Supportive Care of the Older Cancer Patient

  • Lodovico Balducci Email author
Part of the Cancer Drug Discovery and Development book series (CDD&D)


Cancer mainly affects individuals aged 65 and over, so that supportive care for cancer treatment concerns mostly elderly patients. Age is a risk factor for increased incidence and severity of chemotherapy-related toxicity and also for the emergence of different forms of toxicity including delirium and malnutrition; in addition age may modulate the perception of pain and the response to analgesics, and may indicate the need of a caregiver.

The National Cancer Center Network (NCCN) guidelines recommend that all cancer patients aged 70 and older undergo some form of geriatric assessment, receive dose modification to the renal function for the first dose of chemotherapy, receive prophylactic filgrastim or peg-filgrastim for moderately cytotoxic chemotherapy, have hemoglobin levels maintained around 12 g dl−1 and be treated with drugs with best toxicity profiles when that is feasible.

Though the perception of pain may decline with age, pain is endemic in the older population. Special problems include assessment, especially in cognitively impaired elderly, reduced tolerance to nonsteroidal medications, and increased susceptibility to the complications of opioids.

Delirium is a common complication of hospitalized elderly and is associated with increased risk of functional decline and of mortality. A comprehensive geriatric assessment is helpful in the prevention of delirium.

The caregiver may represent the best ally of the practitioner in the management of the older cancer patient, in allowing patients to receive timely treatment and support during emergency, and in being the spokesperson for the family. It behooves the practitioner to advise, train, and support the caregiver.

Cancer is a disease of aging. Currently, 50% of all malignances occur in 12% of the population aged 65 and older. In the year 2030, older individuals will represent 20% of the population and account for 70% of all cancer (Balducci L., Aapro M., Epidemiology of cancer and aging. Cancer Treat Res 2005, 1–16). Clearly, cancer in the older aged person is becoming the most common form of cancer. In general, older individuals may need more supportive care than the younger ones, due to increased vulnerability to stress and reduced personal and social resources. This chapter highlights the special supportive needs of older individuals with cancer after a brief overview of the biology and clinics of aging.


Elderly Supportive care Neutropenia Infection Anemia Delirium Pain Caregiver 


  1. 1.
    . Balducci L, Aapro M: Epidemiology of cancer and aging. Cancer Treat Res 2005, 1–16Google Scholar
  2. 2.
    Lipsitz LA:2004,Physiological complexity, aging, and the path to frailty. Sci Aging Knowledge Environ2004(16):pe16PubMedCrossRefGoogle Scholar
  3. 3.
    Walston A, Headley EC, Ferrucci L et al. 2006,Research agenda for frailty in older adults: Toward a better understanding of physiology and etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults J Am Geriatr Soc54(6):991–1001PubMedCrossRefGoogle Scholar
  4. 4.
    Ferrucci L, Corsi A, Lauretani F, Bandinelli S, Bartali B, Taub DD, Guralnik JM, Longo DL:2005,The origin of age-related proinflammatory state. Blood105(6):2294–2299PubMedCrossRefGoogle Scholar
  5. 5.
    Cohen HJ, Harris T, Pieper CF:2003,Coagulation and activation of inflammatory pathways in the development of functional decline and mortality in the elderly. Am J Med114:180–187PubMedCrossRefGoogle Scholar
  6. 6.
    Wilson CJ, Finch CE, Cohen HJ:2002,Cytokines and cognition: The case for head to toe inflammatory paradigm. J Am Ger Soc50:2041–2056CrossRefGoogle Scholar
  7. 7.
    Hamerman D:2004,Frailty, cancer cachexia and near death. In Balducci L, Lyman GH, Ershler WB, Extermann M:Comprehensive Geriatric Oncology, Taylor and Francis, London, pp. 236–249Google Scholar
  8. 8.
    Maggio Cappola AR, Ceda GP, et al. 2005,The hormonal pathway to frailty in older men J Endocrinol Invest28(11 Suppl Proceedings):15–19Google Scholar
  9. 9.
    Duthie E:2004,Physiology of aging: relevance to symptom perception and treatment tolerance. In: Balducci L, Lyman GH, Ershler WB, Extermann M:Comprehensive Geriatric Oncology, Taylor and Francis, London, pp. 207–222Google Scholar
  10. 10.
    Ferrucci L, Maggio M, Brandinelli S, et al. 2006,Low testosterone levels and risk of anemia in older men and women Arch Intern Med166:1380–1388PubMedCrossRefGoogle Scholar
  11. 11.
    Effros R: Proliferative senescence of lymphoid cells and aging. In Balducci L, Ershler WB, DeGaetano G: Blood Disorders in the Elderly. Cambridge University Press, Cambridge, In pressGoogle Scholar
  12. 12.
    Ble A, Fink J, Woodman R, et al. 2005,Renal function, erythropoietin and anemia of older persons: The In Chianti study Arch Intern Med,165, 2222–2227CrossRefGoogle Scholar
  13. 13.
    Balducci L , Hardy CL: Hemopoietics tree and aging. In: Balducci L, Ershler WB, DeGaetano G: Blood Disorders in the Elderly. Cambridge University Press, In pressGoogle Scholar
  14. 14.
    Carreca I, Balducci L, Extermann M:2005,Cancer chemotherapy in the older patient. Cancer Treat Rev31:380–402PubMedCrossRefGoogle Scholar
  15. 15.
    Hoquet O, Le QH, Mollet I, et al. 2004,Subclinical late cardiomyopathy after doxorubicin therapy for lymphoma in adults J Clin Oncol22(10):1864–1871CrossRefGoogle Scholar
  16. 16.
    Swain SM, Whaley FS, Ewer MS:2003,Congestive heart failure in patients treated with doxorubicin: A retrospective analysis of three trials. Cancer97(11):2869–2879PubMedCrossRefGoogle Scholar
  17. 17.
    Doyle JJ, Neugut AI, Jacobson AS, et al. 2005,Chemotherapy and cardiotoxicity in older breast cancer patients: A population-based study J Clin Oncol23(34):8597–8605PubMedCrossRefGoogle Scholar
  18. 18.
    Meyerhardt JA, Catalano PJ, Heller DG, et al. 2003,Impact of diabetes mellitus on outcomes in patients with colon cancer J Clin Oncol21(3):433–440PubMedCrossRefGoogle Scholar
  19. 19.
    Ershler WB:1993,Tumors and aging: The influence of age-associated immune changes upon tumor growth and spread. Adv Exp Med Biol330:77–92PubMedCrossRefGoogle Scholar
  20. 20.
    Lee SJ, Lindquist K, Segal MR, et al. 2006,Development and validation of a prognostic index for 4-year mortality in older adults J Am Med Assoc295(7):801–808. Erratum in: J Am Med Assoc 2006, 295(16):1900CrossRefGoogle Scholar
  21. 21.
    Mitnitski AB, Song X, Rockwood K:2004,The estimate of relative fitness and frailty in community dwelling older adults using self-report data. J Gerontol A Med Sci59:M627–M632CrossRefGoogle Scholar
  22. 22.
    Fried LP, Tangen CM, Walston J, et al. 2001,Frailty in older adults: Evidence for a phenotype J Gerontol Med Sci56A:M146–M156CrossRefGoogle Scholar
  23. 23.
    Higashi T, Shekelle PJ, Adams JL, et al. 2005,Quality of care is associated with survival in vulnerable older patients Ann Intern Med143(4):274–281PubMedGoogle Scholar
  24. 24.
    Balducci L, Cohen HJ, Engstrom PF, et al. 2005,Senior adult oncology clinical practice guidelines in oncology J Natl Compr Canc Netw3(4):572–590PubMedGoogle Scholar
  25. 25.
    Lyman GH, Dale DC, Friedberg J, et al. 2004,Incidence and predictors of low chemotherapy dose-intensity in aggressive non-Hodgkin's lymphoma: A nationwide study J Clin Oncol22(21):4302–4311PubMedCrossRefGoogle Scholar
  26. 26.
    Chrischilles E, Delgado DI, Stolshek BS, et al. 2002,Impact of age and colony stimulating factor use in hospital length of stay for febbrile neutropenia in CHOP treated non-Hodgkin's lymphoma patients Cancer Control9:203–211PubMedGoogle Scholar
  27. 27.
    Morrison VA, Picozzi V, Scotti S, et al. 2001,The impact of age on delivered dose-intensity and hospitalizations for febrile neutropenia in patients with intermediate – grade non-Hodgkin's Lymphoma receiving initial CHOP chemotherapy: A risk factor analysis Clin Lymphoma,2:47–56CrossRefGoogle Scholar
  28. 28.
    Kim YJ, Rubenstein EB, Rolston KV, et al. 2000,Colony-stimulating factors (CSFs) may reduce complications and death in solid tumor patients with fever and neutropenia Proc ASCO,19:612a, 2411abstrGoogle Scholar
  29. 29.
    Crivellari D, Bonetti M, Castiglione-Gertsch M, et al. 2000,Burdens and benefits of adjuvant cyclophosphamide, methotrexate and fluorouracil and tamoxifen for elderly patients with breast cancer: The international Breast cancer Study Group Trial vii. J Clin Oncol18(7):1412–1422PubMedGoogle Scholar
  30. 30.
    Kuderer NM, Dale DC, Crawford J, et al. 2006,Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients Cancer106(10):2258–2266PubMedCrossRefGoogle Scholar
  31. 31.
    Lyman GH, Dale DC, Crawford J:2003,Incidence and predictors of low dose-intensity in adjuvant breast cancer chemotherapy: A nationwide study of community practices. J Clin Oncol21(24):4524–4531PubMedCrossRefGoogle Scholar
  32. 32.
    Gafter-Gvili A, Fraser A, Paul M, et al. 2005,Meta-analysis: Antibiotic prophylaxis reduces mortality in neutropenic patients Ann Intern Med142(12 Pt 1):979–995PubMedGoogle Scholar
  33. 33.
    Bucaneve G, Micozzi A, Menichetti F, et al. 2005,the Gruppo Italiano Malattie Ematologiche dell'Adulto (GIMEMA) Infection Program: Levofloxocin to prevent bacterial infections in patients with cancer and neutropenia. N Engl J Med353:977–987PubMedCrossRefGoogle Scholar
  34. 34.
    Cullen M, Steven N, Billingham L, et al. 2005,the Simple Investigation in Neutropenic Individuals of the Frequency of Infection after Chemotherapy +/– Antibiotic in a Number of Tumours (SIGNIFICANT) Trial Group: Antibiotic prophylaxis after chemotherapy for solid tumors and lymphoma N Engl J Med353:988–998PubMedCrossRefGoogle Scholar
  35. 35.
    Timmer-Bonte JN, de Boo TM, Smit AJ, et al. 2005,Prevention of chemotherapy-induced febrile neutropenia by prophylactic antibiotics plus or minus granulocyte colony-stimulating factor in small-cell lung cancer: A Dutch Randomized Phase III Study J Clin Oncol23(31):7974–7984PubMedCrossRefGoogle Scholar
  36. 36.
    Zinzani PG, Storti S, Zaccaria A, et al. 1999,Elderly aggressive histology Non-Hodgkin's Lymphoma: First Line VNCOP-B Regimen: Experience on 350 patients Blood94:33–38PubMedGoogle Scholar
  37. 37.
    Sonneveld P, de Ridder M, van der Lelie H, et al. 1995,Comparison of doxorubicin and mitoxantrone in the treatment of elderly patients with advanced diffuse non-Hodgkin's lymphoma using CHOP vs CNOP chemotherapy J Clin Oncol132530–2539PubMedGoogle Scholar
  38. 38.
    Osby E, Hagberg H, Kvaloy S, et al. 2003,CHOP is superior to CNOP in elderly patients with aggressive lymphoma while outcome is unaffected by filgrastim treatment: Results of a Nordic Lymphoma Group randomized trial Blood101:3840–3848PubMedCrossRefGoogle Scholar
  39. 39.
    Doorduijn JK, van derr Holt B, van der hem KG, et al. 2003,CHOP compared with CHOP plus granulocyte colony-stimulating factor in elderly patients with aggressive non-Hodgkin's lymphoma J Clin Oncol21(16):3041–3050PubMedCrossRefGoogle Scholar
  40. 40.
    Balducci L, Tam J, Al-Halawani H, et al: A large study of the older cancer patient in the community setting: Initial report of a randomized controlled trial using pegfilgrastim to reduce neutropenic complications. ASCO Meeting Abstracts Jun 1 2005: 8111Google Scholar
  41. 41.
    Smith TJ, Katcheressian J, Liman GH, et al. 2006,2006 Update of recommendations for the use of white blood cell growth factors: An evidence-based clinical practice guideline J Clin Oncol24(19):3187–3205PubMedCrossRefGoogle Scholar
  42. 42.
    Repettol L, Biganzoli L, Koehne CH, et al. 2003,EORTC Cancer in the Elderly Task Force guidelines for the use of colony-stimulating factors in elderly patients with cancer Eur J Cancer39(16):2264–2272. ReviewCrossRefGoogle Scholar
  43. 43.
    Balducci L : Anemia and aging or anemia of aging? Cancer Treat Res, In pressGoogle Scholar
  44. 44.
    Balducci L : Anemia, cancer and aging. Oncology, In pressGoogle Scholar
  45. 45.
    Stabler S : B 12 deficiency. In: Balducci L, Ershler WB, DeGaetano G: Blood Disorders in the Elderly. Cambridge University Press, In pressGoogle Scholar
  46. 46.
    Ferrucci L, Guralnik L, Woodman RC, et al. 2005,Proinflammatory state and circulating erythropoietin in persons with and without anemia Am J Med118:1288–1296BPubMedCrossRefGoogle Scholar
  47. 47.
    Ershler WB : The pathogenesis of late age anemia. In: Balducci L, Ershler WB, DeGaetano G: Blood Disorders in the Elderly. Cambridge University Press, In pressGoogle Scholar
  48. 48.
    Ganz T : Regulation of iron metabolism. In: Balducci L, Ershler WB, DeGaetano G: Blood Disorders in the Elderly. Cambridge University Press, 2006, In pressGoogle Scholar
  49. 49.
    Extermann M, Chen A, Cantor AB, Corcoran MB, Meyer J, Grendys E, Cavanaugh D, Antonek S, Camarata A, Haley WE, Balducci L:2002,Predictors of tolerance from chemotherapy in older patients: A prospective pilot study. Eur J Cancer38(11):1466–1473PubMedCrossRefGoogle Scholar
  50. 50.
    Schrijvers D, Highley M, DeBruyn E, Van Oosterom AT, Vermorken JB:1999,Role of red blood cell in pharmacokinetics of chemotherapeutic agents. Anticancer Drugs10:147–153PubMedCrossRefGoogle Scholar
  51. 51.
    Ratain MJ, Schilsky RL, Choi KE, et al. 1989,Adaptive control of etoposide administration: Impact of interpatient pharmacodynamic variability. Clin Pharmacol Ther45:226–233PubMedCrossRefGoogle Scholar
  52. 52.
    Silber JH, Fridman M, Di Paola RS, et al. 1998,First-cycle blood counts and subsequent neutropenia, dose reduction or delay in early stage breast cancer therapy. J Clin Oncol16:2392–2400PubMedGoogle Scholar
  53. 53.
    Wolff D, Culakova E, Poniewierski MS, et al. 2005,Predictors of chemotherapy-induced neutropenia and its complications: Results from a propsective nationwide Registry J Support Oncol3(6 supp 4):24–25PubMedGoogle Scholar
  54. 54.
    Penninx BW, Pahor M, Cesari M, et al. 2004,Anemia is associated with disability and decreased physical performance and muscle strength in the elderly J Am Geriatr Soc52:719–724PubMedCrossRefGoogle Scholar
  55. 55.
    Penninx BW, Pluijm SM, Lips P, et al. 2005,Late life anemia is associated with increased risk of recurrent falls J Am Geriatr Soc53:2106–2111PubMedCrossRefGoogle Scholar
  56. 56.
    Curt GA, Breitbart W, Cella D, et al. 2000,Impact of cancer-related fatigue on the lives of patients: New findings from the fatigue coalition. Oncologist5(5):353–360PubMedCrossRefGoogle Scholar
  57. 57.
    Heiss , MMMempel WDelanoff C, Jauch KW, Gabka C, Mempel M, Dieterich HJ, Eissner HJ, Schildberg FW. 1994,Blood transfusion-modulated tumor recurrence: First results of a randomized study of autologous versus allogeneic blood transfusion in colorectal cancer surgery. J Clin Oncol12(9):1859–1867PubMedGoogle Scholar
  58. 58.
    Stasi R, Amadori S, Littlewood TJ, et al. 2005,Management of cancer-related anemia with erythropoietic agents: Doubts, certainties, and concerns. Oncologist,10:539–554CrossRefGoogle Scholar
  59. 59.
    Ferrucci L , Longo DL: Clinical consequences of anemia in the older person. In: Balducci L, Ershler WB, DeGaetano G: Blood Disorders in the Elderly. Cambridge University Press, In pressGoogle Scholar
  60. 60.
    Bohlius J, Langersiepen S, Schwarzer G, et al. 2006,Recombinant human erythropoietins and cancer patients: Updated meta-analysis of 57 studies including 9353 patients J Natl Cancer Inst98(10):708–714PubMedCrossRefGoogle Scholar
  61. 61.
    Henke M, Laszig R, Rube C,. et al. 2003,Erythropoietin to treat head and neck cancer in patients with anaemia undergoing radiotherapy: Randomized, double-blind, placebo-controlled trial. Lancet362:1255–1260PubMedCrossRefGoogle Scholar
  62. 62.
    Leyland-Jones B. 2003,Breast cancer trial with erythropoietin terminated unexpectedly. Lancet Oncol4:459–469PubMedCrossRefGoogle Scholar
  63. 63.
    Henke M, Mattern D, Pepe M, et al. 2006,Do erythropoietin receptors on cancer cells explain unexpected clinical findings? J Clin Oncol24(29):4708–4713PubMedCrossRefGoogle Scholar
  64. 64.
    Boccia R, Malik AI, Raja V, et al. 2006,Darbepoetin alfa administered every three weeks is effective for the treatment of chemotherapy-induced anemia Oncologist11(4):409–417PubMedCrossRefGoogle Scholar
  65. 65.
    Auerbach M, Ballard H, Trout JR, et al. 2004,Intravenous iron optimizes the response to recombinant human erythropoietin in cancer patients with chemotherapy-related anemia: A multicenter, open-label, randomized trial J Clin Oncol22:1301–1307PubMedCrossRefGoogle Scholar
  66. 66.
    Jacobson SD, Cha S, Sargent DJ, et al. 2001,Tolerability, dose intensity and benefit of 5FU based chemotherapy for advanced colorectal cancer (CRC) in the elderly. A North Central Cancer Treatment Group Study Proc Am Soc Clin Oncol20:384a, 1534abstr.Google Scholar
  67. 67.
    Bijleven L, Sonis S:2006,Palifermin (recombinant keratinocyte growth factor-1): A pleiotropic growth factor with multiple biological activities in preventing chemotherapy- and radiotherapy-induced mucositis. Ann Oncol18(5):817–826Google Scholar
  68. 68.
    Hortobagy GN:1997,Anthracyclines in the treatment of cancer. An overview. Drugs. 54(Suppl 4):1–7CrossRefGoogle Scholar
  69. 69.
    Cvektovik RS, Scott LJ:2005,Dexrazoxane: A review of its use for cardioprotection during anthracycline chemotherapy. Drugs65(7):1005–1024CrossRefGoogle Scholar
  70. 70.
    Ewer MS, Martin FJ, Henderson C, et al. 2004,Cardiac safety of liposomal anthracyclines Semin Oncol31(6 Suppl 13):161–181PubMedCrossRefGoogle Scholar
  71. 71.
    Keating ML, O'malley AJ, Smith MR:2006,Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. J Clin Oncol24(27):4448–4456PubMedCrossRefGoogle Scholar
  72. 72.
    Shainian VB, Kuo YF, Freeman JL, et al. 2005,Risk of fracture after androgen deprivation for prostate cancer N Engl J Med352(2):154–164CrossRefGoogle Scholar
  73. 73.
    Smith MR:2003,Bisphosphonates to prevent osteoporosis in men receiving androgen deprivation therapy for prostate cancer. Drugs Aging20(3):175–183PubMedCrossRefGoogle Scholar
  74. 74.
    Higano C:2006,Androgen deprivation therapy: Monitoring and managing the complications. Hematol Oncol Clin North Am20(4):909–923PubMedCrossRefGoogle Scholar
  75. 75.
    Hirbe A, Morgan EA, Uluckan O:2006,Skeletal complications of breast cancer therapies. Clin Cancer Res12(20):6309s–6314sPubMedCrossRefGoogle Scholar
  76. 76.
    Reiner A, Lacasse C:2006,Symptom correlates in the gero-oncology population. Semin Oncol Nurs22(1):20–30PubMedCrossRefGoogle Scholar
  77. 77.
    Balducci L:2003,Management of cancer pain in geriatric patients. J Support Oncol1(3):175–191PubMedGoogle Scholar
  78. 78.
    Anonymous: 1997,Management of cancer pain in older patients. AGS Clinical Practice Committee. J Am Geriatr Soc45(10):1273–1276Google Scholar
  79. 79.
    Stolee LM, Hillier: 2005,Instruments for the assessment of pain in older persons with cognitive impairment. J Am Geriatr Soc53(2):319–326Google Scholar
  80. 80.
    Wilder-Smith OH:2005,Opioid use in the elderly. Eur J Pain9(2):137–140PubMedCrossRefGoogle Scholar
  81. 81.
    Inouye SK:2006,Delirium in older persons. N Engl J Med354(11):1157–1165PubMedCrossRefGoogle Scholar
  82. 82.
    McKusker J, Cole M, Dendukuri N, et al. 2003,The course of delirium in older medical inpatients: A prospective study J Gen Intern Med18(9):696–704CrossRefGoogle Scholar
  83. 83.
    Lacasse H, Perrault MM, Willamson DR:2006,Systematic review of antipsychotics for the treatment of hospital-associated delirium in medically or surgically ill patients. Ann Pharmacother40 (11):1966–1973PubMedCrossRefGoogle Scholar
  84. 84.
    Inouye SK, Zhang Y, Han L, et al. 2006,Recoverable cognitive dysfunction at hospital admission in older persons during acute illness J Gen Intern Med21 (12):1276–1281PubMedCrossRefGoogle Scholar
  85. 85.
    McAway GJ, Van Ness TH, Bogardus PH, et al. 2006,Older adults discharged from the hospital with delirium: 1-year outcomes J Am Geriatr Soc54(8):1245–1250CrossRefGoogle Scholar
  86. 86.
    Extermann M, Overcash J, Lyman GH, et al. 1998,Comorbidity and functional status are independent in older cancer patients J Clin Oncol16:1582–1587PubMedGoogle Scholar
  87. 87.
    Melton LJ, khosla S, Crowson CS, et al. 2000,Epidemiology of sarcopenia J Am Ger Soc48:625–630Google Scholar
  88. 88.
    Fisher A:2004,Of worms and women. Sarcopenia and its role in disability and mortality. J Am Ger Soc52:1185–1190CrossRefGoogle Scholar
  89. 89.
    Guigoz Y, Vellas B, Garry PJ:1997,Mininutritional assessment: A practical assessment tool for grading the nutritional state of elderly patients. In: Facts, Research, Interventions in Geriatrics, Serdi, New York, pp. 15–60Google Scholar
  90. 90.
    Weitzner MA, Haley WE, Chen H:2000,The family caregiver of the older cancer patient. Hematol Oncol Clin14:269–282CrossRefGoogle Scholar
  91. 91.
    Haley WH, Burton AM, LaMonda LA:2004,Family caregiving issues for older cancer patients. In Balducci L, Lyman GH, Ershler WB, Extermann M:Comprehensive Geriatric Oncology, Taylor and Francis, London, pp. 843–852Google Scholar

Copyright information

© Humana Press, a part of Springer Science + Business Media, LLC 2009

Authors and Affiliations

  1. 1.Department of Interdisciplinary Oncology, Division of Geriatric Oncology,H. Lee Moffitt Cancer Center and Research Institute, University of South Florida College of Medicine,TampaUSA

Personalised recommendations