Multidisciplinary Treatment in Older Patients

The treatment decisions for older cancer patients should be multidisciplinary, with the purpose of evaluating the risk of treatment. Geriatricians use the comprehensive geriatric assessment (CGA) [15] to determine life expectancy and the risk of complications. The hand grip dynamometer allows the determination of the handgrip strength of the dominant hand and is a well validated measure of musculoskeletal function but also has a strong association with frailty and time to death. The timed up and go test involves asking the patient to get up from a chair without the use of arms, walk a distance of 3 m, turn around and return [16, 17]. Studies have shown that patients taking longer than 14 s had a high risk of falling and thus are frail or pre-frail and may be at high risk with aggressive treatment.

The CRASH Score (chemotherapy risk assessment scale) for older patients can also be used to predict the risk of chemotherapy toxicity in older patients. This score include a large number of variables such as predictors of hematologic (H) and nonhematologic (NH) toxicity. The predictors of grade 4 H toxicity were lymphocytes, aspartate aminotransferase level, Instrumental Activities of Daily Living score, lactate dehydrogenase level, diastolic blood pressure, and the toxicity of the chemotherapy regimen. Predictors of NH grade 3/4 were hemoglobin, creatinine clearance, albumin, Eastern Cooperative Oncology Group performance, Mini-Mental Status score, MiniNutritional Assessment score and the toxicity of the chemotherapy regimen [18].

Some common conditions in the older subjects such as malnutrition, anemia, neutropenia, and depression should also be treated before or alongside surgical or chemotherapy treatment of the cancer. Co-morbidities as diabetes, hypertension, emphysema, renal insufficiency should be improved after medical intervention and sometimes the dose adjustment of chemotherapy is required. The social support (transportation, nutrition and medical administration of drugs) may be evaluated as it influences the treatment.

The National Network of US Cancer [19 ] recommends that people over 70 should undergo some form of geriatric assessment. After appropriate analysis previously undiagnosed relevant conditions can be detected in more than 50 % of patients. There is clear evidence that CGA improves the functionality and quality of life and promotes the independence in older people undergoing cancer therapy, but its effects on survival are not yet well defined.

In the older patient, neutropenia, anemia, mucositis, cardiomyopathy and neu- ropathy—the toxic effects of chemotherapy—are more pronounced and may be related in part to physiological changes of age or of a higher prevalence of comorbidities [20-24] . The correction of comorbidities and malnutrition can lead to greater safety in the prescription of chemotherapy [25, 26].

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