Older Survivors and Cancer Care

Abstract

The current sizeable population of cancer survivors has brought to the forefront key issues related to treatment decisions, management of adverse consequences of cancer and its treatment, and complex health needs related to cancer and other chronic comorbid conditions ( 1 ). Although improvements in cancer diagnosis, early detection, and treatment have led to dramatically increasing numbers of cancer survivors, cancer continues to be the second most common cause of death in the United States, and an estimated 1 444 920 new patients are expected to be diagnosed with cancer during this year alone ( 2 ). Cancer survivorship research focuses on the health and life of individuals living with the late or long-term effects of can cer or its treatment(s). By defi nition, patients living with advanced disease are cancer survivors. Individuals older than age 65 account for 60% of the estimated 10.8 million cancer survivors in the United States today ( 1 ). With the aging of the population, a rising trend in numbers of older cancer survivors is expected. Given the median age at diagnosis (67 years; all sites combined) and increasing survival estimates, comorbid conditions, especially among older survivors, are and will be an important factor in treatment decisions, posttreatment follow-up care, and palliative care ( 3 , 4 ). Studies have demonstrated that the presence of comorbid health conditions and perceived health vulnerability of the elderly by physicians can lead to under- or less aggressive treatment of the elderly, with resulting poor prognoses. Comorbidity in older patients may limit the ability to obtain (or for patients to undergo procedures that furnish) prognostic information (eg, axillary lymph node dissection), minimize treatment options (eg, breast-conserving therapy), and increase the risk of death from causes other than cancer ( 5 ). We propose that “cancer-related care” can be envisioned at four levels: 1) acute treatment of the cancer; 2) surveillance and follow-up care for disease recurrence, management of adverse treatment – related consequences and noncancer comorbidities; 3) palliative care for advanced cancer; and 4) end-of-life care. Supportive and palliative care have been recognized as important components of quality care for all cancer patients, particularly for those with advanced or incurable disease ( 6 , 7 ). Although it is increasingly accepted that quality palliative care should be provided through an interdisciplinary team approach with a focus on comfort and quality of life ( 8 ), the lack of a strong evidence-based foundation for this important area of research may result in missed treatment opportunities, the provision of nonbenefi cial and burdensome interventions, and over- or undertreatment ( 9 , 10 ). Within palliative surgery and other invasive specialty areas, specifi c concerns include the risks of major morbidity and mortality associated with many cancer-specifi c treatment approaches and the impact of decreased or severely restricted decision-making capacity among patients, especially those who are frail and elderly. The diversity of ethnic, cultural, and religious backgrounds of patients experiencing life- threatening illness at older ages adds further complexity to the provision of acceptable and optimal cancerrelated care. The fact that the Medicaid-insured nursing home patients studied by Bradley et al. ( 11 ), as reported in this issue of the Journal, had a preponderance of late and unstaged disease, high mortality within a few months of diagnosis, low hospice utilization, and little cancer-directed treatment is of concern, and future studies should further examine these issues. Timely cancer treatment and the alleviation of symptoms have the potential to extend life and enhance the quality of survival. Especially noteworthy are the fi ndings that 1) relative to patients aged 86 years and older (the fastestgrowing segment of the US population), patients aged 76 – 80 years and 81 – 85 years were less likely to be diagnosed with late or unstaged cancer at diagnosis; and 2) compared with patients with breast cancer, patients with colorectal, lung, prostate, and other cancers were more likely to be diagnosed with late or unstaged cancer. These results in particular underscore the fact that within the overarching category of “older survivors”, complexities related to early detection and management of the disease increase with age. In addition, some cancers other than breast cancer tended to have been diagnosed relatively late in this study, highlighting the need for vigilance toward possible cancer-related symptoms for some common cancers. These fi ndings also might refl ect the impact of established guidelines and practices relating to mammograms, as opposed to inconsistencies regarding prostate-specifi c antigen testing, colonoscopy, and screening for lung cancer.