The number of older people with cancer and other chronic conditions is rising sharply. Doctors sometimes refer to this as a ‘silver tsunami’: a sharp increase in the number of older patients, many of whom have complex care needs. People are living longer, but they are also more likely to have multiple conditions at the same time, take more medicines and require more support.
Mainly fit elderly people in studies
Clinical trials do not always reflect this reality. In order to assess as accurately as possible whether a treatment is effective and safe, they operate under strict eligibility criteria. As a result, it is mainly relatively fit elderly people who take part, whilst less fit or vulnerable older people are more likely to be excluded from the trials. Consequently, it is not always clear to doctors whether the results of these trials also apply to the older patients they treat on a daily basis. Consequently, some older patients receive treatment that is unnecessarily intensive, whilst others, out of an abundance of caution, miss out on a potentially beneficial treatment.
The team compiled international examples of studies that are more effective at reaching and engaging older patients, drawn from fields including oncology, cardiology, neurology, orthopaedics and endocrinology. Some studies deliberately make provision for vulnerable patients. Others adapt the research, for example by using a lower starting dose, providing extra support, or arranging less burdensome check-ups at home or remotely.
With these examples, the authors wish to provide a source of inspiration for tailoring clinical trials more effectively to older patients, without compromising on scientific quality or safety.
More than just living longer
The researchers emphasise that trials should also assess what is important to older patients themselves. Survival, disease control, side effects remain important outcomes , but don't tell the whole story. For many elderly patients is also important whether they can continue to live independently, can go about their daily life and have a good quality of life. Treatment can be medically efficient, but can but still too much of a burden on someone’s daily life.
Prof. Wildiers, the lead author of the article in The Lancet, also applies this broader perspective to the care of older cancer patients. At UZ Leuven, he is working with a multidisciplinary team to develop a systematic geriatric assessment. In this process, doctors look not only at the tumour, but also at the patient’s physical and mental health. Factors such as mobility, memory, medication use and available support all help to determine which treatment is feasible and appropriate.
The person behind the disease
Not every elderly patient needs to be included in a trial, because, at present, by no means all clinical trials are sufficiently adapted to the elderly. It is important that, right from the design stage, clinical trials are better aligned with the patients that doctors treat in practice. In doing so, researchers must take into account what a person is physically and mentally capable of, what support is available, and which outcomes are truly important to that person..
By involving geriatricians, patients, relatives and informal carers right from the design stage of trials, these trials can become less burdensome and more relevant for elderly people. In this way, the results provide doctors with a better basis for tailoring treatments to the older patient sitting in front of them.
At present, it is mainly fit older people who take part in clinical trials. As a result, we know too little about which treatment works best for vulnerable elderly people, even though it is often with them that we have to make the most difficult decisions.
More information
This study was conducted in collaboration with experts from Belgium, the Netherlands, the United States, France, Italy and Norway, with expertise in areas including oncology, geriatrics, gerontology, internal medicine and public health.