‘Silver tsunami’ requires ‘all-hands-on-deck’ approach to cancer survivorship

The number of cancer survivors in the United States is projected to swell from 15.5 million in 2016 to more than 26 million by 2040.

By then, nearly three-quarters of cancer survivors are expected to be older than age 65 years, according to a study led by Shirley M. Bluethmann, PhD, MPH, postdoctoral cancer prevention fellow at the NCI.

If these estimates hold, the number of American cancer survivors aged 65 to 74 years will have increased by sixfold between 1975 and 2040. The number aged 75 to 84 will have increased by 10-fold during that time, and the number aged 85 years or older will have increased by 17-fold.

This “silver tsunami” — first described by Bartels and colleagues in 2013 to describe the growing population of older adults in the United States — threatens to place a tremendous burden on the geriatric oncology community. The number of clinicians trained specifically to care for older adults is not expected to change considerably, prompting researchers to question whether the U.S. health care system is prepared for the impending wave of nearly 19 million baby boomer–era cancer survivors.

“That’s a very important question,” Bluethmann told HemOnc Today. “Do we have enough geriatricians to meet the needs of these survivors?

“We have wonderful geriatricians, but certainly they cannot do it alone,” Bluethmann added. “This is really more of an all-hands-on-deck scenario. We need to engage the broader medical community — including primary care providers and midlevel providers, ensuring that they have adequate geriatric training — and think more creatively and adaptively about how we can accommodate the needs of this growing population.”

HemOnc Today spoke with geriatric oncology providers about the impact this trend will have on health care delivery in the United States, the unique complications elderly survivors experience from cancer treatment, and the efforts underway to ensure this growing population receives the best possible care.

Health care impact

Geriatric cancer survivors require specialized care to address comorbidities and late complications of treatment, as well as monitor them for recurrence or secondary malignancies.

“It’s on us to give people quality survivorship years and allow them to live productive, healthy lives,” Arti Hurria, MD, director of cancer and aging research at City of Hope and a HemOnc Today Editorial Board member, said in an interview. “Most of our research is focused on the treatment phase, and rightly so. You won’t have survivorship without treatment. But we’re realizing it is as important — if not more important — to understand the long-term impacts of therapy and figure out how we decrease those risks.”

In 2015, there were 46.8 million Americans aged older than 65 years but only 7,428 certified geriatricians to care for them, according to data from The American Geriatrics Society. That equates to one geriatrician for every 6,299 people.

“From a geriatrician’s point of view, we’re never going to have enough pure geriatricians — much less dually trained, board-certifed geriatric oncologists — in the world to take care of the number of people we’re going to have,” William Dale, MD, PhD, associate professor of medicine at University of Chicago Medicine, told HemOnc Today.

The American Geriatrics Society estimates that, to meet projected demand, medical schools would have to train at least 6,250 additional geriatricians between now and 2030, or about 450 more per year than the current rate.

“Fellowship programs in geriatrics have had basically flat enrollments for years now,” Dale said. “We are never going to catch up to the demand if what we are counting on is having enough geriatric specialty-trained people in the world.

“It does not mean we should give up trying to provide care for older adults,” Dale added. “It means we need multiple strategies for how to take care of them. It’s going to require what I call ‘primary geriatric oncology’ care.”

In that model, general oncologists, surgical oncologists and radiation oncologists, with additional training in geriatrics, would serve as the first layer of care, followed by oncologic-based nurses, social workers, physical therapists and nutritionists with such training, Dale said.

“The workforce is going to have to be reconfigured,” he said. “We use the term ‘geriatricized,’ meaning that all the different providers have some age-specific training. All of those other fields are going to have to learn at least some of the principles of geriatrics.”

In 2007, 211,402 PCPs specialized in family medicine, internal medicine or pediatrics. However, only 11,802 physicians — or one for every 25,557 Americans — specialized in hematology/oncology, according to Anne Blaes, MD, hematologist/oncologist at University of Minnesota and a HemOnc Today Editorial Board member.

“We’re going to have a big shortage of oncologists, so we have to figure out how we’re going to provide care for all of these patients,” Blaes said in an interview. “Patients who see a primary care physician and an oncologist get better care. They’re more likely to get influenza vaccines, pneumococcal vaccines and shingles vaccines, and it’s really important to get that preventive care.”

Cancer-specific comorbidities

Older cancer survivors require nuanced care because the challenges they face often are unique to the malignancy for which they were treated. The prevalence of certain cancers, and their corresponding comorbidities, also differs by patient gender.

In their study, Bluethmann and colleagues noted that overall cancer prevalence was similar between men and women of all ages, but that cancer prevalence among men was higher than that for women in every age bracket analyzed after the age of 65 years.

The number of cases among men exceeded cases among women by 2% among those aged 65 to 70 years; 5% among those aged 70 to 74 years; 8% among those aged 75 to 79 years; 11% among those aged 80 to 89 years; and 12% among those aged older than 90 years.

The most common cancers for elderly men are lung, prostate and colon cancers. For women, lung and breast cancers top the list.

Bluethmann and colleagues found that among cancer survivors, the most prevalent comorbid conditions are diabetes, congestive heart failure and chronic obstructive pulmonary disease (COPD).

“The life expectancy of cancer survivors, even if they’ve had curative therapy, is not the same as somebody who never had cancer,” Blaes said. “They have higher rates of cardiovascular disease and secondary cancers, and have a higher risk for relapse, compared with those who were not treated. Undergoing chemotherapy and radiation in surgery can lead to sarcopenia, obesity, metabolic syndrome, higher rates of diabetes and neuropathy, which can affect functional status. They are all huge issues.”

Leach and colleagues determined older cancer survivors experience an average of five comorbid conditions, two of which develop after cancer diagnosis.

Diabetes is consistently the most common comorbidity among cancer survivors, regardless of age. Twenty-two percent to 29% of all survivors develop diabetes.

Bluethmann said diabetes is “far and away” the most common comorbidity associated with prostate cancer. COPD and vascular diseases also are common.

“Those men are often on hormonal treatments, which are becoming more and more commonly used,” Dale said. “They have a lot of side effects, particularly for the cardiovascular system. They can worsen heart disease or heart failure, can increase the likelihood of developing diabetes because they change body composition and, in particular, they decrease muscle mass and increase fat mass. As a result, [male prostate cancer survivors] tend to gain weight and be at higher risk for diabetes. They also more quickly develop osteoporosis. Because of thin bones and weak muscles from sarcopenia, men have a high risk to fall and have hip fractures and compression fractures of the spine.”

Photo credit: Robert Kozloff, a staff photographer at The University of Chicago.

Lung cancer survivors consistently have the worst comorbidity burden of any survivorship group. Severe comorbidity occurs in nearly 50% of lung cancer survivors aged 65 to 70 years, and 57% of those aged older than 85 years.

Lung cancer survivors also have the highest prevalence of COPD; more than 40% of survivors aged 65 to 84 years develop this condition.

“Smoking history is a very common risk factor for lung cancer, and that may come with pre-existing respiratory conditions,” Bluethmann said. “They are going into their diagnosis and treatment with some of those health complications already. Add into that surgeries or radiation — which can affect lung function — and it may take years to not only get through treatment but to recover from treatment. That’s why many people believe lung cancer survivors have a particularly large burden compared with other cancer sites.”

Conversely, breast cancer (17%) and prostate cancer (16%) survivors aged 65 to 70 years consistently have a lower comorbidity burden than similarly aged survivors of colorectal, oral and bladder cancers and leukemia.

Thirteen percent or fewer female breast cancer survivors develop COPD, the lowest prevalence across survivorship groups. However, women who undergo treatment for stage I or stage II breast cancer are more likely to die of cardiovascular disease than their cancer, Blaes said.

“When it comes to breast cancer, a lot of chemotherapy drugs can cause neuropathy,” she said. “Even women who go through chemotherapy for stage II breast cancer who had anthracyclines or trastuzumab [Herceptin, Genentech] have higher rates of heart failure.”

A study by Bluethmann and colleagues, published in 2016, showed colorectal cancer survivors have the greatest overall prevalence of congestive heart failure, with the oldest survivors having the highest burden (22% of those 85 and older).

Overall, these comorbidities may have implications for how current and future generations of patients are treated.

“There is growing data in the adult population that individuals undergoing cancer therapy have an increased risk for certain medical conditions, need assistance and have functional decline,” Hurria said. “That suggests we may be creating or accelerating the development of frailty in this age group. Perhaps it’s led to an accelerating phenotype.”

David Jennings II, MSN, RN, AGPCNP-BC, an oncology nurse practitioner at Levine Cancer Institute at Carolinas HealthCare System and a HemOnc Today Editorial Board member, said he hopes the next generation of cancer survivors has a better understanding of health risks, particularly the harmful effects of tobacco use.

“When today’s geriatric population was young, smoking was very in vogue,” Jennings said in an interview. “Now, people are learning good health practices earlier and, hopefully, health literacy will continue to improve over the next 25 years.”

Blaes agreed but said she is only cautiously optimistic when projecting 25 years down the road.

“There’s an increasing emphasis on physical recovery after cancer treatment and that, I hope, is a good thing,” she said. “Still, a quarter of our young cancer survivors smoke. You would think that would not be the case, but it is.”

Dealing with dementia

One of the primary concerns for members of the geriatric oncology community is the growing number of cancer survivors with dementia and the burden this places on informal caregivers.

Evidence is mixed as to whether changes in cognitive performance are associated with normal aging or exacerbated by adjuvant cancer therapy due to neurotoxic effects. Therefore, it is unclear whether a history of cancer makes it more likely that a person will be diagnosed with dementia or Alzheimer disease.

“People blame being elderly or having a lot on their mind,” Jennings said. “As distressing as a cancer diagnosis can be with its process of chemotherapy, radiation and surgery, we should not confuse added stress with the possibility of an undiagnosed dementia.”

There is concern that hormonal treatments for cancer can lead to emotional and cognitive changes, Dale said.

“Whole-brain radiation therapies and chemotherapies can actually make mild cognitive impairment worse or reveal underlying dementia that becomes a significant problem,” he said.

This can lead to challenges with patient consent for treatments, Dale added.

“A patient may not be able to consent for themselves because they cannot completely understand the risks and rewards of the therapies,” he said. “They need to have a caregiver or a designated proxy, or we might have to reconsider using complicated therapies in patients who are having memory and cognitive problems. At some point, we have to think about how many of these treatments we should really subject people with advancing cognitive issues to, especially since dementia alone limits life expectancy.”

A federally funded study (NCT02122107) stands to shed light on the long-term impact chemotherapy and endocrine therapy have on memory in breast cancer survivors, Hurria said. Additional formal studies can help pinpoint mechanisms behind those impacts and trigger further research.

In a study by Fried and colleagues, published in The New England Journal of Medicine, older patients with chronic diseases — including cancer — were asked if they would agree to therapy if it could have an impact on their function or cognition. Results showed that 74.4% of participants would forgo treatment if they survived but with functional impairment, and 88.8% would forgo treatment if it led to cognitive impairment.

“The vast majority of these respondents said, ‘Thanks, but no thanks. I don’t want to take a therapy that might impact my function or cognition, even if it comes at a cost of survival,’” Hurria said. “This tells us that how therapy impacts someone’s function is really on the minds of our patients. It’s the central core of who we are and how we think, and it’s not necessarily been included in clinical trials. We focus mainly on the acute treatment setting and less so on the long-term survivorship impact.”

Early onset of dementia can dramatically affect treatment of older patients, potentially impacting their ability to remember something as basic as their appointment schedule.

“If patients don’t have a good support system in place, a diagnosis of dementia can cause complications with treatment delays, as well as inaccurate dosing of home medications,” Jennings said.

It also can affect treatment adherence.

“People with comorbidities are typically on multiple medications. Just remembering what they are supposed to take and when is a huge issue,” Dale said. “Specific to cancer care, the chemotherapy regimens come with a lot of extra so-called “supportive-care” medications for nausea, anorexia and fatigue. Patients have to watch for neutropenic fevers and know right away when to get antibiotics. These are all complicated cognitive tasks that are hard for anybody. If they are starting to have memory problems, it is even worse.”

Increased role of caregivers

Because of the anticipated shortage of oncology providers, the roles of PCPs and informal caregivers likely will increase over the next 25 years.

Despite this, an alarming number of patients do not have PCPs, Jennings said.

“It’s easy to blame the economy,” he said. “If patients are unemployed, they are often uninsured. If they are feeling good, patients might not see the value in routine medical care.

“Hopefully, [cancer survivors] are not out there floating by themselves,” Jennings added. “With proper survivorship education and appropriate follow-up, we send them home knowing what signs and symptoms to watch for [that may indicate] recurrence. It is important that primary care doctors also know to look for these signs and symptoms. Patients need to be reminded about routine and preventive medical care like colonoscopies, dental work, annual skin surveys and sun safety.”

Equally important, clinicians say, is the involvement of caregivers. The National Alliance on Caregiving estimates that 73% of caregivers aged older than 75 years communicate with health care professionals on behalf of their care recipient, making them an important part of the medical team.

“The challenges for patients are as much about their caregivers, their families and their friends as it is about them,” Dale said. “If it is a spouse, the caregiver can quite often be older and quite sick themselves. I am shocked sometimes when someone comes in and says, ‘I would love to try to pursue treatment, but my wife is at home, her memory is not so good and I can’t really get out, so I can’t afford to come because I’m their caregiver.’

“Often, the people who shoulder a lot of this care-giving burden are the children who are trying to work and help take care of their parents,” Dale added. “The social circumstances can be very difficult, time-consuming and costly, and they should be included in any assessment of workforce requirements. We’re going to need to compensate family caregivers or we’re going to have to train a lot more people to help with formal caregiving and pay for it.”

Clinicians with whom HemOnc Today spoke agreed efforts need to be made to address the capacity of informal caregivers to support the growing number of care recipients and receive their own health care.

“We need to be thinking about how to accommodate their needs and equip them with the right tools, as well,” Bluethmann said. “Sometimes older caregivers have comorbidities and they put themselves at risk just trying to provide care to their loved one. Being attentive of the health concerns of the caregivers is important, and we should engage them as part of the medical decision-making.”

With the projected increase in cancer survivors, the roles of nurse navigators and social workers will be essential to “ensure nothing falls through the cracks,” Jennings said.

“Multiple studies have shown how important nurse navigators are and how much they influence survivorship,” he said. “They’re certainly an integral part of our health care team and we rely heavily on the additional care that they offer our patients.”

Broadening clinical trials

Despite their growing numbers, older adults continue to be understudied.

Patients with cancer aged older than 65 years largely have been excluded from clinical trials.

Studying people in this age group “is the only way we’re going to really understand what this population is facing,” Hurria said. “If we [only] study our drugs in younger populations, we’re missing the entire point. We might be able to deliver [results] in a 40-year-old, but if we don’t have the data for someone who is 65 or older, it’s a big disservice to society.”

Historically, about 30% of patients enrolled in clinical trials are older than 65 years, yet approximately 60% of those living with cancer are older than 65 years, Dale said.

“In addition, those 30% enrolled in the trials are the healthiest and fittest older people, so we know almost nothing about older people who aren’t healthy and frailer,” he said.

Greater trial participation by elderly patients could provide more clarity in optimal dosing of chemotherapeutic agents, potentially reducing treatment-related toxicity and complications during survivorship, Hurria said.

Because clinicians are worried about the side effects of therapy — particularly combination therapies — for older adults, safety criteria should be built into study design to start older patients at a lower-dose level to ensure they can tolerate the drug, Hurria added.

“Patients want to understand not only how long this will help keep their tumor from progressing, but its impact on their ability to live independently and on their memory,” she said. “Patients don’t want us to create a situation in which they become dependent. Maintaining functioning independence is the most important thing on their minds. It will come at the risk of most everything else.”

Blaes, a member of the Alliance for Cancer Clinical Trials, said there is an inherent problem when drugs approved through clinical trials are given to patients excluded from those trials. She cited the use of trastuzumab in women with HER-2–positive, early-stage breast cancer, as an example.

“We know from clinical trials that about 4% of patients [who receive trastuzumab] can develop cardiac dysfunction,” Blaes said. “But when you look within a large database of what is happening in clinical practice, the rates of cardiac dysfunction in the elderly population receiving trastuzumab was significantly higher than that, up into the 30% range. That’s a problem.”

Redesigned care model

Most oncologists agree that, with more than 26 million cancer survivors projected by 2040, the care model will need to be redesigned to accommodate the “silver tsunami.”

“Sixty-five percent of patients diagnosed with cancer will live for at least 5 years, and there is a rising number of patients who are cured from their cancers, so keeping them healthy after treatments is really important,” Blaes said. “Five years is a long time, and we need to be focusing on how this [extended survival] is affecting their functionality.”

These changes likely will place greater responsibilities on physician assistants and nurse practitioners, Blaes said.

Dale agreed, emphasizing the need for a primary point of contact for survivors.

“Oncology has always been at the center of cancer care, appropriately so, and I don’t disagree with that,” Dale said. “An oncologist leads, but there is a whole team that is going to need to be engaged for the higher-risk patients from the minute they come in, and help track them through the system. Someone with expertise in care coordination has to be the one main contact point for patients.”

Improvements to Medicare’s antiquated coding system also are essential to prepare for an increasing number of patients and survivors, Jennings said.

“Medicare needs to be in tune with the most up-to-date oncologic standards of care to facilitate adequate coverage,” he said. “Sometimes we have difficulty obtaining approval for necessary treatment and imaging. Valuable time is often spent on pre-authorizations and appeals, and this time would not be lost if a more up-to-date and efficient system were in place. Continued updates in Medicare, Medicaid and private insurance will lead to improved outcomes in our vulnerable patients.”

Hurria and a team of other researchers have partnered with the federal government to create a research road map that can help guide the geriatric community through the next wave of adult care.

“It’s a call to action,” she said. “We need to work together with the survivorship community to do rigorous research to understand the issues these patients are facing so we can develop interventions to decrease those risks for the next generation of survivors.”

Further, research advances are contributing to a trajectory of cancer becoming more of a chronic disease.

“If that’s our goal, at the very forefront of our thought process should be, what is the long-term impact of the therapies we are delivering?” Hurria said. “Twenty years down the line, we want life with quality. ...

“We want to study and give these drugs that can lead to that outcome, but we need to understand the impacts,” she added. “If functional independence is such a key factor, this is a teachable moment. If a therapy can impact a patient’s function or even her memory, then I have to think about modifiable things we can do to help lifestyle and decrease other risk factors.”

This vision is now at the forefront of cancer care and will remain a priority through the coming decades, Dale said.

“We need to start thinking about outcomes other than just survival,” he said. “We need to think about what it really means to have quality of life and consider the targets of our therapy. Is the goal independence or living a few extra months? We need to ask if our care speaks to the main issues for older patients of quality of life and independence and meaningful social interactions.” – by Chuck Gormley

Click here to read the , “Is it feasible to require enrollment of elderly patients in oncology clinical trials?” 

References:

Bartels SJ, et al. N Engl J Med. 2013;doi:10.1056/NEJMp1211456.

Bluethmann SM, et al. Cancer Epidemiol Biomarkers Prev. 2016; doi:10.1158/1055-9965.EPI-16-0133.

Fried TR, et al. N Engl J Med. 2002;346:1061-1066.

Ganguli M. Alzheimer Dis Assoc Disord. 2015;doi:10.1097/WAD.0000000000000086.

Hafner K. As population ages, where are the geriatricians? The New York Times. Available at: www.nytimes.com/2016/01/26/health/where-are-the-geriatricians.html?ref=health&_r=0. Accessed on Dec. 13, 2016.

Leach CR, et al. J Cancer Surviv. 2015;doi:10.1007/s11764-014-0403-1.

Rao AV, et al. J Oncol Pract. 2008;doi:10.1200/JOP.0846001.

For more information:

Anne Blaes, MD, can be reached at blaes004@umn.edu.

Shirley M. Bluethmann, PhD, MPH, can be reached at shelley.bluethmann@nih.gov.

William Dale, MD, PhD, can be reached at wdale@medicine.bsd.uchicago.edu.

Arti Hurria, MD, can be reached at ahurria@coh.or.

David L. Jennings II, MSN, RN, AGPCNP-BC, can be reached at david.jennings@carolinahealthcare.org.

Disclosure: Blaes, Bluethmann, Dale, Hurria and Jennings report no relevant financial disclosures.