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CNE Article

Older Adults With Lung Cancer: Assessment, Treatment Options, Survivorship Issues, and Palliative Care Strategies

Diane G. Cope
Anne Reb
Rowena Schwartz
Jody Simon
CJON 2018, 22(6), 26-35 DOI: 10.1188/18.CJON.S2.26-35

Background: Treatment advances offer options for cancer treatment in older adults that are less invasive and have fewer side effects. Geriatric assessment is a key component of treatment planning to identify functional and physiologic status and is the basis of decision making.

Objectives: This article discusses the role of geriatric assessment, treatment options (e.g., surgical, chemotherapy, radiation therapy), survivorship issues, and palliative care strategies for older adults with cancer.

Methods: Literature was reviewed to identify geriatric assessment implications, current treatment strategies, and survivorship and palliative care interventions for older adults with cancer based on a case study approach.

Findings: Geriatric assessment is key to identifying deficits and disabilities in older adults with cancer and is a critical component in oncology treatment planning. Evidence-based, less invasive treatment options are available and offer older adults more tolerable oncologic therapies.

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Aging is associated with a progressive decline in the functional reserve of multiple organ systems, cognition, and social support. Older age comes with increased risk of comorbidities, polypharmacy, malnutrition, and functional dependence. These changes can potentially decrease life expectancy and tolerance of stress, but they occur at different rates in different individuals and are poorly reflected by chronologic age (Balducci, Dolan, & Hoffe, 2015).

The assessment of physiologic or functional age is essential to personalize the treatment of cancer in older adults. Without a complete assessment, treatment decisions may lead to reduced response if undertreated or may result in adverse toxicities, functional decline, or even death if treatment is too aggressive for older adults (Wildiers et al., 2014). A comprehensive geriatric assessment (CGA) includes an interprofessional evaluation of functional status, psychological status, comorbidities, social support, cognitive function, and nutritional status and is conducted as a diagnostic process to identify care needs, plan care, and improve patient outcomes in older adults (Puts & Alibhai, 2018). The geriatric assessment has been shown to identify increased risk of shorter overall survival and chemotherapy toxicity (Li, Soto-Perez-de-Celis, & Hurria, 2017).

The main oncologic treatment options for older adults with cancer consist of surgical intervention, chemotherapy, immunotherapy, targeted therapy, and radiation therapy. This article will explore each treatment strategy and their implications, using a case study of an older adult with lung cancer as an example.

Case Study

Mr. H is a 77-year-old man who presented to his primary care provider with increasing shortness of breath; a dry, frequent cough; 10-pound weight loss; and one episode of hemoptysis. He has a history of chronic obstructive pulmonary disease, cirrhosis, and hypertension; continues to drink two or more vodka tonics daily; and is a heavy smoker (2–3 packs per day for 60 years). Mr. H was sure that he had a cold and was requesting an antibiotic. His physician ordered a chest x-ray for further evaluation. He initially refused because he did not want to be bothered with another appointment when he needed to be with his wife, serving as her sole caregiver. After explanation and discussion that his symptoms needed further evaluation, he agreed to go for the chest x-ray, which showed a mass in the right upper lobe. A positron-emission tomography (PET) scan was ordered, and results confirmed a hypermetabolic right upper lobe mass and a second, smaller hypermetabolic mass in the right upper lobe but no definite adenopathy and no distant metastasis. He underwent a computed tomography (CT) needle biopsy with pathology showing nonsquamous, non-small cell carcinoma consistent with lung primary. Mutational panel studies revealed that the tumor was EGFR and ALK wild type, ROS1 negative, and positive for BRAF V600E mutation. Discussion with Mr. H included the results and potential care options that could include watchful waiting; palliative care; or surgical, medical, or radiation treatment. The oncologist recommended a surgical evaluation because Mr. H may be a surgical candidate for tumor resection. Mr. H was not in favor of surgery because he was the only caregiver for his wife but agreed to go for evaluation.

Surgical Interventions

In general, complete surgical resection of any malignant tumor offers patients with cancer the best chance for curative intent. Less invasive surgical procedures and safer anesthesia have made it feasible for older adults to be considered for surgery. However, surgery in older adults has been associated with increases in complication rates, morbidity and mortality, intensive care unit admissions, and extended hospital stays (Kore-Grodzicki et al., 2014). Normal physiologic changes can affect outcomes to surgical procedures and increase risk for various conditions, such as renal toxicity and fluid overload.

The extent and onset of organ system functional decline varies from individual to individual. The best possible surgical outcomes are based on knowledge of the underlying disease, organ function, and stress of surgical procedures. Frailty and geriatric assessment should be completed with the standard history and physical examination preoperatively. Several baseline factors that increase risk for postoperative complications have been identified (see Figure 1).

The American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society developed a best practices guideline for the optimal preoperative assessment of the geriatric surgical patient (Chow, Rosenthal, Merkow, Ko, & Esnaola 2012). Evidence-based recommendations include assessment of cognitive ability, depression, postoperative delirium risk factors, alcohol and substance abuse, functional status, nutritional status, frailty, medications, treatment goals, family and social support, and diagnostic testing of hemoglobin, blood urea nitrogen, creatinine, and serum albumin (Chow et al., 2012). In addition to basic history, physical, functional status, and frailty assessments, assessing for family and social support is critical for older adults undergoing surgery. Identifying whether the individual will have a caregiver and understanding any support deficits will facilitate postoperative planning for older adults and allow for arrangements to be made for necessary services during the recovery period.

Preoperative anesthesia evaluation focuses on a detailed history and physical with assessment of the functional reserve of each organ system (Bittner, Vassallo, & Wiener-Kronish, 2018). General considerations for older adults include positioning, premedication, sedation, anesthetic agents, and thermoregulation. Positioning may be compromised by older adults’ arthritic changes, limiting optimal positioning for intubation, neck extension, surgery, and regional anesthesia. Skin thinning and decreased skin elasticity can increase risk for skin breakdown, pressure sores, and nerve injury. The choice of premedications, sedation, and anesthetic agents are individualized, and dosage adjustments are recommended because of differences in responses as a result of alterations in distribution and clearance of drugs (pharmacokinetics) and increased sensitivity to the target organs (pharmacodynamics) (Bittner et al., 2018). Two major complications of anesthesia include postoperative delirium and postoperative cognitive dysfunction (Reddy, Irkal, & Srinivasamurthy, 2017). Postoperative delirium may occur in 10%–40% of older adults following surgery, particularly major and emergency surgeries or in patients with multiple comorbidities or current or previous history of cognitive impairment (Reddy et al., 2017). A Clinical Practice Guideline for Postoperative Delirium in Older Adults has been developed by the American Geriatric Society Expert Panel on Postoperative Delirium in Older Adults (2015) and recommends multicomponent nonpharmacologic interventions delivered by an interprofessional team for at-risk older adults to prevent delirium, a medical evaluation to identify and manage underlying contributors to delirium, pain management, avoidance of high-risk medications that could precipitate delirium (e.g., cholinesterase inhibitors, benzodiazepines, antipsychotics), and ongoing educational programs regarding delirium for healthcare providers.

Thermoregulation is important for the older adult with risk of hypothermia because of impaired vasoconstriction, reduced metabolic activity, and alterations in central temperature regulation and shivering threshold. Perioperative hypothermia is associated with poor wound healing, susceptibility to infections, discomfort, and increased cardiovascular stress (Bittner et al., 2018).

A patient who is high-risk for postoperative complications because of physiologic comorbidities or cognitive, social, physical, or nutritional dysfunction should have appropriate consultations and medical management to address the underlying cause of dysfunction and decrease perioperative stress. Multimodal prehabilitation programs that include exercise, nutrition, and psychological interventions could potentially improve the perioperative period and enhance the recovery program and return to baseline activities of daily living (Carli, Gillis, & Scheede-Bergdahl, 2017). The optimal duration of prehabilitation should be at least four weeks before surgery, but programs lasting as long as six to eight weeks reach a better balance between compliance and effectiveness.

In a review of surgical management of thoracic malignancies in older adults by Kamel and Port (2018), findings suggest that lung resections appear to be safe for older adults with lung cancer, with the goal of a lobectomy for patients with good performance status and early-stage disease. Minimally invasive surgical approaches, such as video-assisted thoracoscopic surgery and robotic surgery, are ideal for older adults and are associated with lower morbidity and improved perioperative outcomes.

Related to the case study about Mr. H, surgical assessment determined that he was not a candidate because of his history of chronic obstructive pulmonary disease and cirrhosis. He stated that he probably would not have proceeded with surgery because no one would have been available to care for his partner. He returned to the oncologist for discussion of treatment options, but he is adamant that he does not need or want chemotherapy.

Antineoplastic Therapy Options

Assessing for Treatment Tolerance

Treatment decisions for older adults with cancer can be complex, and geriatric assessment is recommended to select patients for participating in clinical research, undergoing particular treatment regimens, determining prognosis, managing treatment toxicities before and during cancer treatment, and handling issues during the survivorship phase. Several systematic reviews investigating the use of a geriatric assessment and treatment toxicity include functional status, nutritional status, cognition, functional impairment, malnutrition, and comorbidities (Aaldriks et al., 2011; Caillet et al., 2014; Ramjaun, Nassif, Krotneva, Huang, & Meguerditcchian, 2013) related to chemotherapy toxicity.

A CGA is viewed as the gold standard in the assessment of older adults with cancer. However, it is difficult to incorporate in clinical practice because of time and resource demands to complete the assessment. CGA options are assessing components over time based on patient priorities or use of the six-item modified Geriatric 8 as a health status screening tool. Other geriatric assessment tools have been investigated and validated to predict chemotherapy toxicity and include the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) (Extermann et al., 2012) and Cancer and Aging Research Group (CARG) Chemo-Toxicity Calculator (Hurria et al., 2012). The CRASH is made up of a hemotologic score based on need for assistance with instrumental activities of daily living and alterations in diastolic blood pressure and lactate dehydrogenase and a nonhematologic score based on malnutrition, poor Eastern Cooperative Oncology Group performance score, and cognitive impairments (Extermann et al., 2012). The CARG tool assesses age, cancer type, chemotherapy dosing, number of chemotherapy drugs, hemoglobin, creatinine clearance, hearing impairments, number of falls, need for assistance in taking medications, ability to walk one block, and social activity (Hurria et al., 2012).

Role of Precision Medicine

The term precision medicine is used to describe the use of specific aspects of the cancer to determine treatment options and direct care. During the past decade, the specific components of precision medicine in cancer care include stage, histology, and the determination of genetic driver mutations (e.g., EGFR, ALK, ROS1, BRAF for lung cancer) of the cancer.

Biologic considerations about the patient’s tumor cells contribute to treatment options, the patient’s overall health (e.g., renal function, liver function, cardiovascular health), preexisting comorbidities, concomitant medications, nutritional status, psychosocial status, and functional status. These factors may be evaluated with existing geriatric assessment scales and must be continually assessed throughout the treatment course.

Immune Checkpoint Inhibitors

Cancer has the ability to interfere with adaptive immunity, and strategies to interfere with checkpoint pathways that suppress T-cell function have revolutionized treatment of many cancers, including non-small cell lung cancer (NSCLC), allowing the immune system to attack the cancer. Immune checkpoint inhibitors have become a first-line approach to treat advanced or metastatic NSCLC, with evidence of response and survival benefit for nivolumab and pembrolizumab (monoclonal antibodies directed at PD-1) as treatment options for NSCLC. Atezolizumab and durvalumab, monoclonal antibodies directed at PD-L1, are also treatment options for individuals with NSCLC (see Table 1). The use of combinations of immune checkpoint inhibitors is being evaluated in lung cancer because of the success seen in combination pembrolizumab, pemetrexed, and carboplatin as first-line therapy in NSCLC (Gandhi et al., 2018; Langer et al., 2016).

The role of immunotherapy in older adult patients has been an area of significant interest based on the concern that older adults may have less responsive immune systems. To date, there does not appear to be clear evidence that an age limitation exists for immunotherapy (Daste et al., 2017; Elias et al., 2018). Challenges of immunotherapy are uncommon but include potentially severe immune-related adverse events. Guidelines serve as a resource to clinicians caring for patients receiving immune checkpoint inhibitors (Brahmer, Lacchetti, & Thompson, 2018; Puzanov et al., 2017).

Targeted Therapy

Treatment advances for NSCLC include drug therapy that targets mutational driver genes in a subset of patients with NSCLC, including EGFR and ALK. Epidermal growth factor receptor (EGFR) mutation–positive NSCLC, representing 10%–15% of nonsquamous cancers, has shown increased progression-free and overall survival with the use of tyrosine kinase inhibitors compared to chemotherapy for first-line treatment.

The rearrangement of the anaplastic lymphoma kinase (ALK) gene encodes driver fusion oncoproteins found in 2%–5% of individuals with NSCLC. To date, four U.S. Food and Drug Administration–approved ALK inhibitors are crizotinib, ceritinib, alectinib, and brigatinib. BRAF is a serine threonine kinase mutation, representing 2%–4% of lung cancer, mainly in adenocarcinoma histologic subtype. The combination therapy of dabrafenib (a small-molecule oral BRAF inhibitor of some mutation forms of BRAF kinases) with trametinib (a small-molecule oral MEK1 inhibitor) is approved for the treatment of patients with unresectable or metastatic melanoma with BRAF V600E or V600K mutations (Toschi, Rossi, Finocchiaro, & Santoro, 2017).

Chemotherapy

Chemotherapy remains an important treatment option in advanced and metastatic lung cancer when patients have been found to have no mutational driver genes for therapy. Considerations for chemotherapy include single agent versus combination, selection of agents, dose, schedule, duration, and individualization for patient-specific factors and goal of therapy, particularly for older adults. Patients with driving mutations should be considered for targeted therapies (Boolell, Alamgeer, Watkins, & Ganju, 2015).

For Mr. H, with the BRAF V600E mutation, the combination of dabrafenib and trametinib or chemotherapy may be an appropriate treatment option.

Oral Anticancer Therapy and Adherence

An increasing number of treatment options are available for patients with lung cancer, and many of those options are oral anticancer therapies. These treatments have been effective in selected patient populations. However, nonadherence is a challenge. The challenges of an agent must also be considered when initiating therapy and throughout the treatment course. Oral therapies may be even more problematic in older adults who face many factors associated with nonadherence, such as polypharmacy, cognitive impairment, comorbidities, higher risk of adverse events affecting comorbidities, drug toxicities, regimen complexity, financial barriers, and lack of social support (National Comprehensive Cancer Network [NCCN], 2018c).

Much has been written about patient adherence to oral therapy. A consensus statement promoting oral therapy adherence has been published to address the challenges in melanoma (Kottschade & Lehner Reed, 2017). Important to consider is the access to begin drug therapy because many of the oral agents are expensive and have limited availability. Ensuring that an individual receives therapy promptly and can afford the out-of-pocket medication cost is part of coordinated care. Simply ordering the medication is not sufficient; it is essential to coordinate with the patient and caregivers when the drug is initiated to best plan appropriate follow-up for toxicity management and disease evaluation.

Two of the most important aspects of care with oral anticancer therapy are the patient’s continued adherence to medication and the coordinated modification of therapy as needed based on the individual’s response, including toxicities and tolerability. The patient or caregiver is an important member of the healthcare team and should be involved with decision and coordination of information. The understanding of the disease, its treatment, and potential toxicities may help ensure adherence or increase communication about nonadherence. In addition, other members of the patient’s healthcare team play a key role in optimization of care. The potential for inadvertent drug interaction is high when healthcare providers are not aware of all medications. All members of the healthcare team (e.g., primary care providers, pharmacists in the community) should be aware of drug therapy, often dispensed through specialty pharmacies, to help coordinate optimal care. 

Of note, there are a number of barriers that may affect the success of drug therapy, including the complexity of the regimen, cost of medication, and toxicities. The oncology nurse plays a key role in executing oral therapy and providing ongoing, close monitoring for patients taking oral agents, particularly older adults who have unique needs, such as polypharmacy, potential hearing and vision loss, limited income, and increased risk of drug toxicities. Good communication with the patient can address the patient’s beliefs about the risks and benefits of the medication and help to identify potential modifiable barriers. Once any barriers are known, the oncology nurse may provide educational information and interventions that are individualized to the patient (Mislang et al., 2017).

Supportive Care

Patients with lung cancer may receive supportive care treatments before, during, or after primary treatment to improve their quality of life and functionality. Therapies may be prescribed depending on symptoms, treatment-related adverse events, or complications of the disease. These therapies may include pain management, growth factors, antiemetics, cough suppressants, bronchodilators and oxygen for dyspnea, and drugs and procedures to treat pleural effusion.

Returning to the case study, Mr. H met with the oncologist and underwent a geriatric assessment and evaluation for treatment options. Mutational studies revealed that he had the BRAF mutation and was a candidate for targeted therapy of dabrafenib in combination with trametinib. After a review of side effects, benefits, prognosis, overall goal of therapy, treatment schedule, costs, and follow-up, Mr. H agreed to the targeted therapy treatment plan. He started on dabrafenib and trametinib without any side effects. After three months of therapy, he underwent a CT scan to assess treatment response. His oncologist reported that he had an amazing response with 50% shrinkage of the two lung masses. He continued on the medications for two years with ongoing positive therapy response but then developed lower back pain that he rated at an 8 on a scale of 1–10. Despite taking long- and short-acting narcotics prescribed by his primary physician, his pain limited his activity, was unrelieved by the pain medications, and limited his caregiver role. A magnetic resonance imaging of the lumbar spine was performed that showed a lesion at L5. A PET scan confirmed a hypermetabolic lesion at L5, with other osseous metastasis in the right femur and left 8 rib, and showed an increase in size of his two lung nodules.

Mr. H met with his oncologist, and the dabrafenib and trametinib therapy was discontinued because of tumor progression. The oncologist discussed changing therapy to chemotherapy with pemetrexed and carboplatin. After further assessment, the oncologist referred Mr. H to a radiation oncologist for treatment option evaluation. He met with the radiation oncologist and underwent a complete assessment and evaluation. Mr. H described his significant low back pain he had for the past month as limiting his activity and being unrelenting.

Radiation Therapy

Radiation therapy is an important treatment option for older adults because of potential decreased side effects and toxicity. To determine if a patient is a candidate for radiation therapy, the radiation oncologist completes a comprehensive assessment of the patient. The assessment includes the patient’s anticipated tolerability to radiation therapy and a discussion with the patient about goals of treatment (Smith & Smith, 2014).

For older adults, appropriate radiation therapy strategies include shorter (hypofractionated) regimens and stereotactic body radiation therapy, which provide more targeted, cost-effective treatment in shortened time intervals. Because these regimens are shorter, they can be less arduous and require fewer treatment visits if transportation to visits is a challenge (Movsas, 2017). For example, treatment protocols for palliative bone metastases with 30 Gy in 10 fractions, 24 Gy in six fractions, 20 Gy in five fractions, and a single 8-Gy fraction have resulted in equivalency in pain relief (Howell et al., 2013).

The standard of practice to treat bone metastases is three-dimensional conformal radiation therapy (3DCRT) (De Felice, Piccioli, Musio, & Tombolini, 2017). 3DCRT allows dose distribution to conform to the target volume, reducing dose to the surrounding normal tissues. Some of the more common toxicities that older adults may have are fatigue, nausea, vomiting, diarrhea, dehydration, possible infection, and cognitive defects. Partial pain relief of 60%–80% and complete pain relief of 30%–50% in patients three to four weeks after initiation of external beam palliative radiation therapy has been reported (Lutz, Jones, & Chow, 2014).

Following evaluation and explanation of radiation treatment goals and side effects, Mr. H proceeds with radiation therapy for palliative pain relief. Although the treatment was administered with a shortened fractionated regimen to L5 with 50% pain relief, he developed intractable diarrhea, fatigue, and dehydration, resulting in rapid decline and hospitalization. During the hospitalization, Mr. H decided that he wanted no further treatment.

Survivorship Care

The population of cancer survivors includes those treated with curative intent, as well as those living with advanced cancer who may experience remitting-recurring illness or progressive disease. The goal of treatment in advanced cancer is to improve quality of life matching the patient’s values and goals (Chandrasekar, Tribett, & Ramchandran, 2016). With advances in treatment modalities, patients with lung cancer, for example, are receiving life-prolonging treatment (Giuliani et al., 2016). As a result, patients diagnosed with advanced cancer face more uncertainty regarding prognosis (Reb & Economou, in press). Maintaining independence and preventing disability are priorities for older adults with cancer (Fried et al., 2011; Presley, Reynolds, & Langer, 2017).

Survivorship care is a process that should begin with an assessment of the patient’s physical, psychological, and social needs. Brief screening measures assessing symptoms and unmet needs should be incorporated in care settings to help identify concerns. A geriatric assessment can also help to prioritize unmet needs and inform the survivorship care plan (Guerard et al., 2016). Survivorship care plans should be tailored to the needs and values of older adults and address specific components, including comorbidities, nutrition, polypharmacy, exercise, muscle loss, and social support (Mohile et al., 2016).

Comorbidities may affect functional status and require an interprofessional approach to manage side effects and psychosocial needs. Malnutrition and low body mass index are associated with poor outcomes; therefore, early screening and management for nutrition problems are recommended (Koll et al., 2016; Stepney, 2016).

Polypharmacy, another concern among older adults, can lead to poor adherence and adverse drug reactions, which can affect treatment efficacy. Medications should be reviewed and evaluated for potential interactions, and nonpharmacologic approaches should be emphasized.

Medications with potential for long-term risks should be avoided or used only in the short-term (Dy, Isenberg, & Al Hamayel, 2017). NCCN (2018c) guidelines identify potentially problematic medications used for supportive care in older adults, which includes recommendations for dosing and alternative therapies. Examples include corticosteroids, benzodiazepines, antihistamines, nonbenzodiazepine sedative hypnotics, and selective serotonin reuptake inhibitor antidepressants.

Palliative Care

The focus of care for cancer survivors overlaps with palliative care because the components and goals of care are similar (Dy et al., 2017; Economou, 2014). Early introduction of palliative care concurrent with standard oncology care in lung and other advanced cancers is associated with improved quality of life and survival (Bakitas et al., 2017; Presley et al., 2017; Temel et al., 2010). Ongoing assessment of symptoms, psychosocial concerns, and functional status will help identify palliative care needs and should prompt early referrals to services.

Patients with advanced cancer or significant symptoms should be referred to interprofessional palliative care teams (Ferrell et al., 2017). Triggers for palliative care include frailty, functional dependence, cognitive impairment, distress, and caregiver issues (Brighi, Balducci, & Biasco, 2014).

Barriers exist to accessing palliative care services in outpatient and community settings. For example, most community practices do not have resources for dedicated palliative care teams (Presley et al., 2017). Rehabilitation services may be more accessible and can address many common symptoms and functional concerns, communicate with psychiatrists and other specialists who work with the patient to improve function, address gait and balance problems, and individualize exercise plans to build muscle strength and endurance (Koll et al., 2016). Rehabilitation services can address fatigue, breathlessness, pain, cognition, social limitations, and role function in daily activities to enable older adults to maintain independence (Bayly & Lloyd-Williams, 2016; Pergolotti, Lyons, & Williams, 2017).

Rehabilitation services are underused, particularly in the outpatient setting. In a study of 311 patients with advanced lung cancer, the most prevalent patient-reported barrier was the perception that rehabilitation was not needed, even in those with significant mobility limitations (Cheville, Rhudy, Basford, Griffin, & Flores, 2017). The researchers suggest that integrating rehabilitation services with scheduled treatments and appointments could lessen the perceived burden. Nurses should educate patients about the benefits of early rehabilitation services in preserving independence, function, and quality of life. Additional training in palliative care for physicians, nurses, and other clinicians may help to facilitate provision of supportive care services, particularly in settings where palliative care teams are overwhelmed or not available (Reb & Economou, in press).

Symptom Management

Pain, depression, and fatigue are the most frequently reported symptoms by patients with lung cancer. Berman et al. (2016) studied lung cancer survivors who reported neurocognitive symptoms (e.g., fatigue, musculoskeletal/dermatologic, thoracic) as the most common late effects. Nonpharmacologic treatments recommended for cancer-related fatigue include physical activity and psychosocial interventions (NCCN, 2018a). Integrative therapies, including mindfulness-based stress reduction, acupuncture, hypnosis, yoga, massage, and tai chi, are also useful for the treatment of fatigue and other common symptoms (Deng et al., 2013; Lehto, 2017). Pulmonary rehabilitation may improve cardiorespiratory and functional capacity in advanced lung cancer (Deng et al., 2013). Management of dyspnea includes medications, oxygen therapy, exercises, breathing retraining, self-management skills, and smoking cessation (Chandrasekar et al., 2016; Tiep et al., 2015).

Immune checkpoint inhibitors and anti–CTLA-4 agents are significant breakthroughs in lung cancer treatments that have increased survival for some patients. Patients treated with these agents experience a different profile of toxicity, including inflammatory and immune-related events (e.g., colitis, thyroid) and pneumonitis with associated symptoms of rash, diarrhea, and shortness of breath (Dine, Gordon, Shames, Kasler, & Barton-Burke, 2017). The NCCN (2018b) has issued guidelines on the management of common toxicities for immune checkpoint inhibitors.

Psychological and Social Concerns

Psychological distress is associated with poor clinical outcomes and survival in patients with cancer (Vodermaier, Lucas, Linden, & Olson, 2017). Early integration of palliative care services has shown benefit for psychological distress and other symptoms in patients with advanced cancer, including lung and non-colorectal gastrointestinal cancers (Ferrell et al., 2015; Temel et al., 2017).

Studies have found that patients with lung cancer experience more unmet supportive care needs and higher rates of anxiety and depression than other patients with cancer (Liao et al., 2011; Mosher et al., 2014). A survey by Giuliani et al. (2016) of supportive care needs in 89 patients with lung cancer (mean age = 71 years) found that the top three unmet needs were fear of cancer progression (52%), lack of energy/tiredness (48%), and uncertainty about the future (44%) (Giuliani et al., 2016). Uncertainty is very common in older adults with cancer and can result in anxiety and depression (Ghodraty Jabloo et al., 2017).

Clinicians should assess social concerns that may affect well-being, including roles and relationships, financial and work-related concerns, and family concerns. Physical and emotional symptoms may affect social functioning, and roles may shift because patients are dealing with side effects from cancer and treatment (Reb & Economou, in press).

Clinicians should collaborate with survivors and caregivers to capitalize on their strengths and identify resource and support needs (National Consensus Project for Quality Palliative Care, 2013). A variety of psychosocial interventions have shown benefit in managing psychological symptoms, including cognitive-behavioral therapies, psycho-education, mind–body interventions, and exercise (Lehto, 2017). Informal caregivers play a significant role in supporting the patient’s coping and well-being. Nurses, social workers, and other providers can initiate caregiver support for patients with advanced cancer. Interventions may include telephone coaching, symptom management education, in-person meetings, and referrals (Ferrell et al., 2017). Patients and their caregivers also benefit from mind–body coping strategies and stress-management techniques (McCormack et al., 2011).

Concluding the case study, Mr. H’s clinical nurse asked him how he was managing at home. He became tearful, stating that he was most worried about not being able to take care of his wife since learning that his cancer was progressing. The nurse acknowledged his concerns and suggested that he speak with a social worker who could explore some options and preferences for support services.

Implications for Oncology Nurses

With the projected increase in the aging population and cancer diagnoses in older adults, unique care strategies must be considered. Geriatric assessment and consideration of individual patient deficits are imperative when reviewing and selecting the best treatment options for older adults with cancer. Treatment advances offer less invasive approaches with fewer side effects and less toxicity. Oncology nurses should be knowledgeable about newer treatment options, toxicities, and specialized care for older adults with cancer. Nurses should provide written and verbal education regarding drug toxicities and side effects for all types of therapies, including immunotherapy, chemotherapy, and targeted therapy. Ongoing assessment is critical with older adults because of interactions with comorbidities and polypharmacy.

Nurses are in a key role to assess patients’ supportive needs and develop interventions specific to these needs. Working as part of the interprofessional team, nurses should facilitate coordination with other members (e.g., pharmacy, nutrition, social work) to provide necessary services.

Nurses should also assess the sources of uncertainty and coping strategies used to manage uncertainty and fears. Nurses can provide education and information, acknowledge what is known and not known, and encourage patients to express their feelings. Specific strategies include reassurance about commitment to the patient’s care and referring them to counseling, spiritual directors, or support groups depending on their preferences (McCormack et al., 2011).

Conclusion

Treatment of oncologic disorders in older adults presents unique challenges and necessitates thorough assessment and careful treatment planning that takes into consideration key assessment findings and delivers therapy that provides the most benefit with the least toxicities. This article presented treatment strategies using a case study approach with an older adult with lung cancer. Nursing implications were discussed for oncology nurses caring for older adults with cancer.

About the Author(s)

Diane G. Cope, PhD, ARNP, BC, AOCNP®, is the director of nursing and an oncology nurse practitioner at the Florida Cancer Specialists and Research Institute in Fort Myers; Anne Reb, PhD, NP, is an assistant professor in the Beckman Research Institute at City of Hope in Duarte, CA; Rowena Schwartz, PharmD, BCOP, is an associate professor in the School of Pharmacy at the University of Cincinnati in Ohio; and Jody Simon, MS, RPh, is the chief executive officer at the Geriatric Oncology Consortium in Tampa, FL. The authors take full responsibility for this content. Reb has previously received support from AstraZeneca. Schwartz has previously consulted for Horizon CME and has served on speakers bureaus for the Hematology/Oncology Pharmacy Association, the International Society of Oncology Pharmacy Practitioners, and the Oncology Nursing Society. During the writing of this article, Simon was supported by funding through Pfizer Pharmaceuticals. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Oncology Nursing Society. Cope can be reached at dgcope@comcast.net, with copy to CJONEditor@ons.org. (Submitted June 2018. Accepted July 28, 2018.)

 

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