Since the early days of the COVID-19 pandemic, age and comorbidities have been recognised as key risk factors for complications due to the infection. The management of cancer care in elderly patients requires a multidisciplinary assessment driven by biological rather than chronological age: Dr. Capucine Baldini of Gustave Roussy Cancer Campus in Villejuif, France, urges physicians to also reflect on the consequences of prolonged isolation on the health status of this patient group.
How do elderly cancer patients differ from other patients in the face of COVID-19?
Scientific data from Italian (1) and Chinese (2) analyses show that the mortality rate from COVID-19 increases with age: it is about 12.5% between 70 and 79 years, and rises to 20% or more in subjects over 80. However, another specificity of this patient category is that the symptoms associated with a COVID-19 infection can vary greatly, and the disease can present in atypical ways. Cough, fever and fatigue are still the most common signs, but we have also observed some less characteristic symptoms among elderly patients, including digestive symptoms, states of mental confusion and falls. Doctors do not always make the connection with the virus in these cases, which means we must be particularly vigilant when assessing older individuals.
Some changes in cancer management, like dose reductions or postponing treatments, have been recommended during the pandemic. What are the main challenges in reorganising cancer care for the elderly?
It was difficult in the beginning, as we had to adapt very quickly to the situation: the most important thing was to protect our patients while also being careful not to hurt their chances of beating their cancer. This has been especially true for elderly patients, who have been advised to limit the time they spend outside of their homes and are often reluctant to come to the hospital, putting them at greater risk of under-treatment. At Gustave Roussy, we have decided to conduct systematic COVID testing on patients within our unit dedicated to elderly cancer patients, both at the time of hospitalisation and before administering any systemic treatment. We may then adapt our approach based on their PCR test results and on each patient’s unique characteristics. Discussions to continue anticancer treatment in COVID-positive patients always take place on a case-by-case basis with a risk-benefit analysis carried out by a multidisciplinary team.
We have also implemented telemedicine solutions and increased the frequency of remote consultations to ensure that we don’t miss any difficult situations, but it has been a challenge finding a form of telemedicine that our older patients can manage with. For example, we tend to opt for phone calls over videoconferences because many elderly patients do not have an Internet connection at home. Sensory impairments like deafness are also frequent in this patient group and can make it hard to communicate, especially if we as medical professionals have to speak through a protective mask.
How do you balance the benefits and the risks of continuing cancer care in the elderly?
Discussions are always collegial, and we consider patients individually in multidisciplinary meetings. In cases where treatment is controversial, it is crucial to make it clear to elderly patients, in particular, that their age is absolutely not the only criterion we use to assess their level of vulnerability and decide on a course of action. Chronological age does not necessarily match biological age: this has always been true among elderly cancer patients, but it is even more relevant during this pandemic, where we are seeing various other factors like diabetes, hypertension, asthma and obesity put patients at an increased risk. Age is just one of them. That is why we also collaborate closely with geriatricians to help us assess our senior patients’ overall health and frailty, evaluate their life expectancy and weigh in on the risk-benefit analysis regarding treatment on a case-by-case basis.
Are any additional protective measures needed for the elderly, compared to other cancer patients?
Of course, we recommend that our elderly patients follow the same social distancing and hygiene rules that apply to everyone, but in addition we strongly emphasise the importance of limiting contact with other people. We have offered to organise the home delivery of meals or groceries to avoid these patients going into shops and supermarkets, and have worked with pharmacies to arrange for drug deliveries to their homes or for their carers to fill prescriptions on their behalf.
However, this principle of isolation was a huge challenge in the acute phase of the crisis in the hospital. Be it in the COVID divisions or in our palliative care wards, patients were being hospitalised in critical conditions with no visits allowed, and we felt powerless to alleviate their physical and mental suffering. To make matters worse, some of our elderly patients suffer from dementia and memory loss: without their carers present in the hospital they were disoriented, didn’t know where they were and consequently had a harder time respecting hygiene and distancing rules in the absence of medical staff. This led to difficult situations that prompted us to allow support persons back in the rooms with them, because complete isolation was just not sustainable.
What is the possible impact of social distancing and prolonged isolation on this vulnerable population?
We know that these individuals can deteriorate very quickly when they do not leave their homes at all for several weeks. If they no longer engage in regular physical exercise, even just walking, they will be at much greater risk of losing autonomy or injuring themselves in a fall. Depression is also likely in these individuals, and the loss of social activity and interactions can additionally worsen memory loss and cognitive impairments. We need to start thinking today about the consequences that these foreseeable complications in elderly patients are going to have tomorrow, especially as they are associated with cancer or a delayed diagnosis thereof.
What do you think an ideal collaboration between oncologists and geriatricians should look like in this situation?
Multidisciplinary consultation meetings are clearly very helpful to include geriatricians in decision-making processes for elderly cancer patients. Another form of collaboration that I think is highly beneficial, though not every hospital has access to it, is what we call mobile geriatric teams: made up of a geriatrician and a nurse, sometimes backed up by additional care personnel, these teams are mobile across divisions and units to perform visits and participate in discussions with oncologists. Because these teams are physically present in the wards, they actually see the patients and can make evaluations based on more than the paper records we would use in a multidisciplinary meeting.
Important collaborations are also taking place within and between organisations like the International Society of Geriatric Oncology (SIOG) and ESMO. In their joint Working Group on Cancer in the Elderly, of which I am a member, oncologists and geriatricians are working together on a more general level to produce recommendations for the current crisis. We are also carrying out surveys among doctors who care for elderly cancer patients, to find out how they have been managing and adapting their care during the pandemic.
References
- Livingston E, Bucher K. Coronavirus Disease 2019 (COVID-19) in Italy. JAMA; 2020;323(14):1335. DOI: 10.1001/jama.2020.4344
- Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. The Lancet Oncology; Published online 14 February 2020. DOI: 10.1016/S1470-2045(20)30096-6