Book Review

Cancer in the Elderly: Treatment and research

N Engl J Med 1995; 333:673-674September 7, 1995

Article

Cancer in the Elderly: Treatment and research
Edited by Ian S. Fentiman and Silvio Monfardini. 173 pp. New York, Oxford University Press, 1994. $92. ISBN: 0-19-262200-5

“Age is the major risk factor for the majority of cancers, half of which become clinically evident in people over 70 years old.” So ends the first paragraph of the preface to this book addressing problems of cancer in old age. With continuing declines in mortality from cardiovascular causes, cancer will become increasingly important as a cause of death in older persons. This book is an important contribution to the emerging field of geriatric oncology.

About half the book deals with age-related mechanisms of susceptibility to cancer, psychosocial issues, terminal care, radiotherapy, and chemotherapy. These chapters are generally well-written summaries. The remainder of the book concerns specific cancers: breast, prostate, bladder, colorectal, and ovarian, acute myelogenous leukemia, and non-Hodgkin's lymphoma.

The cancer-specific chapters have several important limitations. First, it is not readily apparent why these cancers were chosen for inclusion, or why others, such as lung cancer, were excluded. The reasons for focusing on some tumors but not on others may include epidemiologic features, the degree of curability in old age, or issues of care unique to older persons, but neither these nor other reasons are elaborated.

Second, the book's many European authors give it a distinct perspective that, combined with its high price, will probably limit its value for American clinicians. For example, the chapter on breast cancer emphasizes mastectomy as the preferred local treatment for invasive cancer. The brief discussion of breast-conserving surgery with postoperative radiation therapy conveys little enthusiasm for this approach. In addition, considerable emphasis is given to tamoxifen as an initial primary therapy for invasive breast cancer.

Third, perhaps again reflecting the perspective of the authors, there is no mention of the field of geriatrics or of the role of geriatric clinicians in caring for older patients with cancer. On this side of the ocean, there is increasing emphasis on the partnership among geriatricians, oncologists, and other geriatric clinicians in such care. Together we know how to assess and look after older patients, and we have developed valid, reliable measures of such relevant outcomes as functional status and the quality of life.

Fourth, the chapters vary in length and depth. There is considerable redundancy with respect to the epidemiologic features of cancer and patterns of treatment. Furthermore, the references are inconsistent in style; some are incomplete (in chapters 7 and 10 no article titles are provided), and none are more recent than 1992. I hope these editorial issues will be rectified in the next edition.

I also hope that the next edition will contain reports of clinical trials of therapeutic regimens specifically designed for older persons, including information on quality-of-life outcomes as well as mortality and cancer recurrence. Since the value of findings from clinical trials is always compromised by selection biases, reports of carefully performed observational studies of the effectiveness of treatment in old age will also be extraordinarily useful.

Rebecca A. Silliman, M.D., Ph.D.
Boston University Medical Center, Boston, MA 02118