The Unique Challenges of Treating and Caring for Older Adult Patients With Cancer

Abstract

In older age, tissue degeneration, decreased cellular competition, and the declining efficiency of clearance mechanisms lead to higher rates of survival and accumulation for cells with adaptive mutations, which increase the risk of cancer cell development (Laconi et al., 2020). Thus, age is a significant risk factor for cancer. It is projected that by 2050, the global population aged 60 and above will rise to 2.1 billion, with those aged 80 and above expected to reach 426 million (World Health Organization, 2024). Taiwan, which became an aging society in 2018, is expected to be a nation in which older adults constitute 46.5% of the total population by 2070 (National Development Council, 2024). As the older adult population increases, the number of patients with cancer will also almost certainly continue to rise. Older adults respond differently to traditional cancer treatments than younger individuals, often experiencing declines in physical function, frailty, and cognitive impairment (Extermann, 2000). Moreover, older adult patients frequently have multiple chronic diseases (e.g., cardiovascular disease, diabetes, pulmonary, renal, liver diseases) that increase the complexity and risks associated with cancer treatment (Dale et al., 2012). They may also use over-the-counter medications or herbal supplements in addition to prescription drugs (Maggiore et al., 2010), which raises the risk of treatment toxicity and complications, presenting challenges for treatment decision-making. According to a survey by the National Cancer Institute, only 32% of patients with cancer participating in clinical trials were over 65 years old (Murthy et al., 2004). This may relate to the common exclusion of patients with comorbidities, physician attitudes, and/or the lower willingness of older adult patients to participate (Lewis et al., 2003). Thus, existing data may be insufficient to support the development of optimal treatment plans for older adult patients with cancer (Dale et al., 2012; Extermann, 2000). Age discrimination may lead to undertreatment or overtreatment, affecting patients' functional status and quality of life (Extermann, 2000; Hamaker et al., 2022). Currently, most oncology research relies on either the Eastern Cooperative Oncology Group performance status scale or Karnofsky Performance Scale to assess health status. However, neither adequately differentiates for the characteristics of older adult patients (Pal et al., 2010). In assessing quality of life in patients with cancer, the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire or Medical Outcomes Study 36-item Short Form Health Survey is commonly used. However, these tools lack targeted assessments for cognitive function, activities of daily living, and autonomy (such as cooking, shopping, making phone calls, and managing finances), which are issues of particular concern in older adult patients (Terret et al., 2011). The American Society of Clinical Oncology recommends that older adult cancer care should include geriatric assessments (GAs) of key elements such as functional status, mental health, cognitive ability, nutritional status, chemotherapy toxicity risks, life expectancy, comorbidities, fall history, and social support to provide critical reference data for treatment planning (Chapman et al., 2021; Dale et al., 2023; Hamaker et al., 2022). However, a randomized controlled trial showed that GAs do not significantly improve physical function or quality of life for older adult patients with cancer, suggesting the benefits of these assessments remain unclear (Portielje & van den Bos, 2024). Nevertheless, other studies have shown that GAs significantly reduce chemotherapy toxicity and improve satisfaction among patients and their families (Dale et al., 2023). Despite these recommendations, knowledge of geriatric oncology has not been widely integrated into medical training, and GAs have not been incorporated into clinical care processes (Chapman et al., 2021; Diaz et al., 2024), highlighting a global healthcare system lacking the expertise and skills necessary to provide appropriate targeted care for older adult patients with cancer. Given the increasing importance of geriatric cancer care, this column provides an in-depth exploration of the care needs of older adult patients with cancer, treatment decision-making, cognitive impairment issues, and the burdens faced by family caregivers. The four articles within are geared toward enhancing the knowledge and skills of nursing professionals in geriatric oncology care and, ultimately, improving the quality of care provided to older adult patients with cancer.