Silver Survivors: How do we Know if People are 'Too Old' for Cancer Treatment?

Cancer is primarily a disease of older age. Six in ten new cases each year in the UK occur in those aged 65 years or over,^[1] and 13% of the total UK population aged 65 years or over have been diagnosed with cancer at some point in their lives.^[2] However, while cancer mortality rates fell by 16–17% between 1995 and 2005 for under 75-year age group, they reduced by only 6% in the 75–84-year age group and actually rose in the over 85-year age group.^[3] Relative survival also decreases with increasing age at diagnosis for the majority of cancers. The average relative 5-year survival in England for the top four most commonly diagnosed cancers in the UK (breast, lung, prostate and bowel) decreases from 64% among those aged 60–69 years at diagnosis to 57% among those aged 70–79 years, and 42% among those aged 80–99 years.^[4] Furthermore, relative 5-year survival among those aged 65 years or over is 14% lower in the UK compared with the European average.^[5]

There are many factors that contribute to these poorer outcomes. Later presentation is a recognized problem.^[6] Older patients may be less aware of some cancer symptoms,^[7] wait longer before reporting them and may not know that age increases the risk of cancer. For example, in one study, 75% of women aged 67–73 years did not know that the risk of cancer increases with age.^[8] Older people with cancer also have an average of three other morbidities,^[9] which both mask symptoms of cancer and complicate treatment. Nevertheless, at least part of the reason for poorer outcomes is related to the types of treatment older people with cancer in the UK do, or do not, receive.

A survey of 101 UK oncologists found that while 81% would prescribe chemotherapy for a high-risk breast cancer patient aged 68 years, only 47% would recommend the same treatment for an otherwise identical patient aged 73 years.^[10] A difference of just 5 years suggests oncologists would be 42% less likely to recommend radical therapy. This is not just a hypothetical issue: women aged 85 years or over in England are 82% less likely to receive surgery for operable breast cancer than women aged 70–74 years, after adjusting for overall health and patient choice.^[11]

Of course, decisions not to treat an older person with cancer are often justifiable from a medical point of view – overtreatment is as undesirable as undertreatment – but an oncologist's assessment about a patient's ability to tolerate treatment or what their quality of life will be afterwards cannot be based on chronological age.

There is growing evidence that, in many cases, older people can both tolerate and benefit from the same treatments as younger patients with the right package of assessment, information and support. A recent study of 4775 women receiving anthracycline-based chemotherapy for primary breast cancer showed that although some side effects did increase with age, the majority (73%) of women aged 65 years or over completed their course of treatment and the researchers concluded that all age groups studied were able to cope with the chemotherapy regimens.^[12] A study of 568 men aged 46–89 years who received docetaxel treatment for advanced inoperable prostate cancer showed no significant difference in tolerance, toxicity or overall survival up the age of 80 years.^[13]

Oncologists should not make assumptions about personal preferences based solely on age. One septuagenarian may be bed-bound, while another is planning to run a marathon – or even playing in a rock band for 2 h in front of a crowd of thousands, in the case of the 70-year-old Mick Jagger.

With the right treatment and care, many people diagnosed at 65 years or older can live for years with cancer. Today there are more than 130,000 people living in the UK who have survived for at least 10 years after being diagnosed at the age of 65 years or over. Perhaps more remarkably, there are 8000 people who have lived for at least 10 years after being diagnosed with cancer at the age of 80 years or over.^[14] However, if survival rates for older people in the UK were improved, these numbers would be even higher. So how can we improve outcomes for older people with cancer?

The lack of older people in clinical trials of cancer treatment is a significant issue. Without further evidence that older people can tolerate current treatment regimens, the oncologists who are more reluctant to recommend these treatments are unlikely to change their approach. We also need better follow-up data in studies involving older people, including patient-reported outcome measures and measures of social functioning. While treatment may be initially tolerated, small changes in cognitive function, continence and mobility can have a significant impact on long-term quality of life. Persistent treatment-related symptoms, such as fatigue, can be particularly tough for older people and can be unexpectedly difficult to manage for the previously fit, who lose confidence in their physical and mental abilities. In addition, general improvements to routinely collected data, such as stage at diagnosis, would enable better population-wide comparisons between age groups.

Older people may be more likely to have other problems such as social isolation, difficulties getting to and from hospital, financial difficulties and concerns looking after pets. Recognizing and addressing these nonmedical issues may have a significant impact on the likelihood of older patients taking up cancer treatment and recovering well after it. Oncologists and cancer surgeons also need more support to both recognize and manage medical issues specific to older people in general rather than just cancer, such as falls, incontinence and multidrug use. In a survey of 64 oncology trainees, 66% reported that they have never received any training in the particular needs of older people with cancer.^[15]

Ideally, a thorough individual holistic assessment should be provided as standard for everyone with cancer, but particularly for those of older age. Using a tool such as the Comprehensive Geriatric Assessment would help ensure more people are assessed for treatment based on their general fitness, not their chronological age. These have proved challenging to introduce into oncology multidisciplinary team assessments but there are now several short-form tools available as a first step.

We are increasingly recognizing that people are never simply 'too old' for anything, not even cancer treatment. They may be too frail, or too burdened with other morbidities, or choose not to put themselves through potentially grueling regimens, but chronological age alone can no longer be used as the basis for treatment decisions. Cancer does not discriminate, and neither should oncologists.

Future Oncol. 2014;10(11):1811-1813. © 2014  Future Medicine Ltd.