Cancer in the Elderly
by Hyman B. Muss, MD
“He’s too old to treat.” I hear it all the time. It’s a sign of age bias as well as not being caught up on the major advances in cancer treatment – including treatment of older people.
First, who is old? It’s not an easy question, and certainly, there is no easy answer. Some cancer research trials define elderly as someone 65 and older, as that’s when a person is eligible for Medicare and for many people, Social Security. But it is way off the mark when you look at the data. A healthy 65 year old today will live an average of 20 more years, a healthy 75 year old, 12 more years, and a healthy 85 year old, 6 more years. Moreover, we have compelling research data that show that older people in good health usually derive similar benefits from modern cancer treatments – including surgery, radiation therapy, and chemotherapy – as younger people. For those with breast and colon cancer that is found early, older and younger people receive similar benefits from adjuvant chemotherapy (chemotherapy given to prevent the spread of cancer).
Why should we care about older people with cancer? We need to care because in the United States and other developed countries, cancer is a disease of aging. The average age of developing cancer in the United States is in the late sixties, and the incidence of cancer increases dramatically with age. Moreover, the U.S. population continues to age. At present, about 12 percent of Americans are 65 years and older while in 2025, it is projected that 20 percent of us will be in this older age group. This will put a major strain on an already fragile healthcare system as well as Medicare funding. Considering the present shortage of gerontologists and the concern that there will also be a dramatic shortage of oncology healthcare professionals in the next 20 years, we need to prepare now for caring for elders with cancer. The Institute of Medicine in its seminal 2008 report “Retooling for an Aging America” has clearly defined these issues as well as potential remedies.
We have compelling research data that show that older people in good health usually derive similar benefits from modern cancer treatments as younger people.
Research on treating cancer in older people has previously been sparse. In the past, older people were excluded from clinical trails based on their age alone. Although age restrictions have been eliminated from most clinical trials, age bias remains, and older people are poorly represented in most clinical trials. This results in a lack of information concerning the risks and benefits of newer, better, more expensive, and potentially more toxic treatments in older people, making it harder for physicians to make the best treatment decisions.
In addition, many older people with cancer have other medical illnesses, and sometimes these illnesses are more serious and more likely to result in a decreased life span than the cancer itself. How best to manage cancer in the elderly is frequently uncertain, and much research is needed in this area, as well as in managing cancer in frail people.
Unfortunately, most oncologists have not had adequate training in geriatrics to help in decision making for older people with cancer. Currently, trials are under way, testing tools that can be rapidly completed and that provide a comprehensive geriatric assessment that evaluates functional status, other medical conditions, cognition, nutritional status, psychological state, social support, and the person’s medications. Integrating these tools into clinical trials should provide us the needed information on benefits and side effects of new treatments in older people with cancer. In addition, a small but growing number of clinical trials designed specifically for older people are now in progress and will add to our reserve of knowledge.
What should older people do when faced with a cancer diagnosis? First, they need to have a clear discussion with their healthcare team concerning the details of the diagnosis, whether the cancer is curable or not, what the treatment options are, what the side effects and potential costs are for each of the options, and if there are any clinical trials they might be eligible for. As cancer is a disease that affects the entire family, it is important that the older person with cancer involve the family early on and include family members in key treatment discussions.
Older people should not be afraid to ask questions and to insist on clear explanations concerning diagnosis and treatment. Older people represent the majority of Americans with cancer, but it is crucial that they not remain a “silent majority.”
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Dr. Hyman Muss is professor of Medicine at the University of Vermont and Vermont Cancer Center
This article was originally published in Coping® with Cancer magazine, January/February 2009.