Clinical Oncology

[Geriatric oncology]

TELEKES András

MAY 10, 2017

Clinical Oncology - 2017;4(02)

[Geriatric oncology has an increasing role since in several types of cancer the median age at diagnosis is above 60 years of age. The treatment of elderly patients are frequently set back by prejudice, stereotypes and lack of information. All these lead to the fact that even in well-developed countries elderly cancer patients often do not receive the necessary treatments. This is even more true in poor-countries, where the fi nancial defi cit accumulated in health care is often attempted to be reduced by the treatment of elderly. If a paediatric oncology patient does not get suffi cient cancer treatment there is a fi erce protest, but everybody is silent if this occurs in the case of an 80 years old patient. For this unacceptable situation both authorities (fi nancing) and professional bodies (treatment, education) are responsible. Clinical data show that elderly cancer patients get the same benefi t of active oncology treatment, as younger ones. Age on its own does not contraindicate any cancer treatment. The aim of this review is to prove by data, that elderly cancer patients should also get active oncology treatment. The questions of assessment include frailty, the relationship of cancer development and ageing, and other problems related to the oncology treatment of elderly patients are also discussed.]

COMMENTS

0 comments

Further articles in this publication

Clinical Oncology

[Signaling pathways in cancer stem cells (Notch, Hedgehog, Wnt)]

KOPPER László, NAGY Noémi, SEBESTYÉN Anna

[OThe key regulators in the embryonic life, and later in the differentiation of tissues and organs are the evolutionary reserved signalling pathways, as Notch, Hedgehog and Wnt. Mutations of these pathways have been identifi ed in many tumor types, increasing the risk to the appearance of cancer stem cells (CSC), with very similar geno- and phenotype as normal stem cells have. Such CSCs with stemness functions can be developed not only from normal stem cells, but also from progenitor and differentiated cells. The main characteristics of CSC are the self maintenance, slow growth rate, very effective DNA-repair system, etc. All of these can contribute to the resistance. Further problems are the low number of CSC in the whole tumor mass, which makes rather diffi cult to achieve the effective drug concentration in CSC. The mentioned ancient pathways interact with many other pathways to form a network, which can infl uence the strategy of therapy. No doubt, that these pathways are promising targets, however, till now the clinical effectiveness is very low due to some reasons mentioned above. Nevertheless, some drugs are already in clinical use, either as monotherapy or part of the combinations. Little is known about the relationship between the pathways and the microenvironment, which has an outstanding role in the cellular activities, sometimes resulting opposite output. It is a great challenge to design effective drugs against CSC, similarly to fi nd reliable predictive biomarkers, which unfortunately still missing, since a reasonable drug-marker interactions would speed up the personalized treatment.]

Clinical Oncology

[Paleo-oncology - messages from the past]

MOLNÁR Erika, MARCSIK Antónia, PÁLFI György, ZÁDORI Péter, BUCZKÓ Krisztina, TAKÁCS Vellainé Krisztina, HAJDU Tamás

[Nowadays, cancer is one of the greatest challenges facing mankind. However, there is still no consensus among researchers regarding the antiquity of cancer. Written sources and paleo-oncological studies may help to answer this question. The aim of this study is to present data on the history of cancer based on historical sources, literature data and own research fi ndings. Early historical sources indicate that cancer was already known in antiquity. Paleopathological studies of animal and human fossils show that malignant bone tumors were present in ancient times, although the frequency of the disease was seemingly very low. The increasing number of unearthed fossils and the use of modern diagnostic tools have led to a rise of the number of diagnosed cancer cases. Our comprehensive paleo-oncological study, focusing on the occurrence and frequency change of malignant tumors in historic populations of Hungary was based on the analysis of skeletal remains belonging to 11,000 individuals dated from the Early Neolithic to the late medieval period. During the analysis macromorphological, modern imaging and histological methods were applied. As a result of the extensive investigations osteological evidences of malignant bone tumors were identifi ed in 39 cases. Neoplastic bone diseases were present in all studied historical periods and there were no differences in their occurrence and frequency between the different archaeological periods.]

Clinical Oncology

[Foreword]

A szerkesztők

Clinical Oncology

[Adjuvant treatment of breast cancer]

PAJKOS Gábor

[Choice of optimal adjuvant treatment has been based on present debates, doubts and commit offence against processing or existing evidences. Clinical research has been resulted changes and renewal of practice decisions continuously. 3rd Breast Cancer Consensus Conference held on Kecskemét last year corresponded by Hungarian experts of the fi eld has given up to date and well-defi ned guideline. Present paper try to give a summary of adjuvant treatment courses for early breast cancer in consideration of last results of research since then.]

Clinical Oncology

[Why don’t immune checkpoint inhibitors work in colorectal cancer?]

SHI Yuequan, ZOU Zifang, KERR David

[In recent years, immune checkpoint inhibitors have been shown to be effective in treating manifold types of cancer but less robust in colorectal cancer (CRC). While, the subgroup of CRC with microsatellite instability (MSI; also termed as mismatch repair defi cient) showed a moderate response to Pembrolizumab in a single arm phase II clinical trial, microsatellite stable (MSS) cancers were unresponsive. Possible mechanisms that affect immune response in colorectal cancer will be reviewed in this article. We will also propose that histone deacetylase (HDAC) inhibition may reverse the immune editing commonly seen in advanced CRC and render them sensitive to immune checkpoint blockade.]

All articles in the issue

Related contents

Lege Artis Medicinae

[Treatment of hypercholesterolemia in the elderly]

BARNA István

[The percentage of population aged ≥65 years is mounting worldwide, among them those over 75 years is also growing. Athe­ro­scle­rosis is one of the most important and common disorder in the elderly responsible primarily for premature death and cognitive declining and impaired quality of life. Adequate lipid lowering therapy can decrease the risk of cardiovascular events – the main cause behind mortality – can extend life expectancy and improve the quality of life of patients. Effect of dietary treatment on cardiovascular risk reduction is as beneficial as in the younger populations. Regular physical activity reduces the risk of cardiovascular and overall mortality by 26% in males and 20% in females aged ≥65 years. If the medical history is negative for vascu­lar disorders, statin administration as a primary prevention is indicated for patients 65>years. In the population aged 75≥years individual benefit/risk assessment is needed before statin administration. Larger risk reduction can be achieved between 65-75 years than in subjects over 75 years. Concerning secondary prevention, statin treatment is of pre-eminent significance, and its administration is evidence-based in the elderly. For achieving the lipid goals, combined therapy with statin and ezetimibe is recommended in the primary as well as secondary cardiovascular prevention. ]

Hypertension and nephrology

[Blood presssure paradoxon in very elderly patients]

SZÉKÁCS Béla, BÉKÉSI Gábor, KISS István

[The paper is warning for the necessity of very complex consideration before taking antihypertensive therapeutic decisions (indication, point or points of actiou, blood pressure target levels, dynamics of BP reduction, etc) for elderly hypertensive patients. Blood pressure reduction can mean efficient protection against cardiovascular events also among the elderly hypertensives. However in those old and very old hypertensive patients who have not only severe stiffness of their large vessels but suffer in advanced co-morbidities and integrated pathologic geriatric syndromes, the blood pressure reduction can result in sometimes even life threatening general deterioration. Antihypertensive therapeutic dilemmas of elderly caregivers appear mainly in relation to old hypertensive patients of age over 80 years. For this „very old” age period the HYVET study gave us evidence based conclusions about the cardiovascular protective usefulness of combined antihypertensive treatment resulting in BP reduction to 150 Hgmm systolic BP target levels. However a non-negligable rate of selection of the included patients in HYVET study can weaken the generalizability of the HYVET findings in this age period and the extensibility of its antihypertensive therapeutic conclusions for the entire „very old” population because this population has also a high proportion of patients with chronic progressive illnesses and general decline. Thus the elderly hypertensives’ caregiver must always carefully and critically balance between the messages of the HYVET and the nonselective observational follow up studies among elderlies showing frequently the so-called epidemiologic blood pressure/ mortality paradoxon. The paper is also trying to find potencial pathomechanical interpretations and point of actions for the epidemiologic blood pressure/mortality paradoxon found in the very old population.]

Lege Artis Medicinae

[Hypertension in the elderly - critical review of diagnostic-therapeutic guidelines and their background]

SZÉKÁCS Béla

[In the majority of old and very old hypertensive patients, the reduction of abnormally high blood pressure has been proved to provide a strategic defense of target organs. In patients younger than 80 years, both initial and target blood pressure (BP) values are similar to those of younger age groups. In those older than 80 years, a a systolic blood pressure level >160 mmHg is the threshold of indication for antihypertensive treatment and the therapeutic target value is<150 mmHg. Both values are evidence- based (HYVET). The latest ACCF/AHA guidelines (USA 2011) advise to achieve a BP below 140 mmHg if the use of one or two antihypertensive agents result in sufficient BP reduction. However, this strategy is not yet supported by unequivocal evidence regarding complications in target organs. It is not recommended to aim for target levels lower than the above values (especially the value defined by the ESH guidelines) even in elderly hypertensive patients at high cardiovascular risk, as the results of several studies suggest a J-curve effect. In multimorbid elderly patients it is highly important to adapt antihypertensive treatment to individual needs, rather than to use schematic approaches. The number and progression of comorbid diseases can greatly influence, in certain cases attenuate the aimed BP reduction. A similar medical decision should be made if the target BP level could only be achieved by the combination of multiple antihypertensive medications, which can remarkably impair quality of life in elderly patients. Among non-comorbid elderly patients with hypertension, there seems to be no convincing difference in the efficiency of target organ protection between antihypertensive treatments that have different target sites but can achieve similar target levels. However, the majority of elderly hypertensive patients have comorbidities with variable rates of progression. In those at even low cardiometabolic risk the use of beta-receptor blockers (BRB) and especially a combination of BRB+diuretic (DIU) is not recommended. The adequate therapeutic tactic includes the use of only moderate drug-doses and their early combination. This approach has been convincingly proved mainly with early combinations of RAS inhibitors+CCB-s and RAS inhibitors+small doses of DIU-s. It is very important to monitor the treated patients, as the BP and circulatory response to the same antihypertensive treatment can markedly change in elderly patients when either the enviromental conditions change or a new pathologic process develops and/or is treated. Strict control is also necessary because it occurs quite often that the earlier optimal compliance of elderly patients in taking antihypertensive medicines rapidly deteriorates. The efficiency of statins and acetylsalicylic acid decreases over 80 years of age, but this does not indicate that the previously efficient approach should be suspended.]

Clinical Oncology

[Fatigue - symptom or side effect]

TOKODI Zsófia

[Cancer-related fatigue (CRF) is common in most cancer patient, which has a high impact on the quality of their life. It affects not only the patient itself, but also their families and relationships. It is the most underreported, overlooked and undertreated symptom. The screening and adequate treatment of CFR is getting more attention nowadays and it became the subject of guidelines of several international expert groups like the ASCO) and the NCCN. In this review we would like to summarize the contributory factors of CRF, the screening methods, the clinical assessment and the interventions of patients with cancer related fatigue. We try to give guidance to distinguish fatigue as a symptom of disease progression or as a side effect that we can treat. But lastly the most important question becomes that why CRF is so underreported.]

Hypertension and nephrology

[Therapy of isolated systolic hypertension III.]

FARSANG Csaba

[In the elderly and very elderly (˃80 yrs), a wealth of data from large clinical trials are available, showing the necessity of treatment mostly with drug combinations - fix-combinations are preferred for increasing the adherence/persistence to therapy. Using diuretics, ACE-inhibitors/ARBs with calcium antagonists, and in special cases diuretics and beta blockers are also suggested by recent European guidelines (ESH, HSH). The target is <140 mmHg, but in octogenarians <150 mmHg. Some studies are pressing for even lower SBP (to around 120 mm Hg), but it seems to be wise to balance advantages/disadvantages, so the optimal SBP may be around 130 mmHg.]