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Clinical Practice Guidelines in Oncology – v.1.2005 Senior Adult Oncology Version 1.2005 Continue Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References NCCN Senior Adult Oncology Panel Members * Writing Committee Member Lodovico Balducci, MD/Chair H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida Harvey Jay Cohen, MD Duke Comprehensive Cancer Center Paul F. Engstrom, MD Fox Chase Cancer Center David S. Ettinger, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Leo I. Gordon, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Jeffrey Halter, MD University of Michigan Comprehensive Cancer Center Krystyna Kiel, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Andrew Kneier, PhD UCSF Comprehensive Cancer Center Dean Lim, MD City of Hope Cancer Center Stephen H. Petersdorf, MD Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance Ronnie Rosenthal, MD Consultant Rebecca Silliman, MD, PhD Consultant Jennifer Temel, MD Dana-Farber/Partners CancerCare Julie M. Vose, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Michael J. Walker, MD Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University Babu Zachariah, MD H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida Continue * Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References Table of Contents NCCN Senior Adult Oncology Panel Members Guidelines Index Print the Senior Adult Oncology Guideline Screening, Assessment, and Findings (SAO-1) Special Considerations (SAO-2) Upper, Middle, and Lower Quartiles of Life Expectancy for Women and Men at Selected Ages (SAO-A) Specific Issues Related to the Management of Cancer in Older Patients (SAO-B) Disease-Specific Issues Related to Age (SAO-C) Comprehensive Geriatric Assessment (SAO-D) Criteria Used to Define Frailty (SAO-E) Procedure for Functional Assessment Screening in Elderly Persons (SAO-F) Vulnerable Elders Survey - VES-13 (SAO-G) These guidelines are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2005. For help using these documents, please click here Manuscript References Clinical Trials: Categories of Consensus:NCCN The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN member institutions, All recommendations are Category 2A unless otherwise specified. See NCCN click here: nccn.org/clinical_trials/physician.html NCCN Categories of Consensus Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. ASSESSMENTd � � � � Estimate life expectancy based on function and comorbidity Estimate risk of morbidity from cancer: Stage at diagnosis Risk of recurrence and progression Aggressiveness of disease Assessment of conditions (including geriatric syndromes) that would interfere with cancer treatment and tolerability: Malnutrition Polypharmacy Lack of social support a � � � � � � � � � b,c Depression Dementia Fall risk Patient’s goals of treatment a c e f . and Patients with complex biomedical, functional, and psychosocial needs may benefit from a comprehensive geriatric assessment. and ). It is expected that this will comprise 5-10% of patients. b d and See Histograms for age-specific future life expectancy(SAO-A) See Specific Issues Related to the Management of Cancer in Older Patients (SAO-B) See Procedure for Functional Assessment Screening in Elderly Persons (SAO-F) Vulnerable Elders Survey (VES-13) (SAO-G Disease Specific Issues Related to Age (SAO-C). See Comprehensive Geriatric Assessment (SAO-D) Criteria Used to Define Frailty (SAO-E). FINDINGS Expected to die of cancer or experience complications within lifetime Life expectancy less than developing morbidity from cancer Functionally independent (ADL and IADL independent) Major functional impairment and/or complex comorbidityf Symptom management Supportive care See NCCN Supportive Care Guidelines Geriatric assessment Evaluate functional dependency and comorbidity Detect and correct reversible conditions that may interfere with treatment � � e SAO-1 Symptom management Supportive care See NCCN Supportive Care Guidelines Intermediate functional impairment Specialized precautions, individualized treatment according to patient preferences and caregiver availability SCREENING Able to tolerate treatment Not able to tolerate treatment or declines therapy Able to tolerate treatment Not able to tolerate treatment or declines therapy See Treatment (SAO-2) Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Able to tolerate treatment Surgical Radiation Chemotherapy � � In general, age is not a primary consideration for surgical risk Assess physiologic status (Using standard surgical evaluation tools) Neurotoxicity Cardiac Bone marrow Renal Mucositis � � � � Avoid cisplatin/paclitaxel combination regimens when possible Consider alternative regimens with non-neurotoxic drugs Monitor hearing loss and avoid neurotoxic agents if significant hearing loss present Monitor cerebellum function if high dose cytarabine � � � Imaging assessment of ventricular function MUGA scan Symptomatic or asymptomatic with ejection fraction of < 45% Non-anthracycline, liposomal doxorubicin, mitoxantrone, dexrazoxane consider alternative � � � � � � Prophylactic colony stimulating factors when dose intensity required for response or cure (eg, Decreased dose of chemotherapy if palliation is the goal Maintain hemoglobin levels 12g/dL Concurrent RT/Chemotherapy often not well tolerated, consider sequential therapy Use of growth factors for all patients age 65 y treated with CHOP or CHOP-like chemotherapy) � (See NCCN Cancer and Treatment Related Anemia Guidelines) Adjust dose for glomerular filtration rate (GFR) to reduce systemic toxicity � � � � � � � Give rest period if prolonged infusion Consider capecitabine instead of 5-FU Early hospitalization in patients who develop dysphagia/diarrhea Nutritional support Oral prophylaxis Consider amifostine with head and neck RT Nutrition if RT induced mucositis � � � Use caution with concurrent RT/Chemotherapy, dose modification of chemotherapy may be necessary Consider amifostine with head and neck RT Nutrition and pain control if RT induced mucositis SPECIAL CONSIDERATIONSg SAO-2 gMonitor function, comorbidities, social circumstances, pain, nutrition and distress for all therapies. Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SAO-A UPPER, MIDDLE, AND LOWER QUARTILES OF LIFE EXPECTANCY FOR WOMEN AND MEN AT SELECTED AGES Reprinted and adapted with permission from Walter LC, Covinsky KE. Cancer screening in elderly patients. JAMA 2001;285:2750-2756. A B Life Expectancy for Women Life Expectancy for Men 25 20 15 10 5 0 25 20 15 10 5 0 70 75 80 85 90 95 70 75 80 85 90 95 Age, y 15.7 21.3 9.5 17 11.9 6.8 13 8.6 4.6 9.6 5.9 2.9 6.8 3.9 1.8 4.8 2.7 1.1 1 2.3 4.3 1.5 3.2 5.8 2.2 4.7 7.9 3.3 6.7 10.8 4.9 9.3 14.2 18 12.4 6.7 Top 25th Percentile 50th Percentile Lowest 25th Percentile Years Years Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SAO-B � � � � � � � � � � � � � � � � Detect and correct reversible conditions that may interfere with treatment Geriatric assessment of the older individual Life expectancy Tolerance for treatment Ability of patient to make decisions Amelioration of treatment complications Use of hematopoietic growth factors Control of anemia Dose adjustment of chemotherapy agents Disease-specific issues ( ) Acute myelogenous leukemia Non-Hodgkin's lymphomas Breast cancer Colorectal cancer Lung cancer Management of patients unfit for standard treatment See SAO-C SPECIFIC ISSUES RELATED TO THE MANAGEMENT OF CANCER IN OLDER PATIENTS Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References Disease AML Non-Hodgkin's lymphomas, large cells Breast cancer Colorectal cancer Lung cancer (non---small cell) Ovarian cancer Age-Related Changes � � � � � � � Decreased sensitivity to chemotherapy secondary to increased prevalence of MDR1 Unfavorable cytogenetic profiles Decreased duration of complete response, possibly secondary to increased circulating levels of interleukin-6 More indolent course, secondary to higher prevalence of a well- differentiated hormone-receptor rich, slowly proliferating tumor(s) and to a hormonal and immunologic milieu that is unfavorable to the tumor(s) Decreased tolerance of fluorinated pyrimidines Reduced tolerance of combined- modality treatment in stage III Decreased response rate to cytotoxic chemotherapy Clinical Problems � � � � � � � � � � � � � � Reversal of MDR1 Role of low-dose cytarabine Supportive care Use of chemotherapy in higher doses Biological treatment Alternative regimens Value of radiotherapy after lumpectomy Primary hormonal treatment Value of adjuvant chemotherapy Value of lymph node dissection Use of epirubicin or liposomal doxorubicin in lieu of doxorubicin Explore alternative forms of adjuvant therapy Explore alternative forms of treatment Explore alternative approaches DISEASE-SPECIFIC ISSUES RELATED TO AGE AML, acute myelogenous leukemia; MDR1, multiple drug resistance gene Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SAO-C Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References Assessment � � � � � � � � � � � � � � � � � � � � Activities of daily living (ADL) – Eating, dressing, continence, grooming, transferring, using the bathroom Instrumental activities of daily living (IADL) – Using transportation, managing money, taking medications, shopping, preparing meals, doing laundry, doing housework, using telephone Performance status Number of comorbid conditions Seriousness of comorbid conditions (comorbidity index) Living conditions Presence and adequacy of caregiver Income Access to transportation Dementia---Mini-Mental Status (MMS), other Depression---Geriatric Depression Scale (GDS) Delirium---For minimal infection or medication Falls ( 1 per month) Osteoporosis (spontaneous fractures) Neglect and abuse Failure to thrive Persistent dizziness Number of medications Drug-drug interactions Nutritional risk---Mini-Nutritional Assessment (MNA) � Parameter Function Comorbidity Socioeconomic issues Geriatric syndromes Polypharmacy Nutrition COMPREHENSIVE GERIATRIC ASSESSMENT SAO-D Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References SAO-E Variable Weight loss Exhaustion Physical activity Walk time (cutoff times are gender and height specific) Grip strength (cutoffs are gender and BMI specific) Question Men:¶ Women:¶ Men: Women: “In the past year, have you lost more than 10 lb unintentionally (ie, not due to dieting or exercise)?” Using the CES depression scale, the following two statements are read. (a) I felt that everything I did was an effort. (b) I could not get going. The question is asked: “How often in the last week did you feel this way?”† Based on the short version of the Minnesota Leisure Time Activity questionnaire, subjects are asked about whether they do walking, chores (moderately strenuous), mowing the lawn, raking, gardening, hiking, jogging, biking, exercise cycling, dancing, aerobics, bowling, golf, singles or doubles tennis, racquetball, calisthenics, swimming. Height 173 cm Height 159 cm Height > 173 cm Height > 159 cm BMI 24 BMI 23 BMI = 24.1 – 26 BMI = 23.1---26 BMI = 26.1 – 28 BMI = 26.1---29 BMI > 28 BMI > 29 � � � � Criteria Men: Women: Men: Women: Men: Women: If yes, then subject is frail for weight loss criterion.* Subjects answering “2” or “3” to either of these questions are categorized as frail by the exhaustion criterion.† Those with physical activity < 383 Kcals/wk are frail.‡ Those with physical activity < 270 Kcals/wk are frail.‡ Cutoff for time to walk 15 ft criterion for frailty: 7 seconds 7 seconds 6 seconds 6 seconds Cutoff for grip strength (Kg) criterion for frailty: 29 17 30 17.3 30 18 32 21 � � � � � � � � � � � � CRITERIA USED TO DEFINE FRAILTY BMI, body mass index; CES, Center for Epidemiological Studies. Adapted with permission from Fried L, Tangen C, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci 2001;56A:M146-M156. *At follow-up, weight loss is calculated as: (weight in previous year minus current measured weight)/(weight in previous year) = K. If K 0.05 and the subject does not report that he/she was trying to lose weight (ie, unintentional weight loss of at least 5% of previous year's body weight), then subject is considered frail for weight loss. †0 = rarely or none of the time (< 1 day); 1 = some or a little of the time (1-2 days); 2 = a moderate amount of the time (3-4 days); or 3 = most of the time. ‡Kcals/wk expended are calculated using a standardized algorithm. ¶A medium height is used. � Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Senior Adult Oncology Version 1.2005, 03-01-05 © 2005 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN ® Practice Guidelines in Oncology – v.1.2005 Guidelines Index Senior Adult Oncology TOC MS, References SAO-F Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Target Area Vision Hearing Arm Leg Urinary incontinence Nutrition Mental status Depression ADL-IADL Home environment Social support PROCEDURE FOR FUNCTIONAL ASSESSMENT SCREENING IN ELDERLY PERSONS Assessment Procedure Test each eye with Jaeger card while patient wears corrective lenses (if applicable) Whisper a short, easily answered question, such as “What is your name?” in each ear while the examiner's face is out of direct view. Proximal: “Touch the back of your head with both hands.” Distal: “Pick up the spoon.” Observe the patient after asking “Rise from your chair, walk 10 ft, return, and sit down.”* Ask patient: “Do you ever lose your urine and get wet?” Weigh the patient. Measure height. Tell the patient: “I am going to name three objects (pencil, truck, book). I will ask you to repeat their names now and then again a few minutes from now.”† Ask patient: “Do you often feel sad or depressed?” Ask patient: “Can you get out of bed yourself?”; “Can you dress yourself?”; “Can you make your own meals?”; “Can you do your own shopping?” Ask patient: “Do you have trouble with sta