Education and debate

Cancer in old ageis it inadequately investigated and treated?

N J Turner, specialist registrar ^a,  R A Haward, professor ^b,  G P Mulley, professor ^a,  P J Selby, professor ^c. 

^a Department of Medicine for the Elderly, St James's University Hospital, Leeds LS9 7TF, ^b Research School of Medicine Centre for Cancer Research, Yorkshire Cancer Organisation, Cookridge Hospital, Leeds LS16 6QB, ^c Research School of Medicine Centre for Cancer Research, ICRF Cancer Medicine Research Unit, St James's University Hospital, Leeds LS9 7TF

Correspondence to: N J Turner nicola_turner{at}talk21.com

The proportion of the United Kingdom population over 75 years of age will increase from around 7% to nearly 11% in the next 50 years, with a disproportionate rise in those over 85 years. There will be a large increase in the number of elderly patients with cancer. Already over one third of cancers are diagnosed in people over 75, yet we do not know how best to investigate and treat cancers in these patients. Many clinical trials have used arbitrary upper age limits. Even trials in allegedly elderly subjects start at age 65. Very few studies include large numbers of old (over 75) or very old (over 85) people.¹ The role and effectiveness of many cancer treatments is therefore not evidence based in those most affected.

Studies of cancer care in elderly patients show fewer diagnostic and staging procedures and less treatment with advancing age. Disease specific survival rates decline with age.^2-6 This is illustrated by data from the Yorkshire Cancer Registry on histological confirmation (a useful marker for the adequacy of investigation), receipt of definitive treatment, and relative survival in relation to age group (table).⁷ The Yorkshire Cancer Registry is one of the registries used in the Eurocare study. It covers a population of 3.7 million, constituting 7.2% of the total population of England and Wales.

Why do elderly people seem to be underinvestigated and undertreated? Perhaps the age associated decline in functional reserve and the increase in comorbid conditions discourage aggressive interventions. Do elderly patients refuse to have certain treatments? Do their relatives dissuade them from having therapy? Is there ageism among doctors and other health professionals? Do non-specialists protect frail older patients from what they perceive to be "unnecessary" procedures and treatments? We decided to review published reports on the investigation and treatment of cancer in old age to try to answer some of these questions.

	Methods

We performed a Medline search from 1980 to 1998, using the terms "cancer," "elderly," and "old age." We also scrutinised bibliographies of the articles obtained from the search for additional references. Papers selected included recent review articles and trials specifically in elderly people.

	Comorbidity

Some researchers have tried to correct for comorbidity. One study has shown that the apparent age bias is explained by excess comorbidity in elderly subjects.⁶ However, others show that age is an independent negative predictor of getting definitive treatment.³ After correcting for comorbidity, one group found that the age bias remained for treatments received, but not for diagnostic investigations.⁴ There is no validated scale for measuring comorbidity, so comparison between studies is difficult. Scales of performance status, function, and quality of life are well validated, but practice in the disciplines of oncology and care of the elderly has led to different things being measured. The former has tended to focus on pathology and impairment, and the latter has focused on disability and handicap. However, both specialties are beginning to use health related quality of life measures.

	Reduced function

The word "frail" is often used to describe elderly patients, but it needs a clear definition. Recent efforts at achieving this address four measurable components of reduced function: musculoskeletal function, aerobic capacity, cognitive and integrative neurological function, and nutritional state. Frailty is defined as a multisystem reduction in physiological capacity which renders the old person vulnerable to relatively small environmental challenges.⁸ While this provides a useful, potentially measurable concept, no validated scale for frailty exists for general use.

	Treatment

Chemotherapy
Surprisingly little is clear about the place of chemotherapy in elderly patients. Studies have included patients with controlled comorbidity (for example, hypertension, coronary artery disease, and diabetes mellitus), with no adverse effect on outcome. Known side effects of some chemotherapeutic drugs (such as the cardiotoxicity of anthracycline drugs) might lead doctors sensibly to restrict their use in patients with pre-existing cardiological problems. However, though cardiovascular diseases are said to predispose to the cardiotoxicity of these drugs, this is not certain.⁹

Surgery
Surgery is performed less often in elderly patients with non-small cell lung cancer, despite the tumour being operable.⁴ This surgery can be performed safely in elderly patients selected according to the same anatomical and physiological criteria used in younger subjects.¹³ Operative risk increases with age, but with modern anaesthetic and surgical techniques this can be reduced to acceptable levels, even in the oldest age groups.¹⁴ Attention to good preoperative and postoperative care is of particular importance in elderly patients with comorbidity.

Radiotherapy
Radiotherapy is used less often in elderly patients, although its safe use, without increased toxicity, has been described in this population. This includes radical radiotherapy in pelvic malignancies and radiotherapy of curative intent in thoracic cancers. ^{16 17} Transport for elderly patients can be a problem,³ and protocols to reduce hospital visits can be designed.¹⁸ Elderly patients receive more palliative than curative radiotherapy, but decisions on treatment protocols are not influenced by chronological age once the patient has been referred to a radiotherapist.¹⁹

Hormonal therapy
Tamoxifen may offer great benefit in elderly patients with breast cancer. It has been used as sole therapy after reports that this produced survival equivalent to surgery and tamoxifen combined. Further follow up showed a high local recurrence rate in the tamoxifen group, with many women requiring salvage surgery or radiotherapy. Tamoxifen alone therefore can no longer be recommended as optimum treatment for older women.²⁰ Newer hormonal treatments for breast cancer, such as anastrozole, can also be used in elderly women. Carcinoma of the prostate is responsive to hormonal treatments such as goserelin, which are useful in elderly patients.

Adjuvant therapy
Adjuvant treatments have proved benefit in breast and colorectal cancer, which are common in elderly patients. There are no data on their use in the elderly population, but where normal life expectancy exceeds the survival benefit of treatment, there is no reason why such treatments could not be employed.²¹

	Palliative care

Increasing age is an independent predictor of inadequate pain management. Fear of addiction to opioids, the belief that "good" patients do not complain of pain, and concern that treatment of pain will distract effort from treating the cancer are examples of patient related barriers to the management of cancer pain: older patients are more likely to have these concerns. Family caregivers may have similar concerns, and their views can influence successful pain control. Cognitively impaired elderly patients may underreport pain, but their complaints of pain are no less valid than those of cognitively intact individuals. Pain, as well as other symptoms such as fatigue and dyspnoea, may be caused by comorbid conditions and not the cancer or its treatment. A search for other treatable conditions is especially important in elderly patients.²²

	Screening

Some cancers can be diagnosed at an early stage by screening. There are different screening policies in different countries, particularly for prostate and colorectal cancers. Screening for these cancers is available in the United States but not in the United Kingdom, although screening for colorectal cancer is now being considered.

Established screening programmes for breast and cervical cancers have upper age limits. For cervical carcinoma, if a woman over 65 has an adequate screening history with at least three consecutive negative smears, further screening is inefficient and can stop. However, many older women have never had a smear and may still benefit from screening.²³ The breast screening programme in the United Kingdom invites women for mammography up to the age of 65 and allows women older than this to be screened on request. However, many older women are not aware of this, and many do not realise that they are at risk.²⁴ Routine screening with no upper age limit may save lives.²⁵ Breast examination is often not performed in elderly women, although most would be willing to undergo this.²⁶

	Patient issues

Some elderly patients may decide not to accept recommended investigations or interventions. Others are as likely to agree to chemotherapy as their younger counterparts, though there are differences in their assessment of risk-benefit ratios for more toxic regimens.²⁷ A survey of elderly people's attitudes to invasive procedures showed that most would want investigations and treatments for life threatening illnesses.²⁸ Psychologically, elderly people fare no worse than the young; indeed they may cope better with a diagnosis of cancer.²⁹ There are many myths about cancerfor example, that surgery spreads cancer or that cancer treatments are worse than the diseasethough belief in these myths and level of knowledge about cancer seem to be related more to previous educational level and social class than to age.³⁰

	Issues for healthcare staff

Ageist attitudes persist among healthcare staff.³¹ There is reduced referral to specialists with increasing age, though the rationale behind this is not clear.³² Doctors are poor at judging the health related quality of life of their elderly patients, and they frequently grade this lower than patients do themselves.³³ Older people may be more likely to follow their doctor's recommendations without question, but the way in which treatment options are presented can influence their choice. Lack of knowledge about the ageing process among doctors may also be a problem. Some may be unaware that a 75 year old woman has a life expectancy of 11.1 years and that of a 75 year old man 8.5 years. To help overcome this, there has been a move in the United States to integrate geriatric medicine into the subspecialties of medicine, particularly oncology.³⁴

	Cancer services

There is wide variation in practice for most cancers between different specialists, hospitals, and regions.³⁵ The Calman/Hine report on the organisation of cancer services in the United Kingdom³⁶ recommends that cancer care should be delivered by specialists working in designated cancer units and centres. With increased specialisation, there is a need for interdisciplinary teams. Evidence is increasing that care organised in this way improves outcomes, and it seems reasonable to expect that this should apply equally to elderly patients.³⁷

	Conclusions

The problems of cancer in old age have been the topic of several editorials and feature articles.^38-40 Cancer in old age is not managed the same way as in younger people, and the differences are not wholly explained by appropriate adjustment for the condition of the individual patients. We do not know which variables predominantly influence decision making³⁸is it the patient's or family's acceptance of therapy or the physician's opinions (including possible bias based on chronological rather than biological age alone)? Adjustments are made for comorbidity and functional status, but it is not clear how these are measured in practice. Understanding which criteria are used in making treatment decisions is necessary. It is possible that healthcare professionals are delivering a poor standard of care to some elderly cancer patients.

Where do we go from here? Firstly, we should identify what patients and doctors know about the investigations and cancer treatments that are effective in and acceptable to older people. Secondly, we need answers on how best to manage common cancers in old age, especially breast, colorectal, lung, and prostate cancers. This must include data on disability, handicap, health related quality of life, and psychological wellbeing as well as physical outcome measures.

	Footnotes

   Competing interests: None declared.

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(Accepted 6 April 1999)