Elderly and cancer

Definition:The risk of cancer increases with age. The National Cancer Institute (NCI) reports that 60 percent of new cases of cancer are diagnosed in those over the age of sixty-five. No definitive answer is found among the various theories for the increased risk. Possible connections include a reduced ability of the immune system to fight disease, increased vulnerability to toxic substances that alter deoxyribonucleic acid (DNA), and the cumulative effect of exposure to carcinogens over time. Managing cancer as a chronic disease, with attention to long-term survivor needs, helps this age group maintain a good quality of life. The physical, psychological, emotional, spiritual, social, and financial aspects of living with cancer require multiple tools and resources for individuals and caregivers coping with a malignant condition.

Description of the population: In 2005, there were 36.8 million people aged sixty-five or older, representing 12.4 percent of the United States population. This was an increase of 3.2 million, or 9.4 percent, from 1995. The population under the age of sixty-five increased 13.3 percent during this same time period. However, the group aged forty-five to sixty-four increased by 40 percent, illustrating the exponential growth of the elderly population that will continue. There were 21.4 million older women compared with 15.4 million older men in 2005, a ratio of 139 women for every 100 men. This ratio increases with age because women live longer than men. The population as a whole is living longer. The group of people age eighty-five and up was forty-two times larger in 2005 than that same age group in 1900. According to the U.S. Census Bureau, the elderly population is expected to more than double by 2050, representing 1 out of every 5 people in the United States. Numbers will continue to grow as life expectancy improves and as advances in science are made that lead to improved treatments for cancer and higher survival rates.

The elderly population is vulnerable to depression and a cancer diagnosis may worsen it. The loss of a spouse and deaths of friends create feelings of isolation and despair. They may face pressure to leave a long established residence or need to enter an assisted living facility or nursing home. Financial burdens from living on a fixed income and dwindling resources is another stressor. Visual and auditory deficits strain communication and may necessitate giving up hallmarks of independence such as driving. Coping skills are taxed with advancing age, especially when a person is faced with a new diagnosis of cancer or a recurrence after a period of remission.

Medicare reimbursement for cancer treatments and supportive medications is driven by policy changes and may become insufficient over time. Homelessness among the elderly is not uncommon and may prevent early diagnosis of cancer from lack of health care access.

Incidence, death, and survival statistics: The probability of developing an invasive cancer at the age of seventy or older is 1 out of 3 for men and 1 out of 4 for women. From ages sixty to sixty-nine, it is 1 in 6 for men and 1 in 9 for women. The elderly are ten times more likely to get cancer and fifteen times more likely to die from cancer than people under the age of sixty-five, according to the NCI. Some 70 percent of deaths from cancer occur in this age group. Reasons for increased mortality may be affected by less aggressive treatment, a delay in diagnosis and start of treatment, a personal choice to decline treatment, and the impact of other health problems on the cancer. Cancers linked to aging and common in the elderly include bladder, breast, colon, lung, pancreas, prostate, rectal, stomach, and acute myelogenous leukemia (AML), a cancer of the blood. Approximately one-third of non-Hodgkin lymphomas are diagnosed in individuals over seventy years old. The average age for developing colorectal cancer is seventy-one according to the NCI.

Risk and prevention: People aged fifty-five and older account for approximately 75 percent of cancer diagnoses. The majority of breast cancers occur after age fifty, with the highest incidence in those between the ages of seventy-five and seventy-nine. For women with ovarian cancer, survival is twice as likely in those under the age of sixty-five as in those sixty-five and older. The majority of people with lung cancer are at least seventy years old at diagnosis. Older patients diagnosed with AML are less likely to achieve remission after treatment than younger ones. When elderly people think that their symptoms are related to aging, they may ignore the signs and delay consultation with a physician. The prevention of cancer in the elderly is much the same as in people of any age. Eating a low-fat, high-fiber diet; exercising; avoiding excessive use of alcohol; and limiting exposure to chemicals and radiation are ways to help reduce the risk of cancer. Cancer screening should continue throughout the life span, although there is disagreement among experts about screening frequency and situations in which it is reasonable to discontinue screening for certain cancers.

Treatment considerations: Age is not the only factor used to decide whether aggressive treatment should be pursued. The functional status of older patients indicates their ability to tolerate and respond to therapy. Treatment options may be limited by existing health problems such as hypertension and heart disease, which reduce tolerance to therapies. Drugs and chemotherapy agents may interact with medications taken for other conditions. Cognitive impairment caused by dementia or slowing mental processes compounds the side effects of medications such as opioids for pain, which cause somnolence. The normal effects of aging may alter or slow the way the body metabolizes drugs, increasing toxicities from treatment or reducing efficacy. Bias and stereotypes regarding the elderly may impede full recovery after treatment. For example, sexuality does not necessarily diminish in the elderly, but because many assume the loss of libido, subsequent problems with intimacy after treatment may not be adequately assessed. Another assumption is that a cancer diagnosis is less devastating for an older person than for someone younger because the older person is closer to the end of life. However, the majority of older adults are active and independent, with the potential to enjoy years of life despite cancer. Autonomy is preserved when the elderly learn everything possible about their diagnosis and prognosis, use providers trained in geriatrics, and obtain second opinions before choosing among treatments that include chemotherapy, radiation, immunotherapy, investigational agents, watchful waiting, palliative care, and hospice care.

Perspective and prospects: Scientific data are used to determine appropriate treatment for a particular cancer and are based on the stage of the cancer, its potential for growth, and the order of administration when more than one therapy or regimen is employed. More clinical trials, with a design that accommodates participation of older people, are needed to enhance knowledge about cancer in the elderly and identify the best interventions for this age group. Cancer survivors benefit from a comprehensive plan that facilitates a return to a functional state after treatment. The education and training of health care providers in the specialty of geriatrics promotes the well-being and longevity of this population. Individuals of advanced age who live with cancer understand the unique challenges better than anyone and, as proponents of change, accelerate the gains in cancer management and treatment. Self-advocacy by the elderly is made easier by availability of cancer resources in communities and on the Internet. For example, online cancer support groups provide an alternative for those who are homebound, and pharmaceutical companies have programs that furnish medication at no cost or at a discount.

Bibliography

Beers, Mark H., and Robert Berkow. Merck Manual of Geriatrics. Rahway, N.J.: Merck Sharp & Dohme Research Laboratories, 2000.

Hunter, Carrie P., Karen A. Johnson, and Hyman B. Muss. Cancer in the Elderly. New York: Marcel Dekker, 2000.

Lichtman, M., et al. “International Society of Geriatric Oncology Chemotherapy Taskforce: Evaluation of Chemotherapy in Older Patients An Analysis of the Medical Literature.” Journal of Clinical Oncology 25, no. 14 (May 10, 2007): 1832-1843.