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Anemia and Cancer in Older Persons
Brenda W. Penninx, PhD, Harvey Jay Cohen, MD, and Richard C. Woodman, MD

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lthough the overall prevalence of cancer is declining, many types of malignancies remain common, particularly in the elderly. The risk for cancer in both men and women increases progressively with age. Up to age 40 years, the probability of developing an invasivecancer is about 1% in men and 2% in women; however, for persons aged 60 to 79 years, these rates are 35% and 23%, respectively.1 It is estimated that 60% of all cancer occurs in persons older than 65 years, and by 2050, 80% of all cancers will occur in this group due to a doubling of the proportion of persons > 65 years of age expected by 2030.2 Thus, the typical cancer patient today is 65 years ofage or older, has multiple medical conditions, frequently receives polypharmacy, often has preexisting disability, and has aging organ systems that can influence both the efficacy and tolerability of therapy.3

Abstract Although the overall prevalence for many cancers is declining, cancer still remains a diagnosis more common in the elderly than in younger individuals. As the population ages, theproportion of patients with cancer who are elderly is expected to increase dramatically. Anemia occurs more often in older individuals for a variety of reasons, and its prevalence in elderly patients with cancer is significantly increasing. Although information on anemia in the elderly is limited, data on cancer patients of all ages have shown that the presence of anemia is associated with poorerprognosis and functional status. The impact of anemia on performance status in patients with cancer is matched by results from a large number of studies indicating negative effects of anemia on a wide variety of performance measures. Despite an apparent reluctance to undertake aggressive therapy in elderly patients with cancer, physicians are using a wider range of treatments with increasingfrequency in this older population. Optimizing treatment outcomes in elderly patients with cancer depends on careful determination of performance status as well as the potential of therapies to treat anemia in these patients.

Anemia in Cancer
Anemia is often associated with cancer, and this relationship is particularly strong in older people. The Surveillance, Epidemiology, and End Results (SEER)Program of the National Cancer Institute (NCI) estimates cancer incidence in the United States to be approximately 75% in persons ≥ 60 years of age.4 Results from the European Cancer Anaemia Survey5 indicated that the prevalence of anemia (hemoglobin [Hgb] 12 g/dL reported significantly less fatigue, fewer non-fatigue anemia symptoms, better physical well-being, better functional wellbeing, and highergeneral QOL.47,48 Comprehensive geriatric assessment is a multifaceted approach to evaluation of function in the elderly that includes medical history; medication review; physical and neurologic examinations; and use of specific instruments to measure cognitive, affective, functional, social, and economic status. This approach has been used extensively in the frail elderly who are at risk forfunctional decline.49
RESULTS FOR PATIENTS WITH CANCER AND ANEMIA

Several tools have been developed for assessing performance status in the elderly.38 The Short Physical Performance Battery (SPPB) is a test of lower-extremity function originally devised in conjunction with the EPESE study; it has since been used in many other aging studies. The SPPB uses ratings on three timed tasks: standingbalance, chair rise, and walking speed. It has well-established inter-observer and test-retest reliability and has been used to predict subsequent disability,

Anemia is correlated with poorer performance status in patients with cancer, as evaluated by a wide range of tests. As noted previously, anemia is associated with poorer ECOG scores in patients with lung cancer.29 Results from a study50 of...