Journal of Gerontological Nursing

The articles prior to January 2011 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here

CNE Article 

Physiological Aging in Older Adults with Cancer: Implications for Treatment Decision Making and Toxicity Management

Stewart M. Bond, PhD, RN, AOCN

Abstract

Because the risk of cancer increases with age, the growth of the aging population will lead to a larger number of older adults with cancer. Standard cancer treatments can be safe and effective in older adults and result in improved survival and enhanced quality of life. Because physiological decline varies among older adults, cancer treatment requires an individualized approach. Consideration of physiological age, rather than chronological age alone, is required to guide treatment decision making and prevent and manage treatment toxicities and other complications. This article examines the impact of physiological aging on treatment decision making and toxicity management in older adults with cancer.

Abstract

Because the risk of cancer increases with age, the growth of the aging population will lead to a larger number of older adults with cancer. Standard cancer treatments can be safe and effective in older adults and result in improved survival and enhanced quality of life. Because physiological decline varies among older adults, cancer treatment requires an individualized approach. Consideration of physiological age, rather than chronological age alone, is required to guide treatment decision making and prevent and manage treatment toxicities and other complications. This article examines the impact of physiological aging on treatment decision making and toxicity management in older adults with cancer.

Dr. Bond is Assistant Professor of Nursing and John A. Hartford Foundation Claire M. Fagin Fellow, Vanderbilt University School of Nursing, Nashville, Tennessee.

The author discloses that he has no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Dr. Bond’s research and scholarship are supported by the John A. Hartford Foundation’s Building Academic Geriatric Nursing Capacity Award Program and the Vanderbilt University School of Nursing Postdoctoral Program.

Address correspondence to Stewart M. Bond, PhD, RN, AOCN, Assistant Professor of Nursing and John A. Hartford Foundation Claire M. Fagin Fellow, Vanderbilt University School of Nursing, 505 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240; e-mail: stewart.m.bond@vanderbilt.edu.

Received: May 29, 2009
Accepted: July 15, 2009
Posted Online: February 05, 2010

Cancer risk, incidence, and mortality increase dramatically with age. Approximately 60% of all cancers and 70% of deaths from cancer occur in adults age 65 and older (Yancik & Ries, 2000). With the rapid expansion of the older population and subsequent increase in cancer incidence, health care providers will see a significant increase in the number of older people with cancer (B.D. Smith, Smith, Hurria, Hortobagyi, & Buchholz, 2009). In light of this increase, the care and treatment of older adults with cancer becomes an important issue not only for oncology nurses but also for gerontological nurses and others who provide care for this population. This article will examine the impact of physiological aging on cancer treatment decision making and treatment-related toxicities.

Aging is associated with a decrease in functional reserve capacity in multiple tissue and organ systems. The diminished reserve capacity results in impaired homeostasis and an altered response to stressors. Physiological processes in almost all body systems decline gradually over time. The rate of decline is highly individualized and is determined by environmental, lifestyle, and genetic factors (Adams & White, 2004). Significant heterogeneity exists in physiological and functional reserve capacity among older adults. Until recently, chronological age had been used as a primary factor in cancer treatment decision making. However, chronological age does not adequately predict or reflect the extent of age-related physiological changes in an individual. Thus, parameters of physiological and functional capacity, rather than just chronological age, need to be considered in determining and tailoring cancer treatment in older adults.

The decision to treat cancer in older adults is based not only on the type and stage of cancer but also on the patient’s ability to tolerate treatment. Age alone should not prevent appropriate cancer treatment in older adults. Standard cancer treatment regimens, including surgery, chemotherapy, and radiation therapy, can be used safely and effectively in older adults and can enhance quality of life and improve survival (Extermann, 2004; Saltzstein & Behling, 2002). Toxicity associated with cancer treatment in older adults can be minimized with timely and appropriate supportive care and with increased monitoring and follow up.

Implications for Treatment Decision Making

An evaluation of physiological and functional reserve is needed to determine which older adults will tolerate and benefit from cancer treatment. This evaluation enables clinicians to estimate life expectancy and whether the person is most likely to die from the cancer or another condition. Primary components of the evaluation include the presence and severity of comorbid medical conditions and the functional status of the older adult. Comorbidity and functional status are independent factors in older adults with cancer; therefore, they need to be assessed independently (Extermann, Overcash, Lyman, Parr, & Balducci, 1998). In addition, other components of comprehensive geriatric assessment (CGA) can help identify patients at risk for poor treatment tolerance and adverse outcomes (Chen et al., 2003; Freyer et al., 2005; Maione et al., 2005). Alterations in drug pharmacokinetics resulting from age-related physiological changes also need to be considered in treatment decision making.

Comorbidity

Comorbid medical conditions such as diabetes, heart disease, hypertension, arthritis, and lung disease are prevalent in older adults with cancer, and the number of comorbidities increases with age (Yancik et al., 1998). In Yancik et al.’s (1998) study, patients ages 55 to 64 had an average of 2.9 comorbidities, and those age 75 and older had an average of 4.2 comorbidities. Comorbidity limits treatment options, negatively affects treatment tolerance, and influences the presence and severity of symptoms and other complications (Frasci et al., 2000). Comorbidity is also associated with poorer survival, increasing both cancer and non-cancer mortality (Firat, Bousamra, Gore, & Byhardt, 2002; Piccirillo, Tierney, Costas, Grove, & Spitznagel, 2004).

Comorbidity adds to the complexity of caring for older adults with cancer. The treatment of comorbid conditions during cancer treatment may result in an increased likelihood of drug interactions. In addition, cancer treatments, including chemotherapy, radiation therapy, and other supportive care drugs, may exacerbate comorbid conditions. For example, corticosteroids used to prevent nausea and allergic reactions may cause hyperglycemia in diabetic patients. In addition, angiogenesis inhibitors such as bevacizumab (Avastin®) and tyrosine kinase inhibitors (e.g., sunitinib [Sutent®], sorafenib [Nexavar®]) contribute to treatment-related hypertension in patients with preexisting hypertension and those at risk (Kurtin, 2009).

Functional Status

Functional status in older adults with cancer is a significant consideration in treatment decision making. Specific components of functional status include activities of daily living (ADLs) and instrumental ADLs (IADLs). ADLs include bathing, dressing, ambulating, using the toilet, maintaining continence, and feeding oneself. IADLs are skills needed to maintain one’s independence in the community, such as the ability to use a telephone, travel, shop, prepare meals, do housework or yardwork, take medications, and manage finances. Physical functioning prior to diagnosis (Stommel, Given, & Given, 2002) and pretreatment IADL function (Maione et al., 2005) have been associated with survival in cancer patients following treatment.

Comprehensive Geriatric Assessment

CGA involves a multidimensional evaluation to determine the overall health status of an older adult. Table 1 lists the components of the CGA. In oncology practice, CGA helps clinicians better understand the patient’s physiological age and identify older patients at risk for functional decline and treatment toxicity (Extermann, 2003; Extermann et al., 2005). CGA can be used to guide treatment planning and decision making in older adults with cancer. In other words, CGA helps determine which patients may benefit from and tolerate standard cancer treatment and which patients may benefit most from a palliative treatment approach. CGA also helps identify potentially reversible problems that could be better managed to facilitate cancer treatment.

Components of Comprehensive Geriatric Assessment

Table 1: Components of Comprehensive Geriatric Assessment

CGA, using an interdisciplinary team approach, is time consuming and labor intensive. Thus, it is often not feasible in the busy outpatient oncology setting. The National Comprehensive Cancer Network’s (NCCN) (2009c) senior adult oncology guidelines propose screening to determine which patients may need a more comprehensive assessment. CGA, using a self-report format, has been conducted in outpatient cancer populations (Hurria et al., 2007; Ingram et al., 2002). Overcash, Beckstead, Moody, Extermann, and Cobb (2006) have proposed an abbreviated CGA. When problems are identified, patients undergo more extensive assessments in these areas.

Alterations in Pharmacokinetics

Multiple age-related physiological changes affect the pharmacokinetic properties of chemotherapeutic agents and other drugs. Alterations in drug absorption, distribution, metabolism, and excretion may affect treatment tolerance and result in greater toxicities in older adults with cancer (Lichtman et al., 2007). Age-related physiological changes that affect drug pharmacokinetics must be taken into account when determining drug regimens for cancer treatment, as well as when prescribing drugs to manage treatment side effects and other chronic and acute medical problems.

Absorption. Drug absorption is affected by age-related changes in the gastrointestinal system, such as increased gastric acid secretion, decreased gastrointestinal motility, mucosal atrophy, reduced absorptive surface area, and reduced splanchnic circulation (Lichtman, 2003; Sawhney, Sehl, & Naeim, 2005). These changes result in reduced absorption of drugs and nutrients. Until recently, most chemotherapy drugs were given parenterally, so absorption was not a significant issue in cancer treatment. With the increased use of oral chemotherapeutic drugs, alterations in drug absorption become more important (Skirvin & Lichtman, 2002).

Distribution. Aging is associated with changes in body composition, including reductions in total body water, protein stores, and lean body mass and an increase in total body fat (Elmadfa & Meyer, 2008). These changes alter the distribution of chemotherapeutic agents and other drugs in older adults. The reduction in total body water decreases the distribution of drugs that are water soluble, while the increase in total body fat increases the distribution of lipid-soluble drugs. Decreases in serum albumin and hemoglobin concentration in older adults increase the distribution of drugs that bind to albumin and hemoglobin (Lichtman, 2003).

Metabolism. Drug metabolism refers to the metabolic breakdown of a drug. The liver is one of the most common sites of drug metabolism. Age-related changes in the liver, including decreased liver size, reduction in hepatic blood flow, and impairments in hepatic oxidative pathways and the cytochrome P-450 enzyme system, result in an overall reduction in the metabolic capacity of the liver (Lichtman, 2003; Sawhney et al., 2005). Several chemotherapy agents, including taxanes, cyclophosphamide (Cytoxan®), and vinca alkaloid drugs, are metabolized by cytochrome P-450 enzymes (Lichtman & Boparai, 2008). Treatment with these drugs may be affected by the concurrent use of commonly prescribed drugs and other substances that induce the cytochrome P-450 system (e.g., phenytoin [Dilantin®], phenobarbital, carbamazepine [Equetro®, Tegretol®], omeprazole [Prilosec®], St. John’s wort, cigarette smoke) or those that inhibit the system (e.g., cimetidine [Tagamet®], diltiazem [Cardizem LA®, Dilacor XR®, Tiazac®], verapamil [Calan®, Covera-HS®, Isoptin SR®, Verelan PM®], fluoxetine [Prozac®], sertraline [Zoloft®], paroxetine [Paxil®], grapefruit juice), making dosage adjustments necessary (Lichtman, 2003; Reuben et al., 2009).

Excretion. The decline in renal function that occurs with aging affects drug excretion. A reduction in renal mass leads to a decrease in functional nephrons and a decline in glo-merular filtration rate. The kidneys’ ability to appropriately concentrate or dilute urine and excrete water and electrolytes is also impaired (Luckey & Parsa, 2003; Sawhney et al., 2005). Serum creatinine level has limited usefulness for evaluating renal function in older adults due to reduction in muscle mass. Thus, creatinine clearance should be calculated and used to guide drug dosing. Many chemotherapy drugs, including platinum compounds, alkylating agents, capecitabine [Xeloda®], purine analogues, antimetabolites, camptothecins, and etoposide [Etopophos®], have significant renal excretion (Lichtman & Boparai, 2008). When these drugs are used in older adults, renal function must be evaluated carefully, and dosages reduced accordingly. The concurrent use of other nephrotoxic drugs should be avoided.

Implications for Managing Treatment Toxicities

Treatment tolerance and toxicity are significant concerns in treating older adults with cancer. Age-related physiological changes alter the effects of cancer treatment and make older adults more susceptible to the toxic effects of treatment. Treatment toxicities of particular concern when caring for older adults with cancer are myelotoxicty, mucosal toxicity, cardiotoxicity, neurotoxicity, and musculoskeletal toxicity. These are reviewed below and summarized in Table 2.

Summary of Treatment Toxicities, Age-Related Physiological Changes, Implications, and Interventions for Older Adults with CancerSummary of Treatment Toxicities, Age-Related Physiological Changes, Implications, and Interventions for Older Adults with CancerSummary of Treatment Toxicities, Age-Related Physiological Changes, Implications, and Interventions for Older Adults with Cancer

Table 2: Summary of Treatment Toxicities, Age-Related Physiological Changes, Implications, and Interventions for Older Adults with Cancer

Myelotoxicity

Myelotoxicity is a common effect of chemotherapy treatment. It often results in treatment delay and dosage reduction. Age-related changes in the bone marrow and hematopoiesis, including an increase in bone marrow fat, a reduction in stem cell mass and mobilization, and an increase in cytokines that inhibit hematopoiesis, contribute to greater myelosuppression and delayed recovery after chemotherapy in older adults (Balducci, Hardy, & Lyman, 2000). The manifestations of chemotherapy-induced myelotoxicity include neutropenia, anemia, and thrombocytopenia.

Neutropenia. Neutropenia is the primary dosage-limiting myelotoxicity. Depending on the treatment regimen, neutropenia often develops 1 to 2 weeks after the administration of chemotherapy. Neutropenia in older adults increases the risks of infectious complications and treatment-related mortality (Balducci & Repetto, 2004). Neutropenia in older adults is often more severe and more prolonged (Dees et al., 2000) and frequently results in hospitalizations and increased costs among older adults with cancer (Crawford, Dale, & Lyman, 2004).

While it is important to monitor for febrile neutropenia, older adults who are neutropenic may not exhibit common signs of infection, such as fever (Crighton & Puppione, 2006). They must be monitored for atypical signs of infection, including altered mental status or delirium, increased fatigue, loss of appetite, and changes in activity level. The routine use of prophylactic antibiotic agents is controversial because of concern about promoting antibiotic resistance; however, fluoroquinolone prophylaxis is recommended in high-risk patients with afebrile neutropenia following chemotherapy (Zitella et al., 2006). Good hand washing and minimizing exposure to potentially infectious people are the most effective ways to prevent infection. The effectiveness of the neutropenic diet or protective isolation in preventing infection has not been established (Crighton & Puppione, 2006; Zitella et al., 2006).

The NCCN (2009c) guidelines for senior adult oncology recommend the prophylactic use of colony stimulating factors (CSFs) with dosage-dense chemotherapy regimens in older adults. In addition, the NCCN (2009b) guidelines for myeloid growth factors and the most recent American Society of Clinical Oncology guidelines (T.J. Smith et al., 2006) suggest that CSFs should be used when the risk of developing febrile neutropenia is greater than 20%. The risk of developing febrile neutropenia is estimated by considering the chemotherapy regimen and dosage and patient factors, including older age, prior chemotherapy treatment, prior treatment-related neutropenia, bone marrow involvement, poor performance status, and renal or liver dysfunction (NCCN, 2009b).

Anemia. Anemia is a common problem in older adults with cancer (Penninx, Cohen, & Woodman, 2007). If anemia is present prior to starting therapy, it should be evaluated thoroughly and corrected because chemotherapeutic agents dramatically increase the incidence of anemia (Capo & Waltzman, 2004). Moreover, a reduction in red blood cells affects the pharmacokinetics of chemotherapy agents that bind with and are transported by hemoglobin, including taxanes and anthracyclines (Schrijvers, Highley, De Bruyn, Van Oosterom, & Vermorken, 1999). Mild to moderate anemia in older adults with cancer can contribute to symptoms that negatively affect quality of life.

The NCCN (2009c) guidelines for senior adult oncology recommend maintaining a hemoglobin of 12 g/dL to minimize toxicity and related symptoms. Because of increased risks for thrombosis and mortality, erythropoiesis-stimulating agents (ESAs) should not be used to correct anemia in cancer patients receiving curative treatment; rather, blood transfusions should be used to treat symptomatic anemia (NCCN, 2009a). In cancer patients receiving palliative chemotherapy treatment, the benefits and risks associated with ESAs and blood transfusions should be weighed and discussed with the patient. ESAs should not be used in cancer patients who are not receiving chemotherapy (NCCN, 2009a).

Thrombocytopenia. Thrombocytopenia also occurs following treatment with chemotherapy. The risk of spontaneous bleeding is low in patients being treated for solid tumor cancers (Capo & Waltzman, 2004). Patients with or at risk for thrombocytopenia should be instructed to monitor for and report signs and symptoms of bleeding, including petechia, bruising, nosebleeds, and blood in urine, stool, or emesis. Patients with thrombocytopenia should limit the use of drugs that affect platelet function or bleeding such as nonsteroidal anti-inflammatory drugs and aspirin. If uncontrolled bleeding occurs, platelet transfusions are required.

Mucosal Toxicity

Mucositis, an inflammation of the mucosal lining of the oral cavity and gastrointestinal (GI) tract, is a common toxicity of chemotherapy and radiation therapy. Age-related changes in the mucosa make older adults more susceptible to mucosal injury and mucositis. Diminished renal and hepatic elimination of chemotherapy agents, poor dentition, impaired nutrition, and vitamin deficiencies also contribute to mucositis in older adults (Sonis, 2004). Mucositis occurs more frequently and may be more severe and more prolonged in older adults (Crivellari et al., 2000). Mucositis places older adults at greater risk for poor outcomes including increased hospital admissions, dosage reductions or delays, greater risk of infection, severe pain requiring opioid analgesic agents, and increased treatment costs (Elting et al., 2003; Murphy, 2007).

Oral mucositis often impairs swallowing and limits nutritional and fluid intake. Oral intake may need to be supplemented by enteral or parenteral nutrition. Decreased fluid intake, nausea and vomiting, and diarrhea associated with oral and GI mucositis can rapidly lead to dehydration. In older adults, mucositis that inhibits fluid intake or results in severe diarrhea must be managed aggressively. Intravenous fluids may be needed to prevent and treat dehydration (Bond, 2006).

Cardiotoxicity

The increased prevalence of cardiac disease and cardiovascular changes associated with aging places older adults with cancer at risk for treatment-related cardiotoxicity. Cardiomyopathy with congestive heart failure (CHF) is a common cardiotoxic effect, but myocardial infarction, myocarditis, pericarditis, arrhythmias, and other electrocardiographic changes can occur (Chanan-Khan, Srinivasan, & Czuczman, 2004). Cardiotoxicity is an established complication associated with anthracycline agents, including doxorubicin (Adriamycin PFS®), daunorubicin (Cerubidine®), idarubicin (Idamycin®), and epirubicin (Ellence®). Other chemotherapeutic and biological agents, including mytomycin (Mutamycin®), cyclophosphamide (Cytoxan®), fluorouracil (Adrucil®), interferons, interleukin-2, and monoclonal antibodies (e.g., trastuzumab [Herceptin®]), also have been associated with cardiotoxicities (Meinardi et al., 2000; Suter et al., 2007; Viale & Yamamoto, 2008).

Cardiotoxicity may develop acutely during treatment or it may develop as a long-term treatment side effect (Meinardi et al., 2000). The risk of treatment-induced CHF increases with age (Pinder, Duan, Goodwin, Hortobagyi, & Giordano, 2007; Swain, Whaley, & Ewer, 2003; Tan-Chiu et al., 2005). In Pinder et al.’s (2007) study, rates of CHF in the sample increased over the 10 years of follow up. Older patients with cardiovascular risk factors and those receiving cardiotoxic agents should be monitored for cardiotoxicities during and after treatment. Baseline cardiac function should be established prior to treatment with anthracyclines and trastuzumab. Patients should be monitored for signs and symptoms of early CHF including weight gain, shortness of breath, orthopnea, and pedal edema. After it develops, CHF is treated symptomatically with pharmacological agents, including diuretic agents, angiotensin-converting enzyme inhibitors, beta blockers, and digoxin [Lanoxin®]. Healthy lifestyle behaviors (e.g., physical activity, smoking cessation, weight management, dietary modifications) are also integral in the management of CHF (Chanan-Khan et al., 2004; Viale & Yamamoto, 2008).

Neurotoxicity

Aging is associated with anatomical and physiological changes in the central and peripheral nervous systems. Neuronal loss results in a decrease in brain volume and enlargement of the cerebral ventricles. Cerebral blood flow and glucose and oxygen metabolism in the brain are reduced. The level and functioning of neurotransmitters also change (Sullivan & Pfefferbaum, 2007). Age-related changes in the central nervous system contribute to deficits in multiple cognitive processes, including memory, attention, processing speed, and executive function (Myers, 2008). Age-related nervous system changes also contribute to impairments in sensation, balance, coordination, and movement.

Delirium and Cognitive Impairment. Older adults with cancer may have baseline cognitive deficits that put them at greater risk for delirium during treatment and for long-term cognitive impairment after treatment (Extermann, 2005). In addition, multiple chemotherapy agents and radiation therapy involving the brain and adjacent areas have been associated with acute and chronic cognitive changes (Abayomi, 2002; Plotkin & Wen, 2003).

In older adults it is important to establish a baseline level of cognitive functioning before treatment and to conduct ongoing assessments during treatment to identify changes in cognitive functioning. Polypharmacy, especially the use of anticholinergic drugs and benzodiazepines, should be minimized. The lowest possible dosage should be used for necessary medications. When opioids are needed for pain control, the starting dosage should be low and the dosage should be titrated slowly. The concurrent use of adjuvant pain medications may allow the opioid dosage to be minimized. If cognitive changes occur with a particular opioid, the health care provider can consider switching to another opioid. Fluid and electrolyte imbalances can contribute to delirium and alterations in cognitive functioning. It is important to monitor for and correct electrolyte abnormalities and to prevent and aggressively treat dehydration (Bond, 2009).

Peripheral Neuropathy. Peripheral neuropathy is a common, dosage-limiting toxicity of many chemotherapy agents, including platinum compounds, taxanes, vinca alkaloid agents, thalidomide (Thalomid®), and bortezomib (Velcade®). Age-related changes in the peripheral nervous system, including a reduction in peripheral nerve myelin and the presence of comorbid diseases that affect peripheral nerves, may place older adults with cancer at risk for chemotherapy-induced peripheral neuropathy. The degree of nerve damage associated with chemotherapy depends not only on the drug and total cumulative dosage, but also on preexisting nerve damage from diabetic, alcohol, or inherited neuropathies (Quasthoff & Hartung, 2002).

Chemotherapy-induced peripheral neuropathy may have sensory, sensorimotor, or autonomic components. Sensory alterations include pain, numbness and tingling, dysesthesias, paresthesias, allodynia, and diminished or absent sensation or proprioception. Motor deficits include weakness, gait disturbance, altered balance, and impaired fine motor skills. Autonomic symptoms may include postural hypotension, constipation, urinary retention, and sexual dysfunction (Visovsky, Collins, Abbott, Ashenbrenner, & Hart, 2007). Peripheral neuropathy interferes with ADL and IADL function and negatively affects quality of life. In older adults, peripheral neuropathy may be disabling and contribute to impaired mobility and falls (Wickham, 2007).

There are no treatments to reverse neuropathy, but there are measures to prevent or reduce its occurrence (Armstrong, Almadrones, & Gilbert, 2005). Prior to starting therapy, it is important to identify patients who are at risk for developing neuropathy. Peripheral neuropathy may be prevented by minimizing the use of neurotoxic agents and by avoiding combinations of neurotoxic agents. Patients should be taught signs and symptoms of peripheral neuropathy and instructed to contact their health care provider if any are noted. Health care providers should perform a baseline assessment and ongoing assessments of sensation and motor function (Marrs & Newton, 2003). If neuropathy develops and progresses, it is important to consider discontinuation of the neurotoxic agents. The treatment of peripheral neuropathy focuses on the symptomatic relief of pain and other dysesthias and paresthesias. Patients must also be taught strategies to promote their safety and prevent further complications (Armstrong et al., 2005; Marrs & Newton, 2003; Quasthoff & Hartung, 2002; Visovsky et al., 2007).

Musculoskeletal Toxicity

Osteoporosis and osteoarthritis are common age-related conditions. In addition, cancer treatments contribute to the progression of osteoporosis and development of other musculoskeletal complications. Together these toxicities increase the risk for falls and fracture, and negatively affect quality of life in older adults with cancer. They may also lead to treatment discontinuation.

Osteoporosis. Hormonal therapies, including aromatase inhibitors (AIs) in postmenopausal women with breast cancer and androgen deprivation therapy in men with prostate cancer, decrease circulating levels of estrogen and testosterone. This reduction in hormones accelerates bone loss and contributes to the development and more rapid progression of osteoporosis. Glucocorticoids and other chemotherapy agents used in cancer treatment may also contribute to accelerated bone loss (Pfeilschifter & Diel, 2000).

Preventive strategies and treatments for osteoporosis are most effective when started early. Older adults receiving hormonal therapies and other cancer treatments that cause bone loss should undergo a baseline bone density assessment using dual-energy absorptiometry before starting treatment. Follow-up assessments should be conducted annually (Hillner et al., 2003) Calcium and vitamin D supplementation should be implemented unless there is a contraindication (e.g., hypercalcemia). The pharmacological treatment for osteoporosis includes using oral or intravenous bisphosphonates, selective estrogen receptor modifiers (e.g., tamoxifen [Nolvadex®], raloxifen [Evista®]), and calcitonin (van London, Taxel, & Van Poznak, 2008. Other lifestyle changes, such as smoking cessation, moderate alcohol use, limited caffeine intake, and engagement in weight-bearing exercise and resistance training, promote bone health and slow bone loss (Limburg, 2007; Maxwell & Viale, 2005).

Aromatase Inhibitor-Induced Arthralgias. Increasingly, AIs are being used in postmenopausal women with estrogen receptor-positive breast cancer. Women taking AIs for breast cancer treatment experience musculoskeletal side effects, including joint pain and stiffness (Altundag, Dede, Harputluoglu, & Gullu, 2007; Crew et al., 2007). AI arthralgias can affect the hands, knees, hips, lower back, and shoulders. Women previously treated with taxanes are more likely to experience musculoskeletal symptoms. Joint symptoms contribute to nonadherence and discontinuation of AIs. Anti-inflammatory drugs and opioid analgesics may be used to treat arthralgias. Adjuvant treatments, such as heat and ice or acupuncture, should be considered. Exercise is commonly used to treat osteoarthritis. Regular exercise and weight control may be helpful in managing arthralgias related to AIs (Winters, Habin, & Gallagher, 2007).

NCCN Guidelines for Senior Adult Oncology

The NCCN (2009c) has proposed guidelines for the care of older adults receiving cancer treatment. The guidelines are summarized in Table 3. The NCCN guidelines can help facilitate safe and effective cancer treatment in older adults, as well as prevent and minimize treatment toxicities.

Guidelines for Senior Adult Oncology

Table 3: Guidelines for Senior Adult Oncology

Summary

The growth of the aging population and the subsequent increase in cancer incidence result in an increasing need for nurses to develop their expertise in caring for older adults with the disease. Age-associated changes in physiological function result in diminished functional reserve of most organ systems. These changes may negatively affect the ability of older adults with cancer to tolerate treatment and increase the risk of treatment-related toxicity. An understanding of how age-related physiological changes affect treatment tolerance and toxicity in older adults with cancer is essential to improve patient outcomes.

Although standard treatment regimens may be safe and effective in older adults, the treatment of cancer in older adults requires an individualized approach. In addition to chronological age, measures of physiological age, including comorbidity and functional status, should be taken into consideration in treatment planning and decision making. Variation of standard regimens may be appropriate. Nurses have a key role in educating and supporting older adults with cancer and their caregivers as they go through the treatment process. In addition, nurses caring for older adults with cancer must anticipate and monitor closely for treatment toxicities and aggressively implement supportive care strategies to prevent and minimize complications.

References

  • Aalami, O.O., Fang, T.D., Song, H.M. & Nacamuli, R.P. (2003). Physiological features of aging persons. Archives of Surgery, 138, 1068–1076. doi:10.1001/archsurg.138.10.1068 [CrossRef]
  • Abayomi, O.K. (2002). Pathogenesis of cognitive decline following therapeutic irradiation for head and neck tumors. Acta Oncologica, 41, 346–351. doi:10.1080/028418602760169389 [CrossRef]
  • Adams, J.M. & White, M. (2004). Biological ageing: A fundamental, biological link between socio-economic status and health?European Journal of Public Health, 14, 331–334. doi:10.1093/eurpub/14.3.331 [CrossRef]
  • Altundag, K., Dede, D., Harputluoglu, H. & Gullu, I. (2007). Aromatase inhibitor-associated arthralgias: Pathogenesis, frequency and management. Joint, Bone, Spine, 74, 662–663. doi:10.1016/j.jbspin.2007.04.010 [CrossRef]
  • Armstrong, T., Almadrones, L. & Gilbert, M.R. (2005). Chemotherapy-induced peripheral neuropathy. Oncology Nursing Forum, 32, 305–311. doi:10.1188/05.ONF.305-311 [CrossRef]
  • Balducci, L., Hardy, C.L. & Lyman, G.H. (2000). Hemopoietic reserve in the older cancer patient: Clinical and economic considerations. Cancer Control, 7, 539–547.
  • Balducci, L. & Repetto, L. (2004). Increased risk of myelotoxicity in elderly patients with non-Hodgkin lymphoma: The case for routine prophylaxis with colony-stimulating factor beginning in the first cycle of chemotherapy. Cancer, 100, 6–11. doi:10.1002/cncr.11861 [CrossRef]
  • Bond, S.M. (2006). Symptom management of mucositis. In Cope, D.G. & Reb, A.M. (Eds.), An evidence-based approach to the treatment and care of the older adult with cancer (pp. 349–365). Pittsburgh, PA: Oncology Nursing Society.
  • Bond, S.M. (2009). Delirium at home: Strategies for home health clinicians. Home Healthcare Nurse, 27, 24–34. doi:10.1097/01.NHH.0000343782.11723.ea [CrossRef]
  • Capo, G. & Waltzman, R. (2004). Managing hematologic toxicities. Journal of Supportive Oncology, 2, 65–79.
  • Chanan-Khan, A., Srinivasan, S. & Czuczman, M.S. (2004). Prevention and management of cardiotoxicity from antineoplastic therapy. Journal of Supportive Oncology, 2, 251–256.
  • Chen, H., Cantor, A., Meyer, J., Corcoran, M.B., Grendys, E. & Cavanaugh, D. et al. (2003). Can older cancer patients tolerate chemotherapy? A prospective pilot study. Cancer, 97, 1107–1114. doi:10.1002/cncr.11110 [CrossRef]
  • Crawford, J., Dale, D.C. & Lyman, G.H. (2004). Chemotherapy-induced neutropenia: Risks, consequences, and new directions for its management. Cancer, 100, 228–237. doi:10.1002/cncr.11882 [CrossRef]
  • Crew, K.D., Greenlee, H., Capodice, J., Raptis, G., Brafman, L. & Fuentes, D. et al. (2007). Prevalence of joint symptoms in postmenopausal women taking aromatase inhibitors for early-stage breast cancer. Journal of Clinical Oncology, 25, 3877–3883. doi:10.1200/JCO.2007.10.7573 [CrossRef]
  • Crighton, M.H. & Puppione, A.A. (2006). Geriatric neutrophils: Implications for older adults. Seminars in Oncology Nursing, 22, 3–9. doi:10.1016/j.soncn.2005.10.002 [CrossRef]
  • Crivellari, D., Magri, M.D., Buonadonna, A., Lombardi, D., Paolello, C. & De Cicco, M. et al. (2000). Continuous infusion fluorouracil in the management of advanced breast cancer: A phase II study. Tumori, 86, 42–45.
  • Dees, E.C., O’Reilly, S., Goodman, S.N., Sartorius, S., Levine, M.A. & Jones, R.J. et al. (2000). A prospective pharmacologic evaluation of age-related toxicity of adjuvant chemotherapy in women with breast cancer. Cancer Investigation, 18, 521–529. doi:10.3109/07357900009012191 [CrossRef]
  • Elmadfa, I. & Meyer, A.L. (2008). Body composition, changing physiological functions and nutrient requirements of the elderly. Annals of Nutrition and Metabolism, 52 (Suppl. 1), 2–5. doi:10.1159/000115339 [CrossRef]
  • Elting, L.S., Cooksley, C., Chambers, M., Cantor, S.B., Manzullo, E. & Rubenstein, E.B. (2003). The burdens of cancer therapy: Clinical and economic outcomes of chemotherapy-induced mucositis. Cancer, 98, 1531–1539. doi:10.1002/cncr.11671 [CrossRef]
  • Extermann, M. (2003). Studies of comprehensive geriatric assessment in patients with cancer. Cancer Control, 10, 463–468.
  • Extermann, M. (2004). Management issues for elderly patients with breast cancer. Current Treatment Options in Oncology, 5, 161–169. doi:10.1007/s11864-004-0048-9 [CrossRef]
  • Extermann, M. (2005). Older patients, cognitive impairment, and cancer: An increasingly frequent triad. Journal of the National Comprehensive Cancer Network, 3, 593–596.
  • Extermann, M., Aapro, M., Bernabei, R., Cohen, H.J., Droz, J.P. & Lichtman, S. et al. (2005). Use of comprehensive geriatric assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Critical Reviews in Oncology/Hematology, 55, 241–252. doi:10.1016/j.critrevonc.2005.06.003 [CrossRef]
  • Extermann, M., Overcash, J., Lyman, G.H., Parr, J. & Balducci, L. (1998). Comorbidity and functional status are independent in older cancer patients. Journal of Clinical Oncology, 16, 1582–1587.
  • Firat, S., Bousamra, M., Gore, E. & Byhardt, R.W. (2002). Comorbidity and KPS are independent prognostic factors in stage I non-small-cell lung cancer. International Journal of Radiation Oncology, Biology, and Physics, 52, 1047–1057.
  • Frasci, G., Lorusso, V., Panza, N., Comella, P., Nicolella, G. & Bianco, A. et al. (2000). Gemcitabine plus vinorelbine versus vinorelbine alone in elderly patients with advanced non-small-cell lung cancer. Journal of Clinical Oncology, 18, 2529–2536.
  • Freyer, G., Geay, J.F., Touzet, S., Provencal, J., Weber, B. & Jacquin, J.P. et al. (2005). Comprehensive geriatric assessment predicts tolerance to chemotherapy and survival in elderly patients with advanced ovarian carcinoma: A GINECO study. Annals of Oncology, 16, 1795–1800. doi:10.1093/annonc/mdi368 [CrossRef]
  • Harris, D.J., Eilers, J., Harriman, A., Cashavelly, B.J. & Maxwell, C. (2008). Putting evidence into practice: Evidence-based interventions for the management of oral mucositis. Clinical Journal of Oncology Nursing, 12, 141–152. doi:10.1188/08.CJON.141-152 [CrossRef]
  • Hazzard, W.R. (2000). The clinical physiology of aging. International Urology and Nephrology, 32, 137–146. doi:10.1023/A:1007150529337 [CrossRef]
  • Hillner, B.E., Ingle, J.N., Chlebowski, R.T., Gralow, J., Yee, G.C. & Janjan, N.A. et al. (2003). American Society of Clinical Oncology 2003 update on the role of bisphosphonates and bone health issues in women with breast cancer. Journal of Clinical Oncology, 21, 4042–4057. doi:10.1200/JCO.2003.08.017 [CrossRef]
  • Hurria, A., Gupta, S., Zauderer, M., Zuckerman, E.L., Cohen, H.J. & Muss, H. et al. (2005). Developing a cancer-specific geriatric assessment: A feasibility study. Cancer, 104, 1998–2005. doi:10.1002/cncr.21422 [CrossRef]
  • Hurria, A., Lichtman, S.M., Gardes, J., Li, D., Limaye, S. & Patil, S. et al. (2007). Identifying vulnerable older adults with cancer: Integrating geriatric assessment into oncology practice. Journal of the American Geriatrics Society, 55, 1604–1608. doi:10.1111/j.1532-5415.2007.01367.x [CrossRef]
  • Ingram, S.S., Seo, P.H., Martell, R.E., Clipp, E.C., Doyle, M.E. & Montana, G.S. et al. (2002). Comprehensive assessment of the elderly cancer patient: The feasibility of self-report methodology. Journal of Clinical Oncology, 20, 770–775. doi:10.1200/JCO.20.3.770 [CrossRef]
  • Klepin, H., Mohile, S. & Hurria, A. (2009). Geriatric assessment in older patients with breast cancer. Journal of the National Comprehensive Cancer Network, 7, 226–236.
  • Kurtin, S.E. (2009). Hypertension management in the era of targeted therapies for cancer. Oncology Nurse Edition, 23(4), 41–45.
  • Lichtman, S.M. (2003). Guidelines for the treatment of elderly cancer patients. Cancer Control, 10, 445–453.
  • Lichtman, S.M. & Boparai, M.K. (2008). Anticancer drug therapy in the older cancer patient: Pharmacology and polypharmacy. Current Treatment Options in Oncology, 9, 191–203. doi:10.1007/s11864-008-0060-6 [CrossRef]
  • Lichtman, S.M., Wildiers, H., Chatelut, E., Steer, C., Budman, D. & Morrison, V.A. et al. (2007). International Society of Geriatric Oncology Chemotherapy Taskforce: Evaluation of chemotherapy in older patients—An analysis of the medical literature. Journal of Clinical Oncology, 25, 1832–1843. doi:10.1200/JCO.2007.10.6583 [CrossRef]
  • Limburg, C.E. (2007). Screening, prevention, detection, and treatment of cancer therapy-induced bone loss in patients with breast cancer. Oncology Nursing Forum, 34, 55–62. doi:10.1188/07.ONF.55-63 [CrossRef]
  • Luckey, A.E. & Parsa, C.J. (2003). Fluid and electrolytes in the aged. Archives of Surgery, 138, 1055–1060. doi:10.1001/archsurg.138.10.1055 [CrossRef]
  • Maione, P., Perrone, F., Gallo, C., Manzione, L., Piantedosi, F.V. & Barbera, S. et al. (2005). Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: A prognostic analysis of the multicenter Italian Lung Cancer in the Elderly study. Journal of Clinical Oncology, 23, 6865–6872.
  • Marrs, J. & Newton, S. (2003). Updating your peripheral neuropathy “know-how.”Clinical Journal of Oncology Nursing, 7, 299–303. doi:10.1188/03.CJON.299-303 [CrossRef]
  • Maxwell, C. & Viale, P.H. (2005). Cancer treatment-induced bone loss in patients with breast and prostate cancer. Oncology Nursing Forum, 32, 589–603. doi:10.1188/05.ONF.589-603 [CrossRef]
  • Meinardi, M.T., Gietema, J.A., van Veldhuisen, D.J., van der Graaf, W.T.A., de Vries, E.G.E. & Sleijfer, D.T. (2000). Long-term chemotherapy-related cardiovascular morbidity. Cancer Treatment Reviews, 26, 429–447. doi:10.1053/ctrv.2000.0175 [CrossRef]
  • Murphy, B.A. (2007). Clinical and economic consequences of mucositis induced by chemotherapy and/or radiation. Journal of Supportive Oncology, 5(9 Suppl. 4), 13–21.
  • Myers, J.S. (2008). Factors associated with changing cognitive function in older adults: Implications for nursing rehabilitation. Rehabilitation Nursing, 33, 117–123.
  • National Comprehensive Cancer Network. (2009a). NCCN clinical practice guidelines in oncology: Cancer-and chemotherapy-induced anemia (Version V.3.2009). Retrieved from http://www.NCCN.org
  • National Comprehensive Cancer Network. (2009b). NCCN clinical practice guidelines in oncology: Myeloid growth factors (Version V.1.2009). Retrieved from http://www.NCCN.org
  • National Comprehensive Cancer Network. (2009c). NCCN clinical practice guidelines in oncology: Senior adult oncology (Version V.1.2009). Retrieved from http://www.NCCN.org
  • Overcash, J.A., Beckstead, J., Moody, L., Extermann, M. & Cobb, S. (2006). The abbreviated Comprehensive Geriatric Assessment (aCGA) for use in the older cancer patients as a prescreen: Scoring and interpretation. Critical Reviews in Oncology/Hematology, 59, 205–210. doi:10.1016/j.critrevonc.2006.04.003 [CrossRef]
  • Penninx, B.W., Cohen, H.J. & Woodman, R.C. (2007). Anemia and cancer in older persons. Journal of Supportive Oncology, 5, 107–113.
  • Pfeilschifter, J. & Diel, I.J. (2000). Osteoporosis due to cancer treatment: Pathogenesis and management. Journal of Clinical Oncology, 18, 1570–1593.
  • Piccirillo, J.F., Tierney, R.M., Costas, I., Grove, L. & Spitznagel, E.L. Jr.. (2004). Prognostic importance of comorbidity in a hospital-based cancer registry. Journal of the American Medical Association, 291, 2441–2447. doi:10.1001/jama.291.20.2441 [CrossRef]
  • Pinder, M.C., Duan, Z., Goodwin, J.S., Hortobagyi, G.N. & Giordano, S.H. (2007). Congestive heart failure in older women treatment with adjuvant anthracycline chemotherapy for breast cancer. Journal of Clinical Oncology, 25, 3808–3815. doi:10.1200/JCO.2006.10.4976 [CrossRef]
  • Plotkin, S.R. & Wen, P.Y. (2003). Neurologic complications of cancer therapy. Neurologic Clinics, 21, 279–318. doi:10.1016/S0733-8619(02)00034-8 [CrossRef]
  • Quasthoff, S. & Hartung, H.P. (2002). Chemotherapy-induced peripheral neuropathy. Journal of Neurology, 249, 9–17. doi:10.1007/PL00007853 [CrossRef]
  • Reuben, D.B., Herr, K.A., Pacala, J.T., Pollock, B.G., Potter, J.F. & Semla, T.P. (2009). Geriatrics at your fingertips: 2009 (11th ed.). New York: American Geriatrics Society.
  • Saltzstein, S.L. & Behling, C.A. (2002). 5-and 10-year survival in cancer patients aged 90 and older: A study of 37,318 patients from SEER. Journal of Surgical Oncology, 81, 113–116. doi:10.1002/jso.10160 [CrossRef]
  • Sawhney, R., Sehl, M. & Naeim, A. (2005). Physiologic aspects of aging: Impact on cancer management and decision making, part I. Cancer Journal, 11, 449–460. doi:10.1097/00130404-200511000-00004 [CrossRef]
  • Schrijvers, D., Highley, M., De Bruyn, E., Van Oosterom, A.T. & Vermorken, J.B. (1999). Role of red blood cells in pharmacokinetics of chemotherapeutic agents. Anticancer Drugs, 10, 147–153. doi:10.1097/00001813-199902000-00002 [CrossRef]
  • Sehl, M., Sawhney, R. & Naeim, A. (2005). Physiologic aspects of aging: Impact on cancer management and decision making, part II. Cancer Journal, 11, 461–473. doi:10.1097/00130404-200511000-00005 [CrossRef]
  • Skirvin, J.A. & Lichtman, S.M. (2002). Pharmacokinetic considerations of oral chemotherapy in elderly patients with cancer. Drugs & Aging, 19, 25–42. doi:10.2165/00002512-200219010-00003 [CrossRef]
  • Sonis, S.T. (2004). Oral mucositis in cancer therapy. Journal of Supportive Oncology, 2(6 Suppl. 3), 3–8.
  • Smith, B.D., Smith, G.L., Hurria, A., Hortobagyi, G.N. & Buchholz, T.A. (2009). Future of cancer incidence in the United States: Burdens upon an aging, changing nation. Journal of Clinical Oncology. Advance online publication. doi:10.1200/JCO.2008.20.8983 doi:10.1200/JCO.2008.20.8983 [CrossRef]
  • Smith, T.J., Khatcheressian, J., Lyman, G.H., Ozer, H., Armitage, J.O. & Balducci, L. et al. (2006). 2006 update of recommendations for the use of white blood cell growth factors: An evidence-based clinical practice guideline. Journal of Clinical Oncology, 24, 3187–3205. doi:10.1200/JCO.2006.06.4451 [CrossRef]
  • Stommel, M., Given, B.A. & Given, C.W. (2002). Depression and functional status as predictors of death among cancer patients. Cancer, 94, 2719–2727. doi:10.1002/cncr.10533 [CrossRef]
  • Sullivan, E.V. & Pfefferbaum, A. (2007). Neuroradiological characterization of normal adult ageing. British Journal of Radiology, 80 (Special No. 2), S99–S108. doi:10.1259/bjr/22893432 [CrossRef]
  • Suter, T.M., Procter, M., van Veldhuisen, D.J., Muscholl, M., Bergh, J. & Carlomagno, C. et al. (2007). Trastuzumab-associated cardiac adverse effects in the Herceptin Adjuvant Trial. Journal of Clinical Oncology, 25, 3859–3865. doi:10.1200/JCO.2006.09.1611 [CrossRef]
  • Swain, S.M., Whaley, F.S. & Ewer, M.S. (2003). Congestive heart failure in patients treated with doxorubicin: A retrospective analysis of three trials. Cancer, 97, 2869–2879. doi:10.1002/cncr.11407 [CrossRef]
  • Tan-Chiu, E., Yothers, G., Romond, E., Geyer, C.E. Jr.. , Ewer, M. & Keefe, D. et al. (2005). Assessment of cardiac dysfunction in a randomized trial comparing doxorubicin and cyclophosphamide followed by paclitaxel, with or without trastuzumab as adjuvant therapy in node-positive, human epidermal growth factor receptor 2-overexpressing breast cancer: NSABP B-31. Journal of Clinical Oncology, 23, 7811–7189.
  • van Londen, G.J., Taxel, P. & Van Poznak, C. (2008). Cancer therapy and osteoporosis: Approach to evaluation and management. Seminars in Oncology, 35, 643–651. doi:10.1053/j.seminoncol.2008.08.008 [CrossRef]
  • Viale, P.H. & Yamamoto, D.S. (2008). Cardiovascular toxicity associated with cancer treatment. Clinical Journal of Oncology Nursing, 12, 627–638. doi:10.1188/08.CJON.627-638 [CrossRef]
  • Visovsky, C., Collins, M., Abbott, L., Ashenbrenner, J. & Hart, C. (2007). Putting evidence into practice: Evidence-based interventions for chemotherapy-induced peripheral neuropathy. Clinical Journal of Oncology Nursing, 11, 901–913. doi:10.1188/07.CJON.901-913 [CrossRef]
  • Wickham, R. (2007). Chemotherapy-induced peripheral neuropathy: A review and implications for oncology nursing practice. Clinical Journal of Oncology Nursing, 11, 361–376. doi:10.1188/07.CJON.361-376 [CrossRef]
  • Winters, L., Habin, K. & Gallagher, J. (2007). Aromatase inhibitors and musculoskeletal pain in patients with breast cancer. Clinical Journal of Oncology Nursing, 11, 433–439. doi:10.1188/07.CJON.433-439 [CrossRef]
  • Yancik, R. & Ries, L.A. (2000). Aging and cancer in America. Demographics and epidemiologic perspectives. Hematology/Oncology Clinics of North America, 14, 17–23. doi:10.1016/S0889-8588(05)70275-6 [CrossRef]
  • Yancik, R., Wesley, M.N., Ries, L.A., Havlik, R.J., Long, S. & Edwards, B.K. et al. (1998). Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: A population-based study. Cancer, 82, 2123–2134. doi:10.1002/(SICI)1097-0142(19980601)82:11<2123::AID-CNCR6>3.0.CO;2-W [CrossRef]
  • Zitella, L.J., Friese, C.R., Hauser, J., Gobel, B.H., Woolery, M. & O’Leary, C. et al. (2006). Putting evidence into practice: Prevention of infection. Clinical Journal of Oncology Nursing, 10, 739–750. doi:10.1188/06.CJON.739-750 [CrossRef]

Components of Comprehensive Geriatric Assessment

Cognition
Comorbidity
Emotional state
Functional status
Medication use
Nutritional status
Presence of geriatric syndromes

Dementia

Delirium

Incontinence

Osteoporosis

Failure to thrive

Falls

Pressure ulcers

Neglect and abuse

Social support

Summary of Treatment Toxicities, Age-Related Physiological Changes, Implications, and Interventions for Older Adults with Cancer

Age-Related Physiological Changes by Treatment ToxicityImplications for Cancer Treatment and ManagementInterventions to Manage Treatment-Related Toxicity
MYELOTOXICITY

Decline in hematopoietic reserve

Decreased stem cell mass and mobilization

Increased bone marrow fat

Decreased hemoglobin concentration

Impaired neutrophil, lymphocyte, and monocyte function

Increased risk for myelotoxicity

Neutropenia with increased risk for infection

Anemia with increased fatigue and other symptoms

Altered distribution of drugs that bind with hemoglobin

Thrombocytopenia with increased risk for bleeding

For neutropenia:

Monitor actual neutrophil count

Monitor for atypical signs of infection

Implement prophylactic use of colony stimulating factors

Implement fluoroquinolone prophylaxis in high-risk patients with afebrile neutropenia

Promote good hand washing and hygiene

Avoid contact with potentially infectious people

For anemia:

Treat preexisting anemia

Monitor for signs and symptoms of anemia

Monitor hemoglobin level

Maintain hemoglobin at 12 g/dL

Administer blood transfusions

Screen for vitamin B12 deficiency

Perform iron studies and initiate iron supplementation if indicated

For thrombocytopenia:

Monitor platelet count

Monitor for signs and symptoms of bleeding

Transfuse platelets for uncontrolled bleeding

CARDIOTOXICITY

Progressive loss of myocytes

Increased peripheral vascular resistance

Reduced ability to increase heart rate in response to stress and exercise

Decreased ventricular compliance with diastolic dysfunction

Decreased cardiac reserves

Increased risk of chemotherapy-induced cardiomyopathy

Increased risk for heart failure

Increased potential for arrhythmias

Increased risk for hypertension or exacerbation of existing hypertension

Increased risk for orthostatic hypotension related to drugs and dehydration

For treatment-induced cardiomyopathy:

Identify cardiac risk factors

Evaluate left ventricular function before treatment

Perform serial assessments of left ventricular function during and after treatment

Monitor for signs and symptoms of congestive heart failure

Initiate pharmacological interventions for heart failure

Promote heart-healthy lifestyle behaviors

MUCOSAL TOXICITY

Decreased saliva production

Thinning of oral mucosa

Mucosal atrophy

Altered immune response

Diminished cell proliferation and migration

Increased risk for xerostomia

Increased susceptibility for mucositis

Altered absorption of oral medications and nutrients

Increased risk for infection

Delayed wound healing

For mucositis:

Instruct patient to maintain an aggressive oral care regimen

Conduct ongoing oral examination

Use oral cryotherapy before and after bolus 5-fluorouracil

Prevent and treat oral infections

Maintain adequate pain control

Ensure adequate nutrition; consider enteral or parenteral nutrition if dysphagia develops

Aggressively treat diarrhea; consider octreotide (Sandostatin®) if oral drugs are ineffective

Maintain adequate hydration

Aggressively treat dehydration with intravenous fluid

Consider amifostine (Ethyol®) with head and neck radiation therapy

NEUROTOXICITY

Increased neuronal loss

Cortical atrophy

Diminished cerebral blood flow

Reduced cerebral glucose and oxygen metabolism

Altered levels of neurotransmitters

Reduced sensory input (i.e., vibratory, thermal, tactile, proprioceptive information)

Delayed speed of nerve conduction related to decreased myelin and myelinated fibers

Diminished autonomic responsiveness

Impaired memory and cognitive function

Slowed reaction time

Impaired vision and hearing

Increased risk for delirium

Difficulty learning and retaining information

Decreased compliance

Impaired decision-making capacity

Increased risk for peripheral neuropathy

Altered gait and balance

For delirium and cognitive impairment:

Determine baseline level of cognitive functioning

Perform ongoing assessments to monitor for changes

Minimize polypharmacy

Avoid anticholinergic drugs and benzodiazepines

Use lowest possible drug dosage

Titrate opioids slowly

Monitor for and correct electrolyte abnormalities

Prevent and aggressively treat dehydration

Monitor for and treat infections

For peripheral neuropathy:

Assess for preexisting neuropathy before treatment

Identify risk factors for neuropathy

Conduct ongoing assessments to monitor for neuropathy

Evaluate for sensory, motor, and autonomic symptoms

Use chemotherapy drugs with lowest risk for neurotoxicity

Discontinue drugs if neuropathy develops

Teach strategies to prevent falls, burns, and infection

Refer to physical therapy for assistive devices

MUSCULOSKELETAL TOXICITY

Reduced muscle mass

Decreased muscle strength

Decreased bone mineral density

Altered gait and balance

Increased risk for osteoporosis

Increased risk for falls and fracture

Joint pain and stiffness

Muscle aches

For osteoporosis:

Identify risk for osteopenia and osteoporosis

Obtain baseline bone density assessment

Conduct annual follow-up assessments

Initiate calcium and vitamin D supplements

Use pharmacological interventions

Maintain healthy lifestyle behaviors

Implement fall prevention strategies

For aromatase inhibitor (AI)-induced arthralgias:

Identify risk factors

Provide information regarding potential musculoskeletal effects

Enforce importance of medication compliance

Examine affected joints and muscles for swelling, warmth, and redness

Assess pain level

Maintain adequate pain control

Use adjuvant pain management strategies

Promote regular exercise and maintain weight control

Evaluate effectiveness of interventions

Address concerns about long-term AI therapy

Guidelines for Senior Adult Oncology

• Conduct a geriatric screening assessment on all older adults with cancer.
• Perform a more comprehensive geriatric assessment as indicated.
• Use prophylactic growth colony stimulating factors with dosage-dense chemotherapy regimens or when the risk of febrile neutropenia is ≥20%.
• Maintain hemoglobin levels ≥12g/dL.
• Adjust drug dosages to renal function.
• Consider alternatives to neurotoxic drugs.
• Evaluate hearing and monitor hearing loss with ototoxic/neurotoxic drugs.
• Assess ventricular function prior to using cardiotoxic drugs.
• Administer reduced chemotherapy dosage if palliation is the goal.
• Prevent and aggressively treat dehydration due to mucositis, diarrhea, or vomiting.
• Initiate aggressive oral care to prevent and minimize oral mucositis and infection.
• Consider amifostine (Ethyol®) with head and neck radiation therapy.
• Provide adequate nutritional support.
• Monitor closely and consider early hospitalization for symptom management.

Instructions

2.1 contact hours will be awarded for this activity. A contact hour is 60 minutes of instruction. This is a Learner-Paced Program. Vindico Medical Education does not require submission of quiz answers. A contact hour certificate will be awarded 4 to 6 weeks upon receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours:

  1. Read the article “Physiological Aging in Older Adults with Cancer: Implications for Treatment Decision Making and Toxicity Management” by Stewart M. Bond, PhD, RN, AOCN on pages 26–37, carefully noting the tables and other illustrative materials that are provided to enhance your knowledge and understanding of the content.

  2. Read each question and record your answers. After completing all questions, compare your answers to those provided at the end of the quiz.

  3. Type or print your full name, address, and date of birth in the spaces provided on the registration form.

  4. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

  5. Forward the completed form with your check or money order for $15 made payable to JGN-CNE. All payments must be made in U.S. dollars and checks must be drawn on U.S. banks. Quizzes are accepted up to 24 months from date of issue.

This activity is co-provided by Vindico Medical Education and the Journal of Gerontological Nursing. Vindico Medical Education is an approved provider of continuing nursing education by New Jersey State Nurses Association, an accredited approver, by the American Nurses Credentialing Center’s Commission on Accreditation, P#188-6/09-12.

Activity Objectives

  1. Identify the prevalence of cancers in older adults.

  2. Describe physiological characteristics of older adults that affect treatment regimens for cancer.

  3. Describe common treatment-related toxicities in older adults with cancer.

  4. Recognize interventions to manage treatment-related toxicities in older adults with cancer.

  5. Describe implications for nursing practice identified by the authors.

Author Disclosure Statement

The author discloses that he has no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Dr. Bond’s research and scholarship are supported by the John A. Hartford Foundation’s Building Academic Geriatric Nursing Capacity Award Program and the Vanderbilt University School of Nursing Postdoctoral Program.

Physiological Aging & Cancer

Bond, S.M. (2010). Physiological Aging in Older Adults with Cancer: Implications for Treatment Decision Making and Toxicity Management. Journal of Gerontological Nursing, 36(2), 26–37.

  1. Standard cancer treatments can be safe and effective in older adults, but age-related physiological changes may affect treatment tolerance and increase treatment toxicity.

  2. The treatment of cancer in older adults requires an individualized approach. Parameters of physiological age (i.e., comorbidity and functional status) rather than chronological age alone should be used to determine and tailor cancer treatment in older adults.

  3. Common treatment toxicities in older adults with cancer include myelotoxicity, mucosal toxicity, cardiotoxicity, neurotoxicity, and musculoskeletal toxicity.

  4. Nurses play a key role in educating and supporting older adults with cancer and their caregivers. Nurses must anticipate and monitor closely for treatment toxicities and implement supportive care strategies to prevent and minimize complications.

Authors

Dr. Bond is Assistant Professor of Nursing and John A. Hartford Foundation Claire M. Fagin Fellow, Vanderbilt University School of Nursing, Nashville, Tennessee.

The author discloses that he has no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Dr. Bond’s research and scholarship are supported by the John A. Hartford Foundation’s Building Academic Geriatric Nursing Capacity Award Program and the Vanderbilt University School of Nursing Postdoctoral Program.

Address correspondence to Stewart M. Bond, PhD, RN, AOCN, Assistant Professor of Nursing and John A. Hartford Foundation Claire M. Fagin Fellow, Vanderbilt University School of Nursing, 505 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240; e-mail: .stewart.m.bond@vanderbilt.edu

10.3928/00989134-20091103-98

Sign up to receive

Journal E-contents