Cancer is an older person’s disease. The vast majority of new cancer cases and cancer deaths in Canada occur in individuals aged 50 and older, while the highest proportion of cancer deaths occur in Canada’s oldest – those aged 80 and older.
With a rapidly ageing population, Canada is expected to see cases of cancer balloon in the coming decades with 1 in 2 Canadians being diagnosed in their lifetime and 1 in 4 dying of cancer.
Despite being the overwhelming majority of individuals who are diagnosed with and die of cancer, older adults are less likely than younger cancer patients to be offered chemotherapy and other treatments. This is due to two realities: the increasing risk of negative treatment outcomes among older adults and the assumptions health care professionals make about their vulnerabilities towards their risks.
As they age, older adults may lose some degree of their functional and physiological reserve. This process is known as frailty. While there is disagreement about the definition of frailty, it is generally considered to be a declining state of health in which a person is more vulnerable to negative outcomes including hospitalization, emergency department visits, long-term care admission and death. Individuals living with frailty can also be seen as being part of an overall spectrum from being fit to frail. Currently, 1 million mostly older Canadians are living with some level of frailty.
Frailty and cancer come together at the moment when a clinician and an older patient are deciding whether and what forms of cancer treatment will be beneficial to them overall. Depending on what stage of frailty an individual may be living with, it could influence an individual’s tolerance of cancer therapy and their risk/benefit considerations around cancer treatment.
Another large influence on how to manage cancer in older adults is the presence of chronic health conditions, which become more common as we age. More than 80% of older Canadians have at least one chronic health condition, and 50% live with two or more. The severity of these conditions in older cancer patients can further influence how aggressively their cancer should be treated. For example, if cancer will have less of an impact on an individual’s quality of life than their other conditions, then it may be better managed more conservatively.
Given the complexity of managing chronic health conditions in older patients, it is important to identify which older cancer patients are fit or resilient and therefore able to benefit from standard cancer care, or whether a more tailored and modified approach that avoids under or overtreatment is appropriate to avoid more negative associated outcomes.
This is when the other issue influencing the care that older cancer patients may or may not receive comes in: ageism. In the United Kingdom, the National Cancer Equality Initiative (NCEI) found that clinicians over-rely on chronological age as an indication of frailty or chronic health conditions. These issues are often, but not necessarily, associated with age. As a result, many older adults may not receive beneficial cancer care solely because of their age fuelled as well by a lack of appreciation or knowledge on how to better approach the treatment of cancer in older adults with varying states of health.
Image courtesy of the Canadian Cancer Society, Canadian Cancer Statistics (2018)
According to the World Health Organization, ageism is the stereotyping, prejudice, and discrimination against people on the basis of their age, which has harmful effects on their health.
Fortunately, there is a cure for ageism and the less ideal outcomes being faced by older adults receiving cancer care: geriatric oncology. By performing comprehensive geriatric assessments as part of the provision of cancer care for older adults, geriatricians and oncologists can better estimate life expectancy, identify potentially reversible conditions, assess a patient’s tolerance to chemotherapy and other treatments, and better predict the overall outcomes of an older patient living with cancer. Indeed, rather than using a person’s age to determine the appropriateness of a given treatment, geriatricians have demonstrated how considering aspects of an older person’s health such as functional status, social support, cognitive function, psychological state, and nutritional status, among other factors, can better inform clinical decisions and their outcomes.
By pairing the insights of geriatrics with oncology, cancer care can move from the concept of age-appropriate treatments to more person-appropriate treatments.
At the Older Adults with Cancer Clinic, based at the Princess Margaret Cancer Centre in Toronto, a team of geriatricians and advanced practice nurses work together with an older patient’s cancer specialists to identify the unique needs of their patients and support the development of more personalized care plans that can improve the experience of complex and/or frail older adults with cancer. The clinic is able to better support its patients and their caregivers with enhanced educational support, as well as improved management of patients’ other chronic health conditions. Recommendations are often made to modify cancer treatment delivery or add extra supports for more frail older adults. By incorporating geriatric assessments into its practice, the Older Adults with Cancer Clinic is able to personalize cancer treatment plans and avoid unnecessary over-treatment and under-treatment. In the first three years of operation, the Older Adults with Cancer Clinic saw 364 patients, of whom 199 were seen in the pre-treatment setting. Of these 199 patients, treatment plans were modified after the geriatric oncology consultation in 87 patients (44%). Referring oncologists and patients report high levels of satisfaction in the latest round of surveys.
With the greater incorporation of geriatrics into oncology, we can better ensure that older cancer patients will receive appropriate care that is truly person-centred.
Date modified: 2019-05-14
