Ageism in cancer careBMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g1614 (Published 28 February 2014) Cite this as: BMJ 2014;348:g1614
- Mark Lawler, chair of translational cancer genomics1,
- Peter Selby, professor of cancer medicine2,
- Matti S Aapro, dean3,
- Sean Duffy, national clinical director for cancer4
- 1Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast BT9 7AE UK
- 2Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
- 3Multidisciplinary Oncology Institute, Genolier, Switzerland
- 4NHS England, Medical Directorate NHS England, Leeds, UK
What has happened in the 15 years since the BMJ suggested inadequacies in the treatment of cancer in elderly people?1 Rather less than we might have hoped. The 2013 insight report of HelpAge International’s Global AgeWatch Index highlights the burgeoning challenges that ageing populations present to healthcare systems in general and cancer care in particular.2 The Institute of Medicine’s recent report on cancer care emphasises the urgent need to deal with the problem of age as the global population undergoes a transformational change over the next 50 years.3
For example, the US Census Bureau predicts that the population of the United States aged 65 years or more will double at least, from around 40 million in 2009 to 89 million in 2050.4 Estimates for the United Kingdom suggest that 76% of cancers in men and 70% of cancers in women will occur in the over 65 age group by 2030.5 More people are over 65 years old in both China and India than in the whole of Europe, and six countries currently account for 54% of the total number of people aged 80 years or more.6
Although these demographic changes will affect the global incidence of cancer, the more worrying consequence relates to death from cancer, particularly given the current data for cancer survival in older patients. The International Cancer Benchmarking Partnership (ICBP)—a collaboration that compares outcome data between Australia, Canada, Denmark, England, Northern Ireland, Norway, Sweden, and Wales—has indicated decreased survival for patients older than 65 years.7 A EUROCARE 4 study confirmed this trend, suggesting that the survival gap is widening between older and younger patients in Europe,8 while the EUROCARE 5 study, which has just been released, emphasises the poorer survival in older patients.9
What explains these disparities? Although age in itself should not be a factor in the decision to provide curative treatment, there is increasing evidence that older patients are under-treated and that this inequitable access to cancer care is leading to poorer outcomes. More than 70% of deaths caused by prostate cancer occur in men aged over 75 years, who usually have more aggressive disease. However, few older patients receive treatment for localised prostate cancer, and in most cases they are denied access to chemotherapy for advanced disease.10 Colorectal cancer is another disease of older people, yet the evidence again suggests that optimal treatment is not being provided to this patient cohort.11 A high proportion of older women with triple negative breast cancer (a form of breast cancer that doesn’t express the receptors for erbB2, oestrogen, or progesterone) receive less chemotherapy than their younger counterparts, despite the available evidence of its efficacy in this patient cohort.12 In the UK, the National Cancer Equality Initiative (NCEI)/Pharmaceutical Oncology Initiative (POI) joint report concluded that clinicians may over-rely on chronological age as a proxy for other factors, which are often but not necessarily associated with age, such as comorbidities and frailty.13
How do we close the gap?
We need a fundamental change in the policy on cancer for older patients, whereby decisions on whether to treat are based on a matrix that captures patients’ performance status, comorbidities, and wishes rather than just chronological age. Recognising the disparities that exist for cancer care in older patients, the European Organisation for Research and Treatment of Cancer (EORTC) established a task force to improve access to clinical trials and research so that optimum standards of care can be delivered to the geriatric population. A joint position paper between EORTC, the Alliance for Clinical Trials in Oncology, and the International Society of Geriatric Oncology has recently specified a suggested strategy for research in older patients and emphasised the absolute requirement for clinical trials to be without an upper age, with the proviso that trial design may need to be flexible, particularly to cater for frail or vulnerable patients.14 The application and refinement of geriatric screening tools can also help underpin appropriate treatment decision making in older patients.15 In the UK, the recent publication of the NCEI-POI joint report mentioned above has been part of a concerted effort to redress the balance in favour of older patients with cancer.13 This culminated in the launch last December at the Britain Against Cancer Conference of an “action for the elderly in cancer” initiative as the NCEI’s main priority.
The above evidence highlights that the urgent need to deal with the “age issue” in cancer care must be a key component of global cancer control strategies in the coming years. A “geriacentric” strategy that maximises clinical trial activity in older patients, makes existing treatments more available, develops new approaches that are well tolerated in older people, and espouses the development and application of geriatric decision making tools will be required to deal with the particular needs of this group of patients. Such a strategy will also have to ensure that the principle of early diagnosis (underpinning more effective and less aggressive treatment) is applied in older patients as well as in their younger counterparts. Only then can we truly deliver a comprehensive cancer service to the elderly population in our society.
Cite this as: BMJ 2014;348:g1614
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.