Elderly people with cancer face unique challenges as they battle cancer

Elderly people with cancer face unique challenges as they battle cancer. The normal aging process and its effects on the body, in addition to the psychological stress that accompanies the diagnosis and subsequent surgery and/or treatment, may adversely affect an aging patient’s ability to heal or cope with having cancer. Some of the larger issues elderly patients face include the existence of risk factors, awareness of possible clinical trials and advances in research related to their cancer, planning for palliative care, and financial implications.

Risk Factors

The process of growing older increases the likelihood of cancer. “Older tissues are more susceptible to environmental carcinogens,” says Lodovico Balducci MD, Chief of Geriatric Oncology at H. Lee Moffitt Cancer Center in Tampa, Florida. “Some changes in body environment—decreased immunity, increased resistance to insulin, chronic inflammation—may accelerate the growth of cancer.”

Dr. Balducci outlined several risk factors and their relationship to age.

• Smoking and alcohol consumption: Smoking is definitely a cause of most cancers, such as lung, head and neck, bladder, and pancreas. Screening for lung cancer is very effective in preventing death from lung cancer, and elderly smokers should be encouraged to quit and be screened. Alcohol may have a role in cancer ofthe upper digestive tract and the breast, but the role is less well defined. Still, alcohol should be consumed in moderation.
• Comorbidities: Comorbidities may prevent some forms of cancer treatment. Heart disease may make surgery more risky and may exclude the use of some chemotherapy drugs, such as anthracyclines. Diabetes may increase the risk of peripheral neuropathy (damage to nerves that could result in symptoms ranging from pain and numbness to bladder problems), which in older individuals may be disabling. In addition, comorbidities may reduce the life expectancy of a person, and consequently the benefits of cancer treatment.
• Physical and mental condition/possible frailty: Dr. Balducci reported that recent studies done at his institution have shown that people who are dependent on others for performing the so-called “instrumental activities of daily living,” such as using transportation, takingmedications, preparing meals, shopping, using the phone, and managingfinances have an increased risk of experiencing toxicity associated with chemotherapy. Frailty is an important concept. The frail person is one who is still independent but may become dependent after experiencing a stress such as elective surgery or chemotherapy.

Are Seniors Savvy on Treatment, Clinical Trials, Research?

Stuart M. Lichtman, MD, Medical Oncologist at Memorial Sloan-Kettering Cancer Center in Commack, NY, says the older population has a number of ways they can access information about cancer treatment and cancer centers, and help with finding doctors and clinical trials. “They are increasingly becoming more savvy and self-reliant but still use traditional methods of obtaining information, such as television, newspapers, and family,” he said. “Access to accurate information is an important goal for older patients as they face a greater number of health issues, and use prescription drugs and health care services at a higher rate than younger patients.”

However, Dr. Lichtman cautions, education and income may play a role in access to or understanding of these data. “Older adults are not using the Internet in place of other traditional media channels; they use the Internet in addition to other media channels,” he says. Therefore, he suggests that older adults be given health information in writing. “Additional studies show that despite the use of the Internet, older individuals do not use the information from the Internet to change the way they participate in health care; when it comes to decision-making, older individuals prefer a physician-centered model of care,” Dr. Lichtman added. “They also place reliance on their family and friends.”

Palliative Care

Planning palliative and hospice care are important issues for cancer patients to discuss with their physicians. Palliative care options for the elderly should include goals of care, which may include keeping the patient’s pain under control, managing side effects, managing depression, and incorporating the patient’s personal wishes. “As with patients of any age, there are those who are prepared for their death and those who are not,” says Roma Tickoo, MD, MPH,a geriatrician at Memorial Sloan-Kettering Cancer Center in New York.“I find that most elderly patients are ready to face their death. This is particularly true if the patient has lost loves ones and/or friends and is feeling alone.” Dr. Tickoo says often elderly patients will express the opinion that it is “my time to go and I am ready.”

Challenges often arise with elderly patients in the advanced stages of cancer, such as those who are incapacitated and have not left directives specifying their desire (or lack thereof) for the use of aggressive life-sustaining measures. “Family members frequently wish to protect patients who are frail or who have cognitive deficits, taking on decision making about care,” she says. “If the patient has not expressed their end-of-life wishes, family and/or health care providers may feel compelled to press for more aggressive treatment than might be advisable and desired by the patient.” Therefore, she advises that “every patient should discuss their wishes about end-of-life with their family and health care providers while they are able to ensure that everyone is on the same page.”

Financial Strain

Barbara A. Murphy, MD, Professor of Medicine, Director of Pain and Symptom Management and Program Leader of the Head and Neck Research team at Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, says elderly patients often have financialissues. “Most are retired and no longer working, thus disability is no longer an issue,” she says, and therefore time off from work is not a factor. But that does not mean the disability will not impact a patient’s financial situation in many cases. “A cohort of patients is financially stable in retirement and has sufficient funds for any medical circumstances that arise. Another group of patients has sufficient funds to deal with most medical issues that arise but do not have sufficient wherewithal to provide for custodial care should they require substantial assistance with daily care.” There is yet another group, she continues, of those who live on a small, fixed income. “They may have difficulty dealing with day-to-day finances,” Dr. Murphy adds. “The addition of an illness may cause severe hardship due to insufficient funds. These are patients who may need to make a decision about where to spend their money: daily expenses versus medical expenses.”

Social workers can sometimes help by providing financial counseling and information about community support services. They can also help patients set priorities and find information on pharmaceutical companies that provide assistance programs. Furthermore, Dr. Murphy adds, “a network of families and friends can help by providing meals, transportation, emotional support, and a shoulder to help with the burden.”