Book Review

Cancer in the Elderly

N Engl J Med 2000; 343:306-307July 27, 2000

Article

Cancer in the Elderly
(Basic and Clinical Oncology. Vol. 23.) Edited by Carrie P. Hunter, Karen A. Johnson, and Hyman B. Muss. 606 pp., illustrated. New York, Marcel Dekker, 2000. $195. ISBN: 0-8247-0278-6

The treatment of cancer in older people is an increasingly common problem that is widely acknowledged but poorly understood. The benefits of treatment are smaller for older patients than for younger ones because of the shorter life expectancy of the former. Moreover, the therapeutic risks are increased in elderly patients because of a reduction in the functional reserve of multiple organ systems and the high prevalence of coexisting conditions. Since aging is highly individualized and the older population is diverse, perhaps the main challenge in managing cancer in older patients is to identify those who may benefit and those who may be harmed. This process may require a number of medical and social investigations outside the scope of a general oncology practice. The issue is further complicated by the fact that the biology of some neoplasms may differ depending on the age of the patient and by the absence of objective criteria to define functional age.

Cancer in the Elderly contributes important new insights into these issues. In a very readable style, the book reviews epidemiology, general principles of the prevention and treatment of cancer, and the management of common tumors in the older patient. A detailed review of decision making links this wealth of information to the clinical realities. Decision making is the focus of this book.

In my opinion, the main strength of the book is the perspective it offers. This viewpoint is summarized in the chapter on the quality of life and geriatric assessment, written by two world leaders in the fields. This chapter should be mandatory reading for any medical resident. The scope of treatment of older patients must include outcome assessment, an appreciation of the patient's values, treatment of multiple medical conditions, and psychosocial factors. This chapter makes a strong argument for the use of coordinated care at a time when the practice of medicine has become fragmented into small and largely independent units. The response to this fragmentation is a modern version of bedside assessment, which includes screening for physical dysfunction, depression, and the risk of dependence, an evaluation of home safety, the quality of life, and personal values.

This perspective is reinforced in a number of highly instructive chapters, including Satariano's chapter on coexisting conditions, which outlines the influence of concomitant diseases on cancer management and the current ways of assessing comorbidity; an eloquent case discussion by Hazzard and McGann that offers hands-on experience in the confluence of oncology and geriatrics; and a chapter on international issues, by Extermann and Aapro, which highlights the communality of medical problems in different nations and cultures and underlines the need for the international exchange of medical knowledge. The chapter on the care of the terminally ill and chapters dealing with health service issues and health policy issues also deserve mention. Though the book does not officially endorse geriatric oncology as a new specialty, it makes a strong case for the acquisition of skills germane to the special needs of older patients.

Another strength of the book is an up-to-date review of key areas related to cancer and aging. The chapter on molecular biology and biologic markers will serve as an exhaustive reference for any student, physician, or biologist looking for sound, basic knowledge. The chapters on surgery, radiation therapy, breast cancer, and hematologic cancers provide numerous references on their respective topics, highlight the differences in the approach to older and younger patients, and outline important research perspectives.

The book has some of the weaknesses expected in this type of endeavor: redundancy and repetition (screening for breast cancer is dealt with three times in different chapters); omissions (the chapter on chemotherapy overlooks a number of studies on toxicity in the elderly), and inconsistency of focus (some chapters on prevention and management are general reviews that do not concentrate on elderly patients). These limitations do not negate the important contributions of this book to an evolving field with a scarcity of relevant publications.

Lodovico Balducci, M.D.
H. Lee Moffitt Cancer Center, Tampa, FL 33612