The Flip Side of Longer Life As Population Ages, Number of Elderly Cancer Cases Expected to Increase

It’s a trend generally spoken of in positive terms: people are living longer than ever before, both in the U.S. and worldwide. In industrialized nations, that’s partly due to advances in medical care that helps people survive many years with chronic diseases that would have killed them much sooner in past decades.

But there’s a wrinkle — specifically, the prospect that many elderly people will contract diseases, such as cancer, at a late age that they would not have faced had they died younger. In fact, the World Health Organization (WHO) recently warned that the number of people age 65 or older living with cancer will nearly double between now and 2030. And that poses an intriguing challenge to health care systems worldwide.

“There are not enough health care professionals who have skills and knowledge in both cancer and the best care and treatment for the elderly,” said Kathy Redmond, editor of Cancer World, in announcing the findings. “There is still far too much complacency on this issue.”

“Certainly, there’s an increased incidence in older patients of a lot of common cancers, including breast, colorectal, and prostate,” said Dr. Wilson Mertens, medical director of the Baystate Regional Cancer Program in Springfield.

That’s going to place a burden on health care, partly because — and this is certainly the case with breast cancer — we have well-worked-out treatment algorithms for younger women, but, generally speaking, very few women over age 70 have been included in clinical trials for therapies.”

That could pose problems if, as the WHO predicts, new cancer cases increase worldwide from just under 11 million in 2002 to 16 million in 2020 — with senior citizens expected to account for a steadily increasing percentage of all cases.

When to Treat?

Because so many models of cancer treatment have been built with younger people in mind, it takes an extra level of communication and medical wisdom to steer them toward ideal treatments, doctors say.

“We also have a problem with professionals who often look at older patients and make a judgment that it’s not worth it, that they won’t be able to withstand treatment,” Mertens said. “The difference for older patients is that with advanced age, there’s also increased incidence of other frailties and infirmities, such as heart disease, vascular disease, and impaired kidney function.

“While the treatment algorithms are not particularly different from in older and younger patients,” he explained, “how we can treat a cancer patient is sometimes limited by other health issues — and older patients are frequently more limited than younger ones.”

Many times, it’s not a patient’s health that’s the deciding factor in what kind of treatment to pursue, but how the different options fit into what the patient considers to be a fulfilling life.

“When we talk with elderly people about cancer, what comes up is the idea of aggressive treatment,” said Dr. Steven Schonholz, medical director of the Breast Care Center at Mercy Medical Center.

“A lot of them have already seen their friends go through chemotherapy, they know what kind of life that is, and that it could end up killing them, and many of them prefer not to,” he continued. “They’re 70, 80, 90 years old, and they’re thinking, ‘I’ve had a good life, and to extend it a couple of years like that may not be worth it to me.’ We’ve seen a lot of people deciding ahead of time not to have chemotherapy, not to have any treatment, or just a surgical procedure but no chemotherapy.”

In other cases, doctors are dealing with a elderly patient who has trouble with memory or understanding — or even Alzheimer’s.

“We can do the surgery, but when it’s over, they might not remember, or be confused about what’s going on,” Schonholz said. “A lot of times, that becomes an issue for the family: ‘why am I going to put my mother or father through this when they won’t know what’s going on?’”

In many cases, he said, patients or their families opt for some treatment — perhaps surgery to remove the tumor — but don’t pursue the same aggressive post-surgical regimens that are routine for younger patients.

But he agreed with Mertens that doctors and patients must consider the possibility that an elderly person’s other medical conditions — heart disease, for example — might be more serious and potentially life-shortening than the cancer.

“Undertreatment is sometimes the right decision, where it wouldn’t be for a younger person or an 80-year-old with no other medical problems,” Schonholz said. “A lot of family members say, ‘I can see my relative passing away from their other medical problems, so let’s just follow it to see what happens.’ It’s no longer true that if you have 1, you do 2, and if you have 2, you do 3. Not every operation is appropriate for every patient.”

Lack of Awareness?

In her discussion of the WHO report, Redmond asserted that the elderly have a host of obstacles to cancer care specific to advanced age — for instance, non-adherence to oral, long-term therapies.

“There’s an enormous lack of awareness about the scope of non-compliance in cancer,” she said. “The elderly are at higher risk because they are more likely to have literacy and memory problems, and less likely to receive comprehensive information about their treatment.”

In addition, she claimed, an increasing number of elderly people are living in isolation and lack the social networks of family and friends that can help ensure that drugs are properly taken, and added that persistent negative attitudes toward the elderly, what she called “ageism,” result in less-than-optimal care and otherwise healthy cancer patients dying unnecessarily.

Of course, Redmond was addressing the issue from an international point of view. From what he knows about American health care, Schonholz doesn’t totally buy some of those views.

“I think people are coming in more educated, including the elderly, and they’re able to look at things from personal experience. When people come in, they have an idea what’s going on,” he said. Furthermore, “family is usually a big part of it, but from what I’ve seen, most people living on their own are doing pretty well, and they’re coming in with their own opinions. They understand the options.”

Those options are becoming more sophisticated, but so are many patients. Recently reported statistics suggest that rates of some cancers have been reduced due to more diligent screening — and more awareness by patients in general. But Mertens admitted that as senior citizens take up a larger slice of the population pie, late-in-life cancers will counterbalance that trend, placing added burdens on the health care system.

“Therapies are becoming more sophisticated and, therefore, more expensive,” he said. “Part of that cost is technology and facilities, but it’s also manpower.” He explained that recent workforce analysis reports suggest that over the next 10-12 years, a gap will develop between the number of medical oncologists and demand for their services. “There are going to be some real challenges.”

Cancer, after all, remains a scourge at any age.