By Jeanne Erdmann

As we age, our risk of cancer increases. In fact, age is the single biggest risk factor in developing cancer.

According to the most recent data from SEER, one fourth (25.4%) of new cancer diagnosis occurs in people aged 65 to 74, and 19.5 in ages 75 to 84. These numbers hold true for the most common cancer types, the median age at diagnosis breast, lung, colorectal, and prostate cancers ranges from age 61 to age 70. Older adults also have the highest cancer mortality rate, are more likely to die from the toxic side effects of treatment – and they are underrepresented in clinical trials assessing cancer treatments.

Some cancer treatments may be too harsh for aging bodies, especially those older cancer patients who may already suffer from complex medical needs by the time cancer settles in. Cognitive issues, diabetes, high blood pressure, cardiovascular disease, and problems with vision and hearing are all issues that can make the decision to treat more difficult and can worsen with cancer treatment.

On the flip side, because of improvements in cancer treatment and follow-up care, a greater number of older adults are surviving cancer. Yet, there isn’t much research on how to care for older cancer survivors, who may also suffer from comorbid conditions.

Another barrier for older adults facing cancer is physicians’ attitudes. In a review in Cancer Biology & Medicine, the authors concluded that some physicians may undertreat an older person with cancer because aging stereotypes from the past may still cause doctors to perceive older adults as too frail for cancer treatment.

Complicated treatment decisions

For cancer patients of any age, treatment boils down to risk assessment – finding a treatment that gets rid of the cancer without harming patients. While cancer patients of any age can face side effects that range from uncomfortable to life-threatening, older patients could indeed survive cancer only to suffer lasting side effects that destroy their quality-of-life or threaten their independence.

For starters, oncologists need to ask a patient his or her goals: Whether a patient wants a cure with lifestyle intact or wants to live long enough to attend a wedding or for the birth of a grandchild.

There are also a significant number of issues to consider:

• Whether and how any comorbid diseases would complicate treatment and recovery
• How long recovery from treatment will take
• The number of medications a patient may be taking and whether any of the medication could interact with treatment
• How to manage pain from cancer or the treatment, and also the emotional impact of chronic pain from treatment on patients and their caregivers
• How to manage emotional barriers to treatment, such as depression and anxiety
• Identifying and solving access barriers to treatment – Whether the patient lives alone, or in a nursing home; can drive; whether there are stairs in the home. For example, a 2017 study on a type of lung cancer showed that elderly patients in the UK were three times less likely to receive recommended treatment because of lack of access.
• Whether or not surgery is needed
• Whether or not to treat patients in nursing homes, as this population tends to have more comorbid conditions than those who live alone. A study published in JAMA Surgery in December 2018, followed 6,000 women who underwent a lumpectomy for breast cancer (the most common cancer surgery performed on nursing home residents), and the women in nursing homes had a higher 30-day mortality and functional decline.
• Post-hospital syndrome needs to be taken into account – elderly patients are at risk of spiraling down in the weeks following a hospital stay that puts them at risk of readmission.
• Whether or not people over age 65 undergoing treatment should get the influenza vaccine at the high dose versus the standard.

There are also cancer disparities that fall along the lines of racial and socioeconomic issues. For instance, the efforts to reduce disparities in older African Americans have been taken up in the COACH study, which tested whether health coaches can better help through the cancer spectrum from prevention to diagnosis and treatment.

In addition to all of these issues, the amount of social support needs to be taken into account, such as whether the patient has friends or family who can offer emotional support and help with day-to-day chores, such as meal preparation and house cleaning.

Older cancer patients are more at risk of complications from treatment. Cancer’s physical and emotional stress in older adults can be addressed with palliative care and by addressing the spiritual needs of older cancer patients and their caregivers, can improve emotional healing and help patients stick with treatment plans and improve quality of life.

For those who won’t survive, end-of-life care can ease the transition to death for both patients and their families.

Fighting Mother Nature and Father Time

Cancer risk increases as we age, because over time cells can accumulate enough genetic damage to bypass safeguards and divide out of control, keeping them forever young even as our bodies age. To make matters worse, some cancer treatments may accelerate biological aging because they also damage normal cells.

Speaking of age, our biological age may not necessarily match the age listed on our driver’s license. Physiologically we can be younger or older depending on many factors, including fitness level and nutritional intake. Researchers are looking for biomarkers of aging that could help make treatment decisions for older adults with cancer. This study looked at whether damage to telomeres and DNA in women who had been treated for breast cancer could predict cognitive issues following cancer treatment.

Researchers are also looking to a rare, genetic disease called Hutchinson Gilford Progeria Syndrome, which is marked by accelerated aging but also may be protective against cancer.

Geriatric assessments 

For now, one test designed to assess frailty and predict mortality may be able to help oncologists develop treatment plans for older patients. A Comprehensive Geriatric Assessment (CGA) can encompass cognitive status; nutritional status; the ability to exercise; the number of medications and any adverse reactions to the medications.

The assessments sort out geriatric syndrome, which can include fall risk, frailty, normal muscle loss with aging versus sarcopenia, nutritional status and whether the person already suffers from cachexia, which is a poor marker for survival but can be prevented. They also can assess whether older people with cancer can withstand an exercise program otherwise shown to help people with the disease.

The International Society of Geriatric Oncology (SIOG) recommends geriatric screening to help guide cancer treatment decisions in older patients and identify where people are most vulnerable. CGA’s can take time, and are not part of routine oncology visits, but don’t need to be performed by doctors. They can be done by a trained nurse or a physician’s assistant.

For example, some clinical trials are underway to determine which CGA works best for cancer treatments. One study concludes that geriatric assessment can help optimize prostate cancer treatment among older men.

Survivorship issues among older adults also bring complications, depending on the many factors that complicate treatment, such as overall health and social support.

Researchers are testing web-based programs to determine the best way to follow-up with older cancer patients, such as how to detect problems with mobility that may begin between visits with their oncologist.

Finally, oncology teams, doctors, nurses, nutritionists and social workers may not have specific training in gerontology. In October 2018, FDA and ASCO published the proceedings of a workshop held to help address the lack of clinical research on older adults with cancer.

ASCO last year also published guidelines aimed to assess and manage vulnerabilities in older patients receiving chemotherapy. A study showing that health-related quality of life in women with breast cancer can be as effective in predicting mortality in a 10-year prognosis as cancer state and chemotherapy.

Resources

• The biological underpinnings of aging and cancer have a lot in common. The field of geroscience aims to understand at the genetic, cellular, and molecular level how the processes that makes us age also drive diseases such as cancer. The National Institute on Aging has an initiative to encourage interest in the field across NIH institutes and centers.
• Cancer statistics, incidence, mortality, prevention, and so on, can be found in the first part of Wiley’s Annual Report to the Nation on the Status of Cancer. The American Cancer Society Facts and Figures also provides such statistics.
• The Cancer and Aging Research Group (CARG) aims to pull together geriatric oncology researchers across the U.S. The site includes a tab listing ongoing clinical trials.
• In this interview posted on the NCI’s website, Supriya G. Mohile, director of the Geriatric Oncology Research Program at the University of Rochester’s Jane Wilmot Cancer Center, covers the unique challenges faced by older patients and their caregivers, as well as efforts to encourage doctors to choose the field of geriatric oncology.
• ASCO has a lot of online resources for older adults and cancer. This link details the challenges facing a cancer diagnosis in older adults.  This clinical review from the ASCO journal explains how geriatric assessment can guide treatment decisions for older cancer patients. The Thinking and Living with Cancer study follows long-term cognitive effects of breast cancer treatment.
• This NCI blog post also details some of the issues faced by older adults with a cancer diagnosis.
• This blog post from Dana-Farber Cancer Institute goes into greater detail about why cancer risk increases as we age.

Sources

• Supriya G. Mohile, director of Geriatric Oncology Research Program, University of Rochester’s James Wilmot Cancer Center; Supriya_mohile@urmc.rochester.edu
• Lodovico Balducci, medical director of affiliates and referring physician relations and program leader of Senior Adult Oncology at Moffitt Cancer Center, also professor of Oncologic Sciences at the University of South Florida; Lodovico.balducci@moffitt.org
• Holly Holmes, geriatrician at the University of Texas M.D. Anderson Cancer Center; Holly.M.Holmes@uth.tmc.edu
• Grace Lu-Yao, associate director of population science at the Sidney Kimmel Cancer Center, and vice chair of population science in the Department of Medical Oncology at Thomas Jefferson University; Grace.LuYao@jefferson.edu
• Hyman Muss, M.D. a pioneer in the field of geriatric oncology and a translational researcher at the UNC-Chapel Hill School of Medicine Breast Cancer, Geriatric Oncology Program, also holds the Mary Jones Hudson Distinguished Professorship in Geriatric Oncology; muss@email.unc.edu

Jeanne Erdmann (@jeanne_erdmann) is a health and science independent journalist specializing in cancer, genetics and aging.