Elsevier

The Lancet Oncology

Volume 12, Issue 13, December 2011, Pages 1249-1257
The Lancet Oncology

Review
Polypharmacy in elderly patients with cancer: clinical implications and management

https://doi.org/10.1016/S1470-2045(11)70040-7Get rights and content

Summary

More and more elderly people with cancer are treated in oncology clinics worldwide every year, many of whom have comorbid disorders treated with one or more drugs. Moreover, these patients might also take self-prescribed over-the-counter drugs or complementary and alternative medicines, which they might not tell their doctor about. Initiation of chemotherapy with one or more cytotoxic or targeted agents and drugs for treatment of cancer symptoms or toxic effects related to treatment can result in polypharmacy. We examine the clinical implications of polypharmacy. Challenges for the medical teams who treat elderly patients with cancer include identification of what drugs are actually being taken by the patient, avoidance or management of any adverse effects or drug interactions, and reassessing the patient's overall treatment. We address these issues and propose practical recommendations for management of treatment for elderly patients with cancer.

Introduction

Cancer incidence increases with age, and because the proportion of the population that is elderly is growing, the absolute number of elderly patients (variously defined as >65 years or >70 years) with cancer continues to increase. In the UK, 74% of new cancer diagnoses in 2006 were in people aged 60 years or older, with more than a third occurring in those aged 75 years or older.1 By 2030, about 70% of all cancers in USA will be diagnosed in older adults.2 In the heterogeneous elderly population, many patients can be medically fit until the diagnosis of cancer. However, chronic medical disorders such as cardiovascular diseases (eg, hypertension, heart failure, and coronary artery disease), cerebrovascular disease, arthritis, and diabetes are common in the general elderly population. Therefore, not only are comorbidities common in older people who are newly diagnosed with cancer, but also many of these patients take drugs for primary or secondary disease prophylaxis and treatment, and possibly also take other self-prescribed medicines.3 To tailor treatment decisions on the basis of factors other than age, there is an increasing amount of evidence to suggest the benefits of incorporation of a comprehensive geriatric assessment for elderly patients who are newly diagnosed with cancer.4 Review of patients' medications before starting cancer treatment is an integral part of the assessment, and such reviews have identified potential pre-existing drug-related issues.4, 5 Addition of chemotherapy and supportive drugs to prevent side-effects or manage symptoms to existing polypharmacy can place older patients with cancer at risk of drug interactions that might alter efficacy or increase toxic effects.4, 6

In this Review, we examine the clinical implications of polypharmacy in elderly people diagnosed with cancer and review different procedures for obtaining of complete drug histories, including prescribed and non-prescribed medicines. We examine the accuracy of present methods for assessment of patients' medications for drug interactions and possible clinical significance. We present practical recommendations for drug management of elderly patients with cancer.

Section snippets

Overview of polypharmacy

As an indication of global interest in this topic, we identified nearly 500 citations with a search of the Medline database for “polypharmacy”. Research and reviews on polypharmacy cross many specialty areas from psychiatry to cardiology, and chronic diseases such as diabetes and epilepsy. The prevalence of polypharmacy in older patients ranges from 13% to 92%.7 In oncology, older patients with cancer are now recognised as a risk group.5

Polypharmacy has many definitions but commonly refers to

Polypharmacy in patients with cancer

Various international studies3, 5, 12, 13, 14 have suggested that polypharmacy is common in elderly patients with cancer (table 1). An exploratory study in the UK3 reported a median of seven medications (IQR 1–17) were being taken by 100 patients who had metastatic cancer and a median age of 73 years. 81 patients were taking preventive medications including antihypertensives, lipid-lowering drugs, antiplatelet drugs, anticoagulants, and bisphosphonates (for non-cancer indications). Of the 112

Adverse drug reactions

In older people, including those with cancer, there are various negative outcomes that can result from polypharmacy, including adverse drug reactions, drug interactions, and increased health-care costs.

Data from the non-cancer setting suggest that rates of hospital admission due to adverse drug reactions are highest in the oldest age groups,19 with a median prevalence of 10·7% in patients older than 60 years, 6·3% in adults aged 17–59 years, and 4·1% in children aged 16 years or younger; the

Assessment of elderly patients with cancer

Optimisation of treatment in elderly patients needs a collaborative approach including primary care and specialist doctors, and other health professionals such as clinical pharmacists and nurses. An integral part of the comprehensive geriatric assessment of older patients with newly diagnosed cancer is a medication review of all prescription, over-the-counter, and herbal products.4 In some countries, routine medication reconciliation, in which a complete list of a patient's medications is

Drugs interactions resources

Once a patient's complete medication list has been established, either all patients or those at high risk for drug interactions need to be screened.24 Many resources are available to check for interactions between a patient's treatment drugs and proposed anticancer and supportive medications.24 Numerous articles summarising drug interaction information have been published, and many provide tables of interactions that are clinically relevant.6, 19, 20, 22, 23, 25, 26 However, investigation of

Polypharmacy—practical solutions

Recognition of polypharmacy is the first step towards prevention.46 Rational discontinuation of drugs in older adults is a logical component of management of polypharmacy,59 and is recommended as part of a comprehensive geriatric assessment in such patients with cancer.4 Discussion with the patient and consideration of overall quality of life is essential. The selection of appropriate pharmacotherapy for elderly patients is a challenging and complex process,60 even when cancer is not involved,

Search strategy and selection criteria

We searched the Medline database for articles and abstracts published in English between Jan 1, 1996 and July 2, 2010 with the search terms “polypharmacy”, “neoplasms”, “aged”, “drug interactions”, and “information systems”. We manually searched reference lists from identified articles, our own files, and recent reviews to identify additional articles. We also reviewed relevant conference abstracts. Studies and review articles were included on the basis of their relevance to the specific topic

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      We, therefore, evaluated the incidence of seizures and, as anticipated, fewer older participants reported seizures compared to younger adults, who tend to have slower-growing tumors [46]. Polypharmacy is common in older patients with cancer and leads to additional toxicities, drug interactions, and increased costs [47]. Decreased renal and hepatic function alters drug pharmacology, typically decreasing drug clearance, and is associated with biological aging [48].

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