With many older people living with long-term health problems and developing decreasing mobility, becoming poorly nourished or needing support with daily living, the issues surrounding cancer treatment for older adults can become complex. For individuals diagnosed with gastroesophageal adenocarcinoma (GEA), a cancer that starts in the stomach or at the gastroesophageal junction, it is important that the treatment options available consider the overall health of the individual, their preferences and the potential side effects of treatment, as well as the support they have at home from family and/or caregivers.
Better cancer care for the elderly can be delivered by planning and delivering treatment with more support from health care professionals and patients, and from families, relatives and caregivers. Treatment decisions should be guided by evidence-based options for each stage of the disease, while considering the patient’s health needs, personal preferences, and family circumstances.
Understanding Gastroesophageal Adenocarcinoma in Older Adults
Gastroesophageal Adenocarcinoma (GEA) is a cancer located in the stomach or at the junction with the esophagus. The symptoms of GEA can often be attributed to another more serious condition and can include difficulty swallowing, persistent heartburn, abdominal pain, loss of appetite for food and weight loss. Sometimes there may also be bleeding from the gastrointestinal tract.
For the increasing numbers of older people with cancer, unexplained weight loss, decrease in food intake and difficulty with swallowing are most often reported by family members and resulting in early medical evaluation for complaint of “difficulty swallowing”. Diagnosing gastroesophageal adenocarcinoma typically starts with an upper gastrointestinal endoscopy (Gastroscopy) to take a biopsy of the tumor. Further investigations, like a CT scan, may be considered to assess the extent of the tumor. Tumor biomarker testing may be considered along with the patient’s medical history, overall health, daily functioning, and treatment preferences when evaluating potential treatment options.
Some cancer types have specific tumor biomarkers that can help decide the best cancer treatment for each patient. When deciding on the best cancer treatment for each patient, consideration must also be made of the patient’s individual medical history, co-morbidities, level of function and individual treatment preferences.
It’s also useful to become informed about the different possible treatments for gastroesophageal adenocarcinoma and to discuss these with your oncologist before deciding on treatment. The doctor will determine the appropriate treatment plan considering the individual’s circumstances.
It’s also useful to become informed about the available treatment options and discuss them with your oncologist before deciding. Understanding gastroesophageal adenocarcinoma treatment can help patients and their caregivers prepare relevant questions about treatment goals, potential side effects and the support needed during care. The doctor will determine the appropriate course of treatment considering the individual’s circumstances.
How Age and Overall Health Influence Cancer Care
The age of a patient with cancer is only one of several factors that can influence the choice of a particular treatment. For an older patient, several other factors can play a significant role. These factors can be summarized by the acronym EXPERT and include physical function, Nutritional relevancy, existing comorbidities, current MEDICATION, cognitive function and mental health and the patient’s Expertise/Preferences.
These factors can include:
- Physical function: How well does the person walk, bathe, dress, cook and manage other activities necessary for daily living?
- Nutrition and hydration: The extent to which the patient is able to consume normal amounts of nourishing food and fluids, particularly if there is any difficulty with swallowing or reduced appetite.
- The individual’s exist health problems, including heart disease, kidney disease, liver disease and other health problems affecting other organs.
- The individual’s current use of all prescriptions and of over-the-counter medicines and supplements, including those that can cause interactions.
- Cognitive function and mental health: evidence of declining memory, of anxiety and or depression, or of difficulty communicating and giving and receiving information about treatment and its consequences.
- Personal preferences: patient priorities are noted and considered for treatment decisions, e.g. maintaining independence of function or extending life in some circumstances.
Many factors go into determining how best to treat a patient and so it is very important to assess a patient’s total clinical picture and determine how a particular treatment may affect their ability to perform daily activities and to maintain their independence.
Treatment Options and the Importance of Shared Decisions
Treatment for gastroesophageal adenocarcinoma depends on the size and extent of the tumor and whether there has been previous treatment for the cancer. In addition, consideration must be given to the general health of the patient.
For some patients with early-stage disease and localized cancer, treatment with surgery and in some cases with systemic therapy may be an option. For patients with locally advanced, unresectable or metastatic gastroesophageal adenocarcinoma, chemotherapy, immunotherapy or a combination of both in appropriate clinical circumstances may be considered as treatment options.
Treatments should have benefits that patients describe and list expected side effects. The recommended cancer treatment goals should be outlined for the patient. Patients should describe the expected changes for symptoms and the anticipated frequency of subsequent treatments, including anticipated changes for daily living activities.
For example, an older adult who has limited ability may benefit from having a caregiver or relative attend all medical appointments with him or her to discuss treatment options. Keep a complete a list of questions and organize the information to track the instructions and their implementation.
A list of useful questions with which to inform treatment decisions for the patient and their family.
- What is the aim of the proposed treatment?
- What are the side effects of treatment and how will we monitor them?
- Could treatment affect appetite, mobility or the ability to live independently?
- How often will we need to see you for checks, for blood tests, etc.?
- What support is available if the patient experiences difficulties at home?
These discussions can aid in decision-making for a cancer treatment plan that is not only best for a patient’s cancer but also for the patient as well as their family.
Tislelizumab and Immunotherapy: Information for Patients and Caregivers
Immunotherapy works by helping the immune system recognize and respond to cancer cells. This cancer treatment is administered to patients with certain types of cancer using the medicine Tislelizumab. It is a monoclonal antibody that specifically attaches to the PD-1 receptor on the surface of cells that are part of the immune system.
Tislelizumab is a PD-1 inhibitor that helps support the immune system’s response to cancer by blocking interactions between PD-1 and the PD-L1 and PD-L2 proteins, an approach that has been studied across several types of cancer. Tislelizumab is known by the brand name Tevimbra in some countries.
Clinical studies have evaluated tislelizumab, alone and in combination with chemotherapy, in patients with locally advanced, unresectable or metastatic adenocarcinoma of the stomach and gastroesophageal junction. Availability and approved uses of tislelizumab may vary by country and should be discussed with a healthcare professional. Similarly, for the many older adults with cancer and their family members, a more practical explanation of immunotherapy is also important to help them understand the aspects of the treatment that are relevant to them.
Many people, including older adults and their caregivers, have a naive perception of immunotherapy. While the treatment does work differently to conventional chemotherapy, it is not without the risk of serious side effects, meaning that factors such as the individual’s overall health, other medications that they are taking, and their ability to attend with all other treatment related appointments, will all need to be taken into consideration by the treating oncologist.
Recognizing Side Effects and Supporting Safety at Home
Cancer treatment and immunotherapy such as Tislelizumab can cause extreme fatigue, loss of appetite, diarrhea or other symptoms that affect patients negatively. Since immune checkpoint inhibitors, such as Tislelizumab, are used to treat cancer, they can cause severe, sometimes life-threatening, immune-related side effects. These reactions can be localized to organs such as the lungs, liver, intestines, kidneys and/or hormone-producing glands.
Practical measures that may help support safety include:
- Tracking symptoms: Be sure to include the date these symptoms occur, how often they occur, how severe they are, and whether they are getting worse.
- Record all the patient’s medicines including supplements and remind them about any allergies they have had to medicines in the past.
- Monitoring nutrition and fluids: Report to the medical team persistent vomiting, difficulty swallowing, reduced food intake, signs of dehydration etc.
- Fall risk – Keep floors clear of clutter, make sure there is enough light and aid as needed.
- Transport: Booking of transport for treatment and review appointments where the patient is unable to travel alone safely.
- Knowing when to seek help: Follow the medical team’s advice for symptoms that require urgent attention and make sure they know how to contact you at any time.
Note that new or worsening symptoms should not automatically be attributed to a patient’s aging process. Discuss any new or worsening symptoms with the patient’s healthcare team, particularly if they are severe, unusual or worsening quickly.
Caregivers in Supporting Nutrition, Daily Activities and Emotional Care of Older Cancer Patients
The older person with cancer needs the support of caregivers who can manage the home environment and help them attend for treatment. The caregivers of older people with gastroesophageal cancer may need to adjust to problems with eating and can help the person with cancer to stick to their agreed nutrition plan.
Further attention also needs to be made to the nutrition of older people with cancer, in particular the group of patients with gastroesophageal adenocarcinoma.
Swallowing difficulties, gastrointestinal symptoms and reduced appetite in these patients can lead to a reduced food intake. Dietary changes may be recommended by a healthcare professional or dietitian based on individual needs. It is also important to refer them to a dietitian and to give them a nutrition plan written by a qualified health care provider. Weight loss or a decreased food intake that persists over a longer period needs to be addressed with the medical team. Although changes in diet can often alleviate these problems in some way, it is not always sufficient. Help the person to do as many things for themselves as they are able to. Support them with specific tasks where necessary but do not take over tasks that they are still able to do for themselves.
Supporting the patient’s emotions as well as their physical health is also crucial. The older person and their carers can help the patient to discuss their concerns and to find out about counseling or support groups that would be suitable for them.
It is also important for those caring for the older adult with cancer to recognize their own limits. He or she may need to call on others in the family to assist with care, seek support in the community and/or learn about services that are available to assist with his or her care.
Coordinating Medical Appointments and Long-Term Support
Typically there are many specialists involved in the cancer treatment of a patient including their oncologist, surgeons, nurses, radiologists and dietitians and their supportive care specialists. The treatment plan for a patient can often be complex, and Patients and their families can often become confused.
Remember, there is no problem greater than ensuring all information from all the different specialists involved in a patient’s care is up to date and communicated effectively between them all and between them and you and your family.
Supportive and Palliative Care: This is a further layer of care alongside cancer treatment. The focus is to relieve symptoms and improve the cancer patient’s quality of life. It is often mistakenly believed that palliative care is an end-of-life care but it can be introduced at any stage of a serious illness and is there to support not only the patient, but also their family and caregivers. As the situation evolves, it is important for patients and families to revisit the objectives of treatment and the home care that is required. They should do this with the health care professionals who have responsibility for the patient’s care. The patient’s treatment goals, home care and future health care should be based on the patient’s wishes, and he or she should have control of the decisions that are made on his or her behalf.
Conclusion
Supporting someone with gastroesophageal adenocarcinoma is not just about treating their cancer. We must also consider their overall health, all their medicines, nutrition, their emotional well-being and try to support them to remain independent in all areas of their life and have appropriate care and support to help them in their home.
The care of the older patient with cancer may require that the patient and their family work with their health care providers to explore the options available for their treatment, to identify and manage treatment-related side effects, and to address a variety of practical issues that will help the patient to remain at home during their cancer treatment.
Disclaimer: This is an information article and must not be used as a replacement for medical advice, a doctor’s diagnosis or for any treatment for cancer. You must consult with your healthcare professionals or other qualified healthcare provider about the best cancer treatment for you.