Overscreening, Undertreatment Common for Cancers in the "Oldest Old"

By Marilynn Larkin

August 19, 2019

NEW YORK (Reuters Health) - Cancers diagnosed after age 85 are more likely to be found at a later stage - despite over-screening in this age group - and are less likely to be treated surgically, a large observational study reveals.

"The 'oldest old' are the fastest-growing age group in the United States, yet relatively little is known about their cancer burden," write Dr. Carol DeSantis of the American Cancer Society in Atlanta and colleagues in CA: A Cancer Journal for Clinicians, online August 7.

For the study, Dr. DeSantis and colleagues combined data from the National Cancer Institute, the North American Association of Central Cancer Registries, and the National Center for Health Statistics.

"We were surprised by the relatively high rates of cancer screening in this group," Dr. DeSantis told Reuters Health by email. "The primary purpose of cancer screening is to reduce the risk of premature death from cancer. Thus, individuals with other serious health concerns are less likely to benefit from screening, because they are more likely to die from something else."

"Furthermore, although serious harms from screening, such as gastrointestinal perforation, are relatively uncommon, the risks are much greater in those 85 and older," she noted.

More than half of the oldest old had received either a stool screening test within the past year or a sigmoidoscopy or colonoscopy within the past five to 10 years. Further, nearly 30% of men had received a PSA test within the past year.

Nonetheless, cancers in the oldest old are often more advanced at diagnosis. For example, breast and colorectal cancers are about 10% less likely to be diagnosed at a local stage compared with those diagnosed in patients ages 65 to 84.

"We also reported lower cancer survival in patients 85 and older," Dr. DeSantis said. "Even for colorectal and lung cancers diagnosed early (local stage), five-year cancer survival was 10%-20% lower in patients 85 and older versus 65-84."

"Although the overall cancer incidence rates are declining for men and women 85 and older, we observed rapid increases in the rates of melanoma, particularly among men," she added. "Melanoma will become an increasingly relevant cancer in this age group."

Study coauthor Dr. William Dale of City of Hope in Duarte, California, told Reuters Health in a separate email, "From a clinical care perspective, many older adults get late-stage cancer and die from it. To avoid discriminatory ageism, we should detect/screen and treat cancers based on health status or fitness using a geriatric assessment."

"We should not base clinical decisions primarily on chronological age," he stressed. "Most older patients are either overtreated or undertreated for their cancer because treatment decisions are based on chronological age. They should, instead, be treated based on their health status, which determines life expectancy."

"Even among people who are 85 or older, there is a wide range of fitness levels, with life expectancy ranging from three years for the least healthy 25% of the population to 10 years for the healthiest 25%," he noted.

"From a research perspective, it is important to include older adults in the clinical trials we conduct," he added. "With new changes in eligibility rules that are now encouraging the enrollment of older, less fit and more vulnerable patients, researchers need to design trials and enroll many more older patients in them to learn best practices. This is not currently being done very much, and almost never for patients over 85."

Another area of interest is "Why are the oldest old getting fewer surgeries when they have the same diagnosis as younger people," he said.

The team found, for example, that only 65% of breast cancer patients ages 85 years and older received surgery compared with 89% of those aged 65 to 84 years.

Age discrimination, appropriate decisions to avoid risky surgery, and personal preference of patients to avoid the consequences of surgery are possible reasons, Dr. Dale suggests.

Dr. Efrat Dotan, Associate Professor, Department of Hematology/Oncology at Fox Chase Cancer Center in Philadelphia commented in an email to Reuters Health, "In clinical practice, the increased number of older patients is evident on a daily basis. Furthermore, the challenges in caring for the oldest old are significant and would clearly explain the decreased rates of therapy provided to this population, as was demonstrated in this analysis."

"The recommendation for discontinuation of cancer screening in the oldest adults stems from the lack of clear benefit of these procedures among patients with less than 10 years of life expectancy," noted Dr. Dotan, who was not involved in the study.

"Accurate estimation of life expectancy in this patient population is challenging, leaving the decision for screening arbitrary at times, and based on the patient's wishes," she said. "More research is needed to understand the factors contributing to these high rates of screening and determining the appropriate schedule in this patient population."

"Cancer in patients over the age of 85 often develops in the setting of multiple other geriatric syndromes that directly affect the patient's care and outcome," she said. Therefore, like Dr. Dale, she concluded, "Only through (a comprehensive geriatric) assessment we can fully understand the patient's need and provide comprehensive care."

SOURCE: http://bit.ly/2Z7E24O

CA Cancer J Clin 2019.

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