and classification of non-Hodgkins lymphoma (NHL) in the elderly

D. Staging and prognostic factors

E. Prognostic information

F. Therapy of diffuse large B-cell lymphoma in the elderly

G. Therapy of follicular lymphoma in the elderly

H. The role of transplantation in the elderly with NHL

I. Summary

References

Chapter 20 Management of multiple myeloma in older adults

A. Introduction

A.1. Monoclonal gammopathy of undetermined significance

A.2. Active myeloma

B. Clinical presentation and biology of disease

C. Treatment

D. Lenalidomide

E. Bortezomib

F. Stem cell transplantation

G. Approach to the care of older adults with myeloma

References

Part 4 Symptom management and supportive care of older adults

Chapter 21 Optimizing quality of life in older adults with cancer

A. Introduction

B. Psychological state

C. Older cancer patients in need

C.1. Geriatric interventions to optimize the adjustment of older cancer patients

D. Support groups

E. Education

F. Screening and referral

G. Exercise

H. Cognitive therapy

I. Multimodality interventions

J. Patient characteristics

K. Medication

K.1. Other psychosocial interventions tested on nonelderly cancer patients that might be effective in improving adjustment of older cancer patients

L. Internet cancer support groups

M. Supportive-expressive group therapy

N. Behavioral activation and problem-solving skills training

O. Relaxation therapies

P. Conclusion

References

Chapter 22 Optimizing functional status in older adults with cancer

A. Overview

B. Rationale for care directed at functional status in older cancer patients

B.1. Linking disease and disability: Implications for cancer care

B.2. Measuring function

B.3. Prevalence of functional impairment in older cancer patients

B.4. Functional assessment across the phases of cancer care

Prior to initiation of therapy

During cancer treatment

Survivorship

Palliative care

C. Interventions to promote function in the older cancer patient

C.1. Comprehensive geriatric assessment

C.2. Exercise

C.3. Rehabilitation

C.4. Pain management

C.5. Nutritional interventions

C.6. Psychological interventions

D. Priorities for future research

References

Chapter 23 The myeloid growth factors in older adults with cancer

A. Introduction

B. Chemotherapy-induced neutropenic complications

B.1. Risk of neutropenic complications

B.2. Age and the risk of neutropenic complications

B.3. Risk of serious complications of febrile neutropenia

B.4. Reduced chemotherapy dose intensity

C. The myeloid growth factors

C.1. Myeloid growth factor use in older cancer patients

D. Clinical practice guidelines for the myeloid growth factors

D.1. Overview of clinical practice guidelines

D.2. Comparison of recent myeloid growth factor guidelines

D.3. Recommendations for the myeloid growth factors in the elderly cancer patient

E. Clinical decision support for myeloid growth factors

F. Economic considerations for the myeloid growth factors

G. Safety of the myeloid growth factors

H. Conclusions

References

Chapter 24 Erythropoiesis-stimulating agents in older adults with cancer

A. Introduction

B. Prevalence and morbidity/mortality associated with anemia in the aged

C. Mechanisms of aging-related anemia

D. Morbidity and mortality of anemia among the geriatric population

E. Erythropoietin structure, function, and pharmacology

F. Use of erythropoiesis-stimulating agents (ESAs) in cancer- and chemotherapy-associated anemia

G. ESAs and impact on survival in patients with cancer

H. Biology of erythropoietin receptors

I. Positive ESA clinical studies

J. Conclusions

References

Chapter 25 Management of depression and anxiety in older adults with cancer

A. Introduction

B. Depression

B.1. Depression in patients with cancer

B.2. Depression in geriatric patients with cancer

B.3. Treatment for depressed patients with cancer

C. Anxiety

C.1. Anxiety in patients with cancer

C.2. Anxiety in geriatric patients with cancer

C.3. Treatment for anxious older patients with cancer

D. Summary and conclusion

References

Chapter 26 Management of pain in older adults with cancer

A. Why focus on the elderly?

B. Undertreatment of pain

C. Barriers

D. Assessment

E. It is more than just pain

F. Heterogeneity in aging

G. Aging physiology: Pain management

H. Management

I. Nonopioid analgesics

I.1. Acetaminophen

I.2. Nonsteroidal anti-inflammatory drugs

I.3. Bisphosphonates

J. Opioids

K. Opioid adverse effects

K.1. Nonpharmacological treatment

L. The future

References

Chapter 27 Management of fatigue in older adults with cancer

A. Introduction

B. Review of the current evidence

C. Practical recommendations for managing fatigue in the elderly

C.1. Case 1: Mr. L

Discussion

C.2. Case 2: Mrs. J

Discussion

D. The future of fatigue-related research in the elderly

E. Conclusion

References

Chapter 28 Management of dyspnea in older adults with cancer

A. Etiology of dyspnea

B. Goals of care for the elderly patient with dyspnea

C. Assessment of dyspnea

D. Evidence-based pharmacologic strategies for management of dyspnea

E. Oral and parenteral opioids

F. Palliative oxygen

G. Psychotropic drugs

G.1. Benzodiazepines

G.2. Other anxiolytics

G.3. Selective serotonin reuptake inhibitors

G.4. Inhaled furosemide

G.5. Heliox28

H. Pharmacologic strategies not supported by current evidence

I. Nonpharmacologic approaches to dyspnea management

J. Breathlessness clinics

K. Breathing techniques

L. Psychosocial support

M. Caregiver support

N. Global intervention strategies

References

Chapter 29 Management of the gastrointestinal side effects of therapy in older adults with cancer

A. Diarrhea

B. Constipation related to cancer therapy

C. Cancer treatment–related nausea and vomiting

D. Oral mucositis and alimentary tract mucositis

E. Neutropenic enterocolitis

F. Graft-versus-host disease

G. Conclusions

References

Index