Chemotherapy in Advanced Age – Weighing a Hefty Cost against Slim Odds of Success
Elderly patients are predicted to represent, in the near future, the largest group of cancer patients. This demographic is already coming into place, with a longer average lifespan and improved access to medical facilities. Thus a large number of patients receiving cancer chemotherapy are of advanced age. This warrants discussion of the challenges of tailoring treatment to these patients, and also of the central question of informed decision-making concerning patient management.
Chemotherapy by its nature is highly cytotoxic: it works by inhibiting the growth and multiplication of cancer cells as well as normal cells in the human body. Chemotherapy regimens may be employed alone, in combination with novel targeted drugs, or as an adjunct to surgical intervention.
To quote Reppeto (2006), “the cytotoxic effects of chemotherapy agents prevent neoplastic cells and normal cells from dividing by disturbing the cell cycle. It is during the phase of mitosis that rapidly dividing cells are most sensitive to chemotherapy”. It thereby follows that intensive chemotherapy comes with intensive collateral damage to normal cells of the body.
As reiterated by Matti et al (2005), pharmacokinetic profiles of chemotherapeutic drugs are different in elderly patients, yielding different efficacy and safety levels. Variability of gastrointestinal absorption, hepatic metabolism and renal excretion alters bioavailability in older patients. This necessitates careful dosage reduction and monitoring for untoward effects.
In addition, patient-specific comorbidities are important to take into account when devising treatment plans.
Age is possibly the most important risk factor for treatment-related morbidity and mortality seen with conventional chemotherapy. Common systemic adverse effects of chemotherapy include alopecia, anorexia, nausea, vomiting, diarrhea, constipation, and malaise. Among the graver consequences of chemotherapy are myelosuppression, cardiotoxicity, hepatotoxicity, hemorrhagic cystitis, mucositis, peripheral neuropathy etc. Appropriate management of these side effects is essential to providing patient care, ensuring patient compliance to treatment, and ultimately determining quality of life of cancer patients.
In my clinical experience I have seen many patients rushing to the emergency department with chemo-related side effects such as neutropenia, thrombocytopenia, anemia, dehydration and electrolytes imbalance. These events have their own costs, physical, psychological and monetary, which patients must be prepared to deal with.
The poor outcome, high rate of adverse effects and unreliability of chemotherapy bears a significant impact on the psychological health of cancer patients and their families. Anxiety, mood disturbances and depression interfere with the functional wellbeing of patients, and may even affect their response to cancer treatment (Marsdon 2006).
All of these factors underscore the importance of involving patients and their caregivers in making informed treatment decisions for elderly cancer patients. For these terminally ill patients, quality of life is a parameter of utmost importance, and since chemotherapy takes a significant toll on patients’ functionality, it is necessary to take into account every patient’s individual preferences while making treatment plans.
Reppeto,L.(2006).Greater risks of chemotherapy toxicity in elderly patients with cancer. The Journal of Supportive Oncology, 2, 18-24.
Matti, S.A., Claus, H.K., Harvey, J.C.,& Martine, E.A. (2005). Never too old? Age should not be a barrier to enrollment in cancer clinical trials. The American Journal of Medical Oncology,10(3),198-204.
Vermorken, J.B. (2010). Quality of life of patients receiving platinum-based chemotherapy plus cetuximab first line for recurrent and/or metastatic squamous cell carcinoma of the head and neck. Journal of Annals of Oncology. doi:10.1093/annonc/mdq077
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