Geriatric oncology: perspectives from decision analysis. A review

The management of advanced cancer in the older person is variable. In some patients with common malignancies chemotherapy may palliate symptoms and prolong survival, while in other patients chemotherapy is a cause of overwhelming toxicity and supportive care is the preferred form of treatment. We explored the principles of individualized management for the older person with cancer and we used decision analysis as a guide. From a decisional standpoint, geriatric malignancies may be subdivided into two categories: diseases whose management is not affected by age and diseases whose management may be age-conditioned. In the latter group one can distinguish three clinical situations: diseases with short survival when untreated, which are responsive only to highly toxic chemotherapy; diseases with short survival when untreated, which may be responsive to low-toxicity chemotherapy; and diseases with prolonged survival when untreated, whose clinical course may be affected by chemotherapy. From the analysis of these clinical situations, a critical paucity of information has emerged in five areas: prognostic evaluation of the older patients, interaction of comorbid conditions and cancer chemotherapy, availability of low-toxicity alternative treatment regimens, life expectancy and estimate of outcome utilities. Further research in these areas, according to the lines we propose, may fill critical gaps of knowledge and allow optimal management of geriatric cancer.