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October 10, 2019

Prolonging Life, but at What Price?

Author Affiliations
  • 1Section of Otolaryngology–Head and Neck Surgery, Biological Sciences Division, Department of Surgery, University of Chicago Medicine, Chicago, Illinois
  • 2Comprehensive Cancer Center, Biological Sciences Division, Department of Medicine, University of Chicago Medicine, Chicago, Illinois
JAMA Otolaryngol Head Neck Surg. 2019;145(12):1103-1104. doi:10.1001/jamaoto.2019.2855

“Doc, how long have I got to live anyway if I do nothing?” This is a question from an elderly patient that is familiar to any oncologist. As the proportion of elderly patients continues to increase steadily worldwide, clinicians can expect that this will become an increasingly present scenario in medical offices. In particular, there will be a dramatic increase between 2015 and 2050 in patients currently regarded as the so-called oldest old (those 80 years and older) to more than 440 million worldwide, tripling the current population in this category.1 Whether to subject patients who have already exceeded normal life expectancy to the stressors of major surgery for an aggressive malignant condition is as much an ethical issue as it is a medical one, and clinicians are badly in need of tools to assist patients in shared decision-making. The lay press has caught wind of this issue as well; witness the title to a New York Times article published in June 2019: “The Elderly are Getting Complex Surgeries. Often It Doesn’t End Well.”2

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    1 Comment for this article
    "Often It Doesn’t End Well": a valid reason to do better.
    Edoardo Cervoni, M.D., ENT Specialist | LD4u, Southport, UK
    I very much welcome this paper as it does highlight very well some "sore issue" in the current management of the elderly population with head and neck cancer diagnosis. First of all, the older adults are under-represented in clinical trials in general and this does automatically put them at a disadvantage when considering approval of new immunotherapy agents, and not only. Considering the population trends, the recruitment procedures appear to be anachronistic. Of course, most elderly patients seen in the community-based oncology practices are not considered eligible for such studies as the results of these studies are difficult to generalize to a broader patient population with these competing risks, evaluation of toxicities, effect on quality of life and functional status, and immunosenescence. However, it is also true that the status quo is suboptimal and, in any case, proposing chemotherapy, or major surgery, appears to be often unwise for the very same, above mentioned reasons. Our overall approach seems to be wrong, giving priority to standardised treatment modalities, such as chemotherapy combinations, which have already shown to provide less than brilliant results and significant side effects. At the same time, we are gravely failing to look at each patient, and indeed head and neck cancer, as potentially distinct entities from the very start of the diagnosis. For instance, we do a treatment plan prior to having received a complete genetic characterisation of the cancer. Sometimes, it may be already clear that the patient, perhaps elderly, may be unable to tolerate more than 1-2 cycles of chemotherapy, yet we propose this option as its lack of response may be a requirement to a different type of pharmacological intervention.
    The negative implications of this approach are obvious.
    Overall, I think that guidelines ought to be re-thought, bearing in mind biomarkers from the very beginning of the treatment, coupled with the co-morbidities and probable resilience of the patient to treatment options. Clinical trials should aim to include more elderly patients. Ultimately, the results may be more difficult to analyze and generalize, but the truth is that co-morbidities are the rule rather than the exception in day to day clinical practice and they should be taken into account when offering meaningful options.