Problems in the use of anticancer drugs in the elderly

The elderly represent a special challenge to the physician in providing effective cancer chemotherapy. Though they represent the majority of the patients who eventually will need such therapy, until recently little information was available on its use in this population. There are variable age changes in pharmacokinetics, particularly in renal elimination of drug and metabolites, which may necessitate dosage amendment. Concomitant renal impairment or hepatic disease may further alter drug disposition. Other common pre-existing conditions in the elderly also may increase susceptibility to adverse drug effects. For example, the risk of toxicity from doxorubicin and vincristine can be increased in the presence of pre-existing cardiac disease or peripheral neuropathy, respectively. Because of the variability of the ageing process and the effects of concomitant disease, each patient must be assessed on an individual basis. Furthermore, in treatment planning, not only age and health status but also the patient's attitude and the tumour type are important considerations. Chemotherapy for most malignancies appears beneficial and well tolerated in the elderly, and there is little evidence that age per se is a determinant of chemotherapy regimen selection and dosing. The exceptions may be the curable haematological malignancies for which chemotherapy seems less efficacious and more toxic in geriatric than younger patients. The complications of chemotherapy such as vomiting, mucositis and bone marrow depression must be anticipated, diagnosed early and managed aggressively in aged patients. Guidelines are provided to help manage these problems. Chemotherapy in the elderly is still at a relatively early stage of development. Further research is required to establish optimal regimens for use in this population, in particular for curable haematological neoplasms.