FACET - European Journal of Cancer Care

FACET - European Journal of Cancer CareDecember 2004

slides available at: www.blackwellpublishing.com/journals/ecc

Older People and Cancer: Considerations for Healthcare

PractitionersForte, D.1 McGregor, R.2

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*Click on “View”; “Notes Page” for explanatory notes

Population ageing in United Kingdom

• Currently over one fifth of the population is over 60 years

• By 2025 those over 80 years will increase by almost 50%

• By 2025 those over ninety will have doubled

• Estimated percentage of older people 65 years or more in population in 2004 is 15%




Practitioners (continued)

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Incidence of cancer in older people

• Cancer generally increases with age

• Incidence of most malignant cancers increase with age up to 85 years

• Decline in these cancers after 95 years

• 12% of newly diagnosed breast cancer patients are 80 years or more



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Link between cancer and old

ageThe link between old age and

cancer is the result of three main factors according to Repetto & Balducci (2002)

• Substantial length of time required for carcinogenesis

• The occurrence of age related molecular changes that mimic carcinogenesis

• Changes in bodily environment that favour cancer progression





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What do we mean by ageing?

“The universality of ageing

places it outside the realm of

pathologic study. The

changes that occur are

normal for all people but take

place at different rates and

depend on accompanying

circumstances in an

individual’s life”.(Ebersole & Hess 1998, p85)





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Challenges of chronological ageing

versus biological ageing

• Ageing varies not only among individuals but within different systems of the same person” (Eliopoulos 1997 p45)

• “Aging is a highly individualised process, demonstrated by the differences between persons of similar ages” (Eliopoulos 1997 p45)

• Chronological ageing is an indicator of the number of years lived but is only a crude indicator for ageing




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Loss of function in old age and

implications for cancer (1)

• Nervous system 10%

• Basal metabolic rate 15%

• Cardiovascular system 30%

• Pulmonary system 50%

• Renal system 30%





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Loss of function in old age and

implications for cancer (2)

• Bone marrow

• Reduced tissue repair

• Changes to sensory system





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Are cancer services inherently ageist? • Often older people receive

less screening for cancer

• They are less likely to be referred to a main cancer centre

• Once diagnosed, often receive less aggressive treatment leading to an increase in mortality from the cancer rather than comorbidities

• Problems related to early detection of cancer





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The National Service Framework for Older People

(DoH, 2001)

has as its first standard, the

need to root out age

discrimination in the health

service. It states that:

“NHS services will be

provided; regardless of age,

on the basis of clinical needs

alone”





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Older people and access to clinical

trials (1)

• Researchers indicate that for all cancers, older people are under-represented in clinical trials. This is due to

• The strict exclusion criteria built into many research protocols


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Older people and access to clinical

trials (2)

• Older people often present with comorbidity which pre dates the diagnosis of cancer and which many clinicians feel makes the older person too vulnerable for the more aggressive forms of treatment

• Misconceptions about ageing and cancer may have a negative effect when it comes to influencing clinical decisions about treatment




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Problems related to early detection and access to treatment

• Effects of ageism on early presentation of symptoms

• Signs and symptoms of cancer can be vague and non specific

• Clinical presentation may be slow to develop and be masked by other age related physical changes and comorbidities

• Importance of raising awareness of early detection in older people.

• Need for comprehensive assessment by multiprofessional team


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Screening (1)

Breast

• A 30% reduction in mortality from breast cancer in the last 10 years in the United Kingdom

• The figures are similar in the USA but have remained static in Europe (Rosin, Cancer Services Collaborative 2001)

• By the end of 2004 all women in the United Kingdom will be offered routine breast screening


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Screening (2)Cervical

• Screening is estimated to save around 1,300 lives per year

• Primarily aimed at people under 65 years

• Need for older women to be included in routine screening

Prostate

• The evidence for prostate screening is less clear than for other cancers

• PSA testing fails to differentiate between slow and fast growing prostate cancers





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Screening (3)

Bowel

• The incidence increases with age and is mainly a disease that affects older people

• In 2000 the National Cancer Plan announced that it would implement a pilot study to look at the population most likely to benefit from bowel cancer screening




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Comprehensive assessment

• Needs to include:

• Biographical data

• Physical assessment

• Psycho/social assessment

• Cultural preferences

• Multidisciplinary input

• Patient and carer involvement




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Single assessment

• Should facilitate better communication within and between teams, and other service providers with whom the older person has contact

• Reduces the need for the older person to repeat the same assessment information to a variety of service providers at a time when they are feeling vulnerable




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Key assessment areas for older

people at risk of cancer

• Physical

• Psychological

• Social

• Spiritual

• Financial support




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• Comorbidity

• Natural ageing process

• Understanding of the impact of multi-pathology/chronic illness/cognitive impairment

• Thorough assessment of past medical history and medication

• Identifying risk factors including smoking, nutritional status




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Psychological state (1)

• Impact of cancer on the older person’s sense of wellbeing

• Motivation and adjustment to the situation

• Quality of life




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Psychological state (2)

• Psychological support

• Cognitive function

• Sexuality and self image




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Social assessment needs to consider:

• Social support networks

• Carer support

• Housing

• Finance

• The older person’s perception of health




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Summary

• Need for more research

• Greater consideration of the impact of ‘normal’ ageing changes

• Rights of older people to being told their diagnosis and the options available to them




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References and further reading

• Bouchardy C., Rapiti E., Fioretta G., Laissue P., Neyroud-Caspar I., Schäfer P., Kurtz J., Sapprino A. & Vlastos G. (2003) Undertreatment strongly decreases prognosis of breast cancer in elderly women. Journal of Clinical Oncology. 21 (19): 3580-3587.

• Cooley C. & Coventry G. (2003) Cancer and Older People. Nursing Older People. 15(2): 22-26.

• Cunningham S. (1996) The biological basis of cancer. British Journal of Nursing. 5:14 869-874.

• Department of Health (2000) NHS Cancer Plan for England. Department of Health. London. www.doh.gov.uk/cancer/cancerplan.htm

• Department of Health (2001) National Service Framework for Older People. Department of Health. London

• Ebersole P. & Hess P. (1998) Towards Healthy Ageing, 5th edition, Mosby. Missouri.

• Eliopoulos C. (1997) Gerontological Nursing. 4th edition ch.4:p44-52; ch.7:p74-94. Lippincott. Philadelphia.



http://www.doh.gov.uk/cancer/cancerplan.htm


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References (continued) • Fee L., Cronin A., Simmons R. & Choudry S.

(1999) Assessing older people’s health and social needs. Health Education Authority. London.

• Gearing B. & Coleman P. (1996) Biographical Assessment in Community Care, in Birren J.; Kenyon G.; Ruth J.; Schroots J. & Svenson T. (1996) Ageing & Biography: Explanations in Adult Development. Springer. New York. Chapter 15:265-282.

• Girotto J., Schreiber J. & Nahabedian M. (2003) Breast Reconstruction in Older Women: Preserving Excellent Quality of Life. Annals of Plastic Surgery. 50(6): 572-578.

• Heflin MT, Cohen HJ. (2001) Cancer screening in the elderly. Hospital Practice. 36(3): 61-9.

• Lewis J., Kilgore M., Goldman D., Trimble E., Kaplan R., Montello M., Houseman M. & Escarce J. (2003) Participation of Patients 65 Years of Age or Older in Cancer Clinical Trials. Journal of Clinical Oncology. 21:1383-1389.




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References (continued) • Lichtman S. & Zaheer W. (1996) Breast

cancer screening is underused, although clearly beneficial, in elderly women. Primary Cancer Care. 16(5): 5-6.

• Matsushita I., Hanai H., Kajimura M., Tamakoshi K., Nakajima T & Matsubayashi Y. (2002) Should Gastric cancer Patients More Than 80 Years of Age Undergo Surgery? Journal of Clinical Gastroenterology. 35(1): 29-34.

• Nolan M. & Caldock K. (1996) Assessment: identifying the barriers to good practice. Health & Social Care in the Community. 4(2): 77-85.

• Patel S. & Zenilman M. (2001) Outcomes in Older People Undergoing Operative Interventions for Colorectal Cancer: Surgery for Colorectal Cancer in Older Patients: A Systematic Review. Journal of the American Geriatrics Society. 49(11): 1561-1564.

• Posner R. (1995) Ageing and Old Age. The University of Chicago Press, Chicago.




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References (continued) • Reinbart Ayres M. (2004) Cancer and the

Older Population: Considerations for Healthcare Professionals. Topics in Geriatric Rehabilitation. 20(2): 75-80.

• Repetto L. & Balducci L. (2002) A case for geriatric oncology. The Lancet Oncology. 3(5): 289-297.

• Robinson J. & Turnock T. (1998) Investing in Rehabilitation. Review Findings. Kings Fund. London.

• Rosin D. (2001) Breast Cancer – Cancer Services Collaborative http://www.nelh.nhs.uk/nsf/cancer/breast_sig/summary/summary-intro.htm

• Schmitt C. (2004) Treatment Strategies for Colorectal Cancer in Older People. Journal of Clinical Gastroenterology. 38(5): 387-389.

• Thomé B., Dykes A., Gunnars B. & Hallberg I. (2003) The Experience of Older People Living With Cancer, Cancer Nursing, 26(2): 85-96.



http://www.nelh.nhs.uk/nsf/cancer/breast_sig/summary/summary-intro.htm

http://www.nelh.nhs.uk/nsf/cancer/breast_sig/summary/summary-intro.htm


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References (continued) • Turner N., Haward R., Mulley G. & Selby P.

(1999) Cancer in old age – is it adequately investigated and treated? British Medical Journal. 319: 309-312.

• Vardaxis N. (1995) Pathology for the Health Sciences. Churchill Livingstone. Edinburgh.

• Westin E. & Longo D. (2004) Lymphoma and myeloma in older patients. Seminars in Oncology. 31(2): 198-205.

• Wyld L., Garg D., Kumar I., Brown H. & Reed M. (2004) Stage and treatment variations with age in postmenopausal women with breast cancer: compliance with guideline. British Journal of Cancer. 90(8): 1486-91.

• Yancik R., Wesley M., Reis L., Havlik R., Edwards B. & Yates J. (2001) Effects of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA. 285(7): 885-92.



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