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  Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 1  |  Page : 157-161
 

Patterns of care in geriatric cancer patients – An audit from a rural based hospital cancer registry in Kerala


1 Department of Medical Oncology and Hematology, Malabar Cancer Center, Thallassery, Kerala, India
2 Department of Radiation Oncology, Malabar Cancer Center, Thallassery, Kerala, India
3 Department of Surgical Oncology, Malabar Cancer Center, Thallassery, Kerala, India
4 Department of Cancer Registry and Epidemiology, Malabar Cancer Center, Thallassery, Kerala, India
5 Department of Biostatistics, Malabar Cancer Center, Thallassery, Kerala, India

Date of Web Publication3-Feb-2016

Correspondence Address:
V M Patil
Department of Medical Oncology and Hematology, Malabar Cancer Center, Thallassery, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175590

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 » Abstract 

Background: There is deficit of data from India on elderly patients with cancer. Comprehensive geriatric assessment may lead to a better decision making capacity in this population. However, routine implementation of such assessment is resource consuming. Aim: The aim of this study was to determine the patterns of care in elderly patients treated at a tertiary rural cancer center in India. Materials And Methods: All patients with age 70 or above with solid tumors without any definitive treatment prior to the registration at our center and registered between 01/01/2010 and 31/12/2011 were selected for this study. The baseline demographic pattern and the pattern of care of treatment were analyzed. SPSS version 16 (IBM Inc, Armonk, New York, U.S.) was used for analysis. Descriptive data are provided. Results: A total of 761 patients were evaluable subject to the aforementioned inclusion criteria. The median age of this cohort was 75 years (70-95 years). The most frequent primary sites of malignancies in 451 males were head neck (32.4%), lung (23.3%) and gastrointestinal (23.3%). In 310 females, the most common sites were head neck (31.6%), gynecological (18.4%) and gastrointestinal (24.5%). 228 (30%) of the patients had localized disease, 376 (49.4%) had loco-regionally advanced disease and 145 (19.1%) had distant metastases at presentation. 334 (46.32%) of patients were treated with curative intent. On logistic regression analysis the factors that predicted use of curative intent treatment were age <75 years, performance status 0-1, primary site and clinical extent of disease. Conclusion: Routine comprehensive geriatric assessment needs to be implemented in our setting as almost 50% of our geriatric patients undergo curative intent treatment.


Keywords: Geriatric cancer, geriatric assessment scale, rural cancer center


How to cite this article:
Patil V M, Chakraborty S, Dessai S, Kumar S S, Ratheesan K, Bindu T, Geetha M, Sujith K, Babu S, Raghavan V, Nair C K, Syam V, Surij S, Sathessan B. Patterns of care in geriatric cancer patients – An audit from a rural based hospital cancer registry in Kerala. Indian J Cancer 2015;52:157-61

How to cite this URL:
Patil V M, Chakraborty S, Dessai S, Kumar S S, Ratheesan K, Bindu T, Geetha M, Sujith K, Babu S, Raghavan V, Nair C K, Syam V, Surij S, Sathessan B. Patterns of care in geriatric cancer patients – An audit from a rural based hospital cancer registry in Kerala. Indian J Cancer [serial online] 2015 [cited 2017 Nov 23];52:157-61. Available from: http://www.indianjcancer.com/text.asp?2015/52/1/157/175590



 » Introduction Top


Cancer is regarded as a disease of the aging,[1] with almost 50% of the cancers occurring in patients older than 65 years in USA.[2] Data from five Indian Hospital based cancer registry (HBCR) also shows that roughly 20.3% of all malignancies occur in the population above 65 years.[3] Relatively however the burden of geriatric cancers in the two nations is likely to be similar considering that 65 + age group accounts for 13% of the population in USA and only 5.4% in India.[4],[5]

Despite the high burden of cancer in the elderly they have been traditionally underrepresented in clinical trials.[6],[7],[8] The difference in median ages of patient recruited in randomized trials and that in surveillance, epidemiology and end results database for chronic lymphocytic leukemia varies from 5 years to 10 years.[9] Data generated from clinical trials conducted among the younger population cannot be extrapolated straight away to the elderly in view of the numerous aging related physiological changes and decline in functional organ reserve.[10]

In developing countries like India witnessing an increase in the proportion of the elderly population over the past few decades the burden of geriatric cancers is also going to rise exponentially.[11] The magnitude of the problem facing such nations can easily be gauged by the fact that even the definition of elderly is ambiguous. Thus while in west ages above 70 years is considered elderly, in India an age above 60 years is often considered as elderly as this is the age at which the working force retires.[12]

Ours is a dedicated tertiary cancer center catering to one of the largest rural population in India. Indian Council of Medical Research funding for the establishment of HBCR was obtained in 2010 and the first HBCR report for our hospital was published in 2011. Our burden of geriatric cancer patients is higher given the higher life expectancy in Kerala. In order to better tailor hospital services and clinical care for our elderly population we decided to audit the demographic data, disease sites and patterns of care in geriatric patients from our HBCR reports of 2010 to 2011. We hypothesize that if more than 30% of our elderly patients are treated with curative intent then it would be worthwhile to consider dedicated resources for our geriatric patients.


 » Materials and Methods Top


A retrospective audit was conducted using the HBCR data of the years 2010-2011. The entire audit plan was pre-approved by the institutional review board. Patients were included if they were of the age 70 and above at presentation and had not received any definitive anticancer treatment outside. Definitive treatment included any surgical excision done with the intention of removal of complete tumor and the regional lymph nodes (biopsies were excluded.), radiation (radical or palliative) or any chemotherapy.

The following data was extracted from hospital registry database age, sex, tumor details (site of malignancy), staging details, intention of treatment and treatment details (surgery, radiotherapy or chemotherapy). The intention of treatment was divided into either palliative or radical and this decision is taken at our center by a multispecialty board. SPSS version 16 (IBM Inc, Armonk, New York, USA) was used for statistical analysis and descriptive analysis has been presented. Demographic data and cancer site were also analyzed by dividing the population into two groups by the median age in order to elucidate significant differences in between elderly and very elderly patients. Chi-square test was used to test for significant differences in the age strata and P values were taken as significant after Bonferroni correction. Logistic regression analysis was performed in order to evaluate the factors that predict the intent of treatment.


 » Results Top


A total of 761 patients were included in the analysis subject to the inclusion criteria. The median age of the population was 75 years (70-95). 338 (44.4%) patients were aged <75 years and 423 (55.6%) were 75 years or more. The demographic profile of the patient population is indicated in [Table 1] divided into two groups. As can be seen there was a greater proportion of females, single patients and patients with poorer performance status in the age group 75 years or older.
Table 1: Demographic profile of the patient population divided by the median age into two groups

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In 761 patients, 643 (84.5%) had pathological confirmation of their diagnosis. Among the 334 (43.89%) patients treated with curative intent in 320 (95.8%) patients the cancer diagnosis was confirmed pathologically. In contrast among the 427 patients treated palliatively, 323 (75.7%) had a pathological diagnosis (P < 0.001). There was no significant difference in the proportion of patients who had pathological confirmation prior to treatment as per age (86.4% in patients with age <75 vs. 82.9% in patients with age ≥75, P = 0.402). 596 patients (92.7%) had a biopsy to obtain tissue for pathological diagnosis.

The primary site of malignancy as per the major sites of cancer is indicated in [Table 2]. The most frequent primary sites of malignancies in 451 males were head neck (32.4%), lung (23.3%) and gastrointestinal (23.3%). In 310 females, the most common sites were head neck (31.6%), gynecological (18.4%) and gastrointestinal (24.5%). 228 (30%) of the patients had localized disease, 376 (49.4%) had loco-regionally advanced disease and 145 (19.1%) had distant metastases at presentation. Patients with hepatobiliary cancers and lung cancers had the highest incidence of distant metastases at presentation [Figure 1]. [Figure 2] shows the proportion of patients treated with curative or palliative intent according to the primary disease site. There was no significant difference in the disease extension at presentation according to the age groups. The proportion of patients who had a pathological diagnosis was 89.9%, 88.6% and 69% in patients with localized, loco-regionally advanced disease and distant metastases. Overall the treatment offered were surgery in 215 (28.3%), radiation in 233 (30.6%), chemotherapy in 46 (6.04%). Multimodality treatment in the form of surgery and adjuvant radiotherapy or chemotherapy was delivered in 27 (3.6%) and chemoradiation in 58 (7.62%). Eight patients (1.09%) were treated with hormones while 174 patients (22.9%) received best supportive care only. [Table 3] shows the treatment intent in patients according to the disease extension at diagnosis. It can be appreciated that even in localized disease 30.9% patient received palliative treatment.[Table 4] shows use of different treatment modalities in accordance with the intent of treatment. It seemed that combined modality treatment was used predominantly in curative intent patients. [Figure 3] depicts data about different modalities which were used for treatment according to tumor site.
Table 2: Major cancer sites in the patient population divided by median age into two groups

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Figure 1: Proportion of patients according to the extent of disease in accordance with the site

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Figure 2: Proportion of patients treated with curative or palliative intent according to the primary disease site

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Table 3: The intent of treatment according to the disease extension at diagnosis

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Table 4: The treatment types and modalities according to the treatment intent in the treatment population

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Figure 3: Modality of treatment according to site

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 » Discussion Top


India is a nation poised at the threshold of a demographic shift. Between 1961 and 2026, the proportion of elderly patients in India would almost double from 5.6% to 12.4%.[13] The latest census data shows that amongst all states Kerala has the highest proportion of elderly at 10.5% of the total population when compared with the national average of 7.4%. Amongst all HBCRs Thiruvananthapuram has the highest proportion of cancer patients above the 65 years age group (24.8%).[3] A similar situation reported by our HBCR with the 2011 report showing 24.6% of patients are above the age of 65 years.[14]

Due to the vast disparity in access to quality cancer care most of the rural patients move to various urban centers for cancer care. Since cancer is not a notifiable disease in India this often leads to data duplication as patients move from one center to another. Further population based registries cover barely 7% of the total population of India.[3] Given these factors the National Cancer Registry Program assists the establishment of HBCRs so that the pattern and burden of cancers can be obtained from the area catered to by the hospital. A web-based remote data entry portal is provided to ensure that high quality data is collected from the individual registries, which is then checked and audited regularly. HBCR can thus provide reliable data about cancer incidence, basic demographic patterns, method of staging, staging details and treatment.[3]

Few tertiary care centers in India are located in rural areas and ours is one of them. Further separate data for elderly patients is not available as data from HBCR as patients above 65 years are grouped together.

In addition to being at a higher risk of developing cancer, elderly patients have a higher burden of comorbidities,[15] immobility, mortality, economic dependence and destitution.[16] These factors frequently lead them to be treated with less aggressive treatment approaches. Even in western literature geriatric cancer data suggests that in many situations these patients are treated with palliative intent approaches or non-standard approaches.[17],[18],[19],[20] [Table 5] tabulates selected studies focusing on the head and neck cancer, lung cancer and breast cancer reported from Western literature. It can be seen that the majority of patients are treated with radical intent. Though treatment decisions are not solely based on age a multitude of factors are taken into account, age remains one of the predominant factor.[21],[22]
Table 5: Selected geriatric cancer data from some of the prevalent cancer subsites

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In the present series as can be appreciated except in lung cancers, hepatobiliary malignancies and unknown primaries all other sites more than one third of patients were treated with curative intent [Figure 2]. In these three areas none of the patients had presented with localized disease, which may have influenced the choice of treatment. In multivariate analysis however age, performance status, cancer site and disease extent all predicted the choice of treatment intent independently. This attests that decision to treat patients palliatively was not made solely on the basis of age.

Data regarding the burden and patterns of care in elderly cancer patients is lacking. Yeole et al. presented a demographic analysis of geriatric cancer patients from Mumbai cancer registry.[12] From 1961 to 2001 the proportion of geriatric cancers had increased from 5.6% to 7.5% of all cancer patients. They projected that the proportion would be increasing to 12.4% by 2026. Similar analysis about geriatric patients was done from another metropolitan city by Vora et al.[23] However, both studies focus on the demographic of the population and have not dealt with the patterns of care in these patients. Both these reports are from metropolitan cities, which may not be representative of a rural population as seen in our data.

Although approximately 46% of the patients received curative intent treatment in the present series most patients received unimodality treatment. Surgery and radiation were the primary modalities used in curative patient. This might be the reflection of the site and extent of malignancy seen at our center where head and neck cancers predominate. However, it cannot be denied that very few patients received chemotherapy in curative intent treatment protocols. An area of concern is the minimal use of palliative intent chemotherapy in our patient. Although this may be a reflection of physician bias, it may also be secondary to the fact that these patients had poorer performance status, deranged organ functions or had poor socio-economic support. Detailed site specific analysis of the reasons and outcomes of treatment is being conducted to better understand the reasons for the choice of treatment.

In this setting the use of dedicated geriatric assessment may be useful for allowing wider use of multimodality therapy including systemic chemotherapy. There is good data regarding the utility of comprehensive geriatric assessment tools in identifying the unrecognized problems, reducing the hospitalizations and improving the function.[24] Such efforts are required as palliative and adjuvant intent chemotherapy have been consistently shown to improved survival even in the elderly population.[25],[26],[27]

Although retrospective in nature our data generates certain important insights in the elderly population which form the basis of our recommendations for improvement in organizing geriatric cancer care at our center. These recommendations are presented below in [Table 6].
Table 6: Recommendations to the hospital administration for implementation of geriatric cancer care

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 » Conclusion Top


Elderly patients form a significant chunk of the patient population in our setting. The proportion of patients receiving curative multimodality treatment is lower than that reported in western literature. Utilization of palliative chemotherapy is also low. Phased implementation of comprehensive geriatric assessments may help in improving the proportion of patients undergoing the above.

 
 » References Top

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Extermann M, Aapro M, Bernabei R, Cohen HJ, Droz JP, Lichtman S, et al. Use of comprehensive geriatric assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005;55:241-52.  Back to cited text no. 24
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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