Cancer and Aging
Arash Naeim, MD, PhD, Director, UCLA Geriatric-Oncology Program, Assistant Professor of Medicine, David Geffen School of Medicine, medical oncologist and researcher
This is a summary of a lecture that was presented on December 14, 2004. We thank Ortho Biotech for their support of this lecture in the Insights Into Cancer series.
The population in the world and in the United States is aging. In 1995 there were 5.7 billion people over the age of 65 and in 2050 there are expected to be 9.4 billion. In 1995 there were 37,000 people over the age of 100 and that is expected to grow to one million in 2050. Historically, we have classified people as “older persons” when they reached the age of 65 but this has been an artificial determination for the purpose of delivering benefits such as social security. Realistically, the age of 75 may be more appropriate and we may see changes in the definition for benefits as we, as a society, struggle with how to meet the needs of this growing aging population. It is important to note that there are wide variations in physical, mental and functional status within these age groups. By 2030 one in five Americans will be over the age of 65, the number of persons aged 65 or older will double as will the number of people 85 years old. The life expectancy in 1900 was 45-50, in 1995 it was 70-80, and in 2030 it is expected to reach the late 70s for men and early 80s for women.
The incidence of cancer also increases dramatically as people age. It starts to rise at 40-45, but there is a sharp increase in the 60-65 range. The age-adjusted incidence of cancer is 10 times greater for those over 65 than for those under 65. However, the mortality rate due to cancer is 15 times greater for those over 65 than those under 65. Some of the potential reasons for this increased mortality rate may be because older patients may be less likely to get the proper screenings (e.g., rectal exams, colonoscopies, mammograms), they may not be staged appropriately once they are diagnosed, they may receive less aggressive treatments compared to patients aged 40-50, and some may not get treated at all.
These data raise two important questions: (1) are there unique issues for older patients with cancer, and (2) should older patients with cancer be treated differently than younger patients with cancer?
Co-Morbid Illness and Comprehensive Assessment
A thorough, accurate medical assessment of an older cancer patient should provide important prognostic information and lead to medical decisions that improve the patient’s quality of life. An important issue facing aging patients is that they may have other illnesses, which are superimposed on the cancer experience. As people age they tend to collect more illnesses. It is important for the doctor and patient to be aware of these. Some of the most common co-morbid illnesses include diabetes, stroke, and heart disease. Having co-morbid medical conditions may be predictors of survival and resource needs. Co-morbid illness can affect the physician’s choices in treatment. It is imperative that a physician treating an older person recognize and record all co-morbid illness as well as other difficulties identified after doing a thorough multi-disciplinary assessment. The greatest difficulties often come from problems that neither the patient nor the physician identify. Participation by family members can be essential in identifying these areas.
Co-morbid illnesses may contribute to physiological decline and may create vulnerability to other geriatric syndromes such as incontinence, mobility problems and cognitive declines. Older patients may have reduced immune function, and, thus, may be more susceptible to infectious disease. They also may have significant physical conditions, such as arthritis, that affect their ability to move around. When evaluating a patient for treatment it is important to consider the whole person. Treatment plans must be individualized, taking into consideration the needs of each patient and making certain that quality of life is not compromised. It is very important to try to evaluate whether treatment interventions will lead to improved quality of life or possibly cause a problem from which the patient is not able to recover. Social and ethical issues also need to be considered. For example, patients cannot really give consent to treatment if they cannot hear their options or do not understand the implications. Patients who are older should be assessed on the following domains with the goals of using this information to remediate problems and prevent outcomes that make these conditions worse:
Cognitive function is very important to well being and is essential to patients’ ability to participate in their own care and make decisions that they feel are right for them. There are two distinct conditions that need to be considered: dementia and delirium. Dementia is typically defined as a decline in two or more areas of cognitive function such as memory, comprehension or attention. It can affect a patient’s ability to understand information presented to them and make choices. About 6-8% of patients 65 or older have some dementia and about 30-40% of patients over age 80 have it. Delirium, on the other hand, is a disturbance in consciousness with decreased attention, and it may include a change in cognition or a perceptual disturbance that develops over a short period of time. Delirium often fluctuates. These patients are often confused. About 10-24% of patients who present to an emergency department have delirium and about 25-65% of hospitalized patients have it. Delirium can take a long time to resolve. About 55% have a prolonged course while only about 4% of patients have it resolved by the time of hospital discharge.
Cognitive function is necessary in giving informed consent and planning for end-of life issues. If the patient is not able to do these things, they must rely on family members and their doctors to make decisions for them. For a patient who is about to undergo treatment for cancer it is imperative that these discussions take place in advance of treatment in part because treatment can affect cognitive function. For example, many chemotherapy drugs have neurotoxicities and it is important for the doctor to know the patient’s baseline to be able to assess changes. Further, chemotherapy can increase dehydration, malnutrition and electrolyte disorders which put patients at an increased risk for delirium.
- Functional Status
It is important to understand how functional patients are prior to treatment. Daily living activities include bathing, dressing, feeding and transferring from the bed to a chair. Higher function activities include using the telephone, traveling, shopping, preparing meals, doing laundry, doing housework, taking medicine and managing money. Many older people already have a difficult time getting around and it is important to consider the impact of treatment on this ability. If a person does not spend more than 50% of their time out of bed prior to treatment then they will probably not benefit from cancer treatment. If cancer treatment negatively affects the patient’s ability to function that will increase the burden on the caregiver.
- Visual Impairment
Common causes of visual impairment include cataracts, macular degeneration, diabetic retinopathy and glaucoma. Approximately 4-5 % of patients over 65 years old have some visual impairment and about 10-21% of patients over 75 have a visual impairment equivalent to 20/40 eyesight or worse. Visual impairment has important consequences in patients who are being treated for cancer. Chemotherapy regimens as well as the underlying cancer can cause fatigue, dizziness, reduced sensitivity of nerves in the extremities such as hands and feet (peripheral neuropathy) which, when combined with visual impairment, can increase the chance of falls. Falls are very serious for older patients. Further, visual impairment can be a serious problem for patients who are trying to comply with treatment. Pharmaceutical instructions are often small, and reading labels and instructions may be difficult for visually impaired patients. This is especially problematic for a patient who lives alone or takes medications that look alike. There are specific interventions that can be helpful, e.g., writing medication labels in large print, prescribing medications that look significantly different and developing a protocol for putting pills in a weekly pill box with directions written in large print.
- Hearing Impairment
Hearing impairment in the general population of patients over the age of 65 is about 25-40% and much higher, 70-80% in patients over the age of 75. A baseline level of hearing is important because chemotherapy and antibiotics can cause hearing loss. In addition, hearing impairment can be a barrier to patients being able to understand and follow the directions given by their medical team. It may be important to find quiet places to talk with hearing impaired patients, making certain they have their assistive hearing devices and trying to avoid as much background noise as possible. Patients who do not hear well may not be able to provide proper informed consent, so this issue needs to be taken into consideration and remedies found whenever possible.
- Gait and Balance
Balance and stability are significant problems for older adults and chemotherapy can make these already difficult problems worse. Balance can be affected by the ability to perceive spatial distances. Patients’ ability to sense changes in the ground with their feet may also be altered. Falls have high morbidity in older adults who are likely to fracture bones. This can be more problematic with patients who have metastases to their bones. In addition, because platelets affect one’s ability to clot, patients with low platelet blood counts are more likely to bruise and bleed as a result of a fall. Assessing these issues and offering assistive devices such as walkers, grab bars, bedside toilets and four point canes can be helpful to patients during these times. Physical therapy to strengthen muscle groups and increase conditioning and balance can prevent falls and may be an important component of comprehensive care.
Patients who are well nourished and have good eating habits tend to have better outcomes of their cancer treatments. Unfortunately, some patients have weight loss at the time of their cancer diagnosis and malnutrition can be a factor for some older frail patients prior to treatment. Chemotherapy can complicate these issues because of changes in taste and other side effects which may reduce their appetite and contribute to poor nutrition. Nutritional supplements can be helpful and it is important for patients to remember that they need to ingest the same number of calories as they expend in order to maintain their weight. Nutritional consultation and plans for easy access to meals are important interventions for the older adult population.
Incontinence is a problem faced by 15-60% of people over the age of 65. It can be exacerbated by metastatic cancer to the brain or spinal cord. In addition, diuretics which are given to help patients excrete fluids and/or increased fluids given to help wash out chemotherapy may make incontinence worse. Incontinence can be embarrassing for anyone and can definitely affect quality of life. It is also important to assess incontinence at the beginning of your treatment because it is sometimes an early sign of infection and it is important to be able to differentiate these early signs from other conditions
Depression is a treatable condition that affects approximately 17-37% of adults over the age of 65. Approximately 20% have major depression. Depression affects your quality of life and puts older adults at higher risk for suicide. Depressed patients are less likely to adhere to treatment. Depression is also common in caregivers of patients who are undergoing cancer treatment. Depression can be treated with both psychotherapy and medications and needs to be included in the patient’s and caregiver’s care.
- Environmental Factors
How people live in their homes is important especially for older patients with cancer. Hazards at home can increase the potential for falls. A home visit done by a home health agency with a nurse and/or a social worker can help determine what barriers exist within the home environment that might constrain or facilitate the day-to-day function of frail older persons. A home assessment usually assesses the following areas: nutrition (food in the refrigerator, identification of someone to cook), sanitation, if medications are being properly taken and making certain that medications among partners is not mixed up, social interactions and the potential for abuse or neglect.
- Social Support
Having good social support is beneficial to patients and facilitates their physical functioning and their rehabilitative potential. It is important to identify who is in the social support network and their availability to help. Potential sources include spouse or partner, family, friends, caregivers, neighbors, other patients, and volunteers from agencies. Family involvement appears to prevent or slow functional deterioration in older patients. The caregiver must be part of the team and health care professionals need to know what the impact of the illness is having on caregivers.
- Religion and Spirituality
While there is not much rigorous research in this area, there is some evidence to suggest that patients who are accustomed to participating in spiritual and religious activities continue to derive benefit and it is important for them to stay connected to these rituals and social networks. These connections can help older patients cope or adapt with losses and other difficulties. Religious and spiritual beliefs appear to be positively associated with physical health.
Sleep difficulties are common in newly diagnosed or recently treated patients with cancer; 30-50% report having insomnia. Sleep problems can lead to fatigue and functional impairment, including cognitive impairment and psychomotor impairment. Factors that contribute to sleep difficulties can be chemotherapy, nausea and vomiting associated with treatment, medications that are used to inhibit nausea and vomiting, hormone therapies, anxiety, depression and pain. Each of these areas must be continually evaluated to make certain that the best quality of sleep is achieved for the patient.
Quality of Life
Every cancer treatment decision should include questions about quality of life. Quality of life has to do with how patients spend their time and whether they feel that they are able to do what they want and need to do. There are many aspects that determine quality of life, such as physical symptoms, physical functioning, vocational functioning or volunteer activities, psychological states, family/social functioning and sexual functioning. Independence and autonomy are very important for older patients. This is summarized in the following quote by TF Spiker in 1990, “An overriding goal and concern of older people for their own quality of life is that they maintain (or regain) as much personal independence as possible…It is the personal autonomy and the freedom to make choices and to live one’s own life according to one’s own decisions both small and large, that means most.” Cancer treatment need not decrease patient’s quality of life. Many patients who are treated with chemotherapy have a reduction in symptoms from the cancer and, as a result, have a better quality of life. When thinking about quality of life it is important to remember that the side effects of treatment should be weighed against the side effects or consequences of the disease.
Adjustment to Cancer
Despite the many areas of need for older patients, there are data from studies which suggest that older patients with cancer generally adjust better than younger ones. They seem to express less distress and depression and have fewer unmet psychological needs. One of the reasons older patients adjust better is they may have more life experiences which have given them skills to handle crises. They also may have different expectations about physical illness and may not feel the same degree of distress about life coming to an end because they have had more opportunity to have lived their lives. Perhaps they feel they have accomplished a lot of the things in life they wanted to accomplish. Older patients may also have fewer competing demands on them such as children and careers. On the other hand, some health practitioners think that older patients are just less willing to complain or disclose problems than younger patients. It is an area where additional research is needed.
Type of Cancer and Clinical Trials in Older Patients
Different cancers present differently in older people. For example, there are some cancers which may be more aggressive in older patients such as acute myelogenous leukemia, acute lymphoblastic leukemia, thyroid cancer, small-cell lung cancer, prostate cancer, Hodgkin’s disease, lymphoma, vulvar cancer and carcinoid tumors. On the other hand, breast cancer tends to be less aggressive and some cancers tend to present with decreased stage as age increases such as pancreatic, rectal and stomach cancer. For some cancers there are no differences in age groups such as multiple myeloma, sarcomas, and cancers of the gastrointestinal tract, head and neck, non-small-cell lung, kidney, and bladder.
Older patients are often excluded from clinical trials, which is a problem because physicians often make treatment decisions based on clinical trial data. Since older patients are often not in these trials we do not know the true impact of these treatments on older adults. One of the goals at UCLA is to increase the involvement of older patients in clinical trials when appropriate. It should be noted, however, that there are significant barriers to participation, such as transportation, costs, logistics, and caregiver burden. Older patients can also be excluded from clinical trials if they have co-morbid illnesses or functional disorders.
UCLA Geriatric Oncology Research and Training Initiative
The UCLA Geriatric Oncology Program sees patients over the age of 70 with breast, prostate, lung or colon cancer. We also see patients over the age of 65 with any hematology-oncology problem that is complicated by a geriatric syndrome requiring special attention. Patients can self-refer and should call (310) 794-1663 or (310) 206-6979. Patients who are not referred by the geriatric division will have a dual appointment with a geriatrician who will provide a comprehensive assessment including the areas discussed in this presentation.
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