Lawler et al. signal a very relevant and timely topic, i.e., the seeming inequality in cancer treatment administered to elderly as compared to younger individuals with similarly advanced disease. [1] Also, they note several relevant issues such as the demographic transition and the lack of evidence for ‘ageism’ solely based on calendar age, or in fact properly designed clinical studies to either corroborate or challenge the present practice across many countries. However, fundamental issues that should be part of the equation of clinical decision making are not really alluded to.
First and foremost is the fact that with increasing age co-morbid conditions become rule rather than the exception. These may very well determine the prognosis and overall survival. Thus deciding on treating or not, and if, how to treat is not straightforward. One should first decide on what outcome to optimize. Is this going to be disease free survival or should an outcome less alien to individuals such as functioning and well-being be considered. Without first addressing this challenging yet prominent ‘geriatric’ question the entire discussion looses solid ground as no one can judge whether the current practice variation reflects a ‘common sense’ of optimizing quality survival time or indeed under-treatment. Importantly, should one decide to take the shortcut and simply treat regardless of age and co-morbidity, overtreatment, squander and transgressing the ‘primum non nocere’ might be the result.
Next, more or less related is the issue of optimizing the return on investment of scarce resources. All over the world, and particularly in the Western part that is in the privileged position to even be able to consider prescribing increasingly costly personalized cancer treatment, one recognizes the fact that the costs of health care are rising at a pace surpassing that of the GDP by at least two-fold, and therefore non-sustainable. [2] Clearly without simply pleading for crude and simplistic budget cuts, scarce public resources have to be consumed such that the balance between costs and effects reflect our equitable societal values.
The demographic transition makes these issues, which a propos are by no means limited to cancer care alone, all the more pressing. The challenge Lawler et al. began to touch upon is broader still and goes beyond a “geriacentric” strategy, to the full scope of an ageing society.
Rapid Response:
Re: Ageism in cancer care
Lawler et al. signal a very relevant and timely topic, i.e., the seeming inequality in cancer treatment administered to elderly as compared to younger individuals with similarly advanced disease. [1] Also, they note several relevant issues such as the demographic transition and the lack of evidence for ‘ageism’ solely based on calendar age, or in fact properly designed clinical studies to either corroborate or challenge the present practice across many countries. However, fundamental issues that should be part of the equation of clinical decision making are not really alluded to.
First and foremost is the fact that with increasing age co-morbid conditions become rule rather than the exception. These may very well determine the prognosis and overall survival. Thus deciding on treating or not, and if, how to treat is not straightforward. One should first decide on what outcome to optimize. Is this going to be disease free survival or should an outcome less alien to individuals such as functioning and well-being be considered. Without first addressing this challenging yet prominent ‘geriatric’ question the entire discussion looses solid ground as no one can judge whether the current practice variation reflects a ‘common sense’ of optimizing quality survival time or indeed under-treatment. Importantly, should one decide to take the shortcut and simply treat regardless of age and co-morbidity, overtreatment, squander and transgressing the ‘primum non nocere’ might be the result.
Next, more or less related is the issue of optimizing the return on investment of scarce resources. All over the world, and particularly in the Western part that is in the privileged position to even be able to consider prescribing increasingly costly personalized cancer treatment, one recognizes the fact that the costs of health care are rising at a pace surpassing that of the GDP by at least two-fold, and therefore non-sustainable. [2] Clearly without simply pleading for crude and simplistic budget cuts, scarce public resources have to be consumed such that the balance between costs and effects reflect our equitable societal values.
The demographic transition makes these issues, which a propos are by no means limited to cancer care alone, all the more pressing. The challenge Lawler et al. began to touch upon is broader still and goes beyond a “geriacentric” strategy, to the full scope of an ageing society.
References:
1 Lawler M, Selby P, Aapro MS, Duffy S. Ageism in cancer care. BMJ 2014;348:g1614
2 Health: spending continues to outpace economic growth in most OECD countries. http://www.oecd.org/newsroom/healthspendingcontinuestooutpaceeconomicgro...
Competing interests: No competing interests