Health Articles

Attitudes toward the older patient have affected the management of cancer. Many health care professionals associate chronologic age with poor prognosis, cognitive impairment, decreased quality of life, limited life expectancy, and decreased social worth. Thus, the elderly receive less screening for cancer, less staging of diagnosed cancer, less aggressive therapy, and often no treatment at all.
In the elderly, mammography, breast self-examination, and thorough clinical breast examination are performed less often than recommended. Likewise, prostate examination and stool guaiac testing are not performed yearly on most elders. Also, older patients may attribute the symptoms of cancer to the aging process, delaying medical attention even further. When older patients do seek medical attention, physicians tend to pursue a diagnosis less aggressively than they would with younger patients. Thus, for these reasons alone, the higher mortality rates among the elderly are not surprising. Screening for cancer in the elderly should follow the guidelines in TABLE 20-1.
Diagnostic and treatment decisions should not be based on a person’s age alone. However, age-related reductions in organ function—including losses in renal, pulmonary, and immune function—and the patient’s ability to tolerate procedures and treatment must be considered. Treatment regimens and dose adjustments should be based on physiology, health status, and the patient’s wishes, not age alone.
Currently, older persons receive treatment less often than younger people; when older persons do receive treatment, often it is less aggressive. One reason is that the risks associated with aggressive therapy and the best modifications to standard protocols when applied to the elderly are not fully understood. As a result, a great need exists for basic and clinical research of cancer in older persons to guide clinical practice. Another reason is that older patients may decline diagnostic and therapeutic procedures because they do not understand the advances in medical care and believe that cancer is hopeless. Sometimes, the decision to forgo treatment or to accept less aggressive treatment is appropriate. Patients and families should receive honest, detailed explanations of the risks and benefits along with advice on support programs such as family counseling, group counseling, and home health care services.

Whether the increased incidence of cancer in the elderly results primarily from the biological changes of aging or from prolonged exposure to carcinogens is not known. Observations support both theories. Age-dependent decreases in mitochondrial activity lead to an impaired ability to fight cancer. Changes in the immune system, often called immune senescence, include decreased interleukin-2 levels, decreased T-cell function, and impaired mitogen responsiveness, which are thought to lead to a decreased ability to recognize and destroy cancerous mutations at the microscopic stage. Decreased immune function may also place older persons at risk of viral infections that lead to cancer, such as Kaposi’s sarcoma and lymphoma.
However, prolonged exposure is also likely to play a role. Some cancers (eg, gastric, lung, skin, colon) are clearly related to exposure to carcinogens. These cancers rarely occur in younger adults, and when they do, exposure has usually been extraordinary or a genetic defect has impaired the ability to detoxify the carcinogen. Moreover, the incidence of these cancers, even within the elderly population, has been closely associated with the duration and degree of exposure to toxic substances.

The probability of developing cancer increases rapidly with advancing age. More than 50% of new cases of cancer and 67% of all cancer deaths occur in people > 65 yr. The enormous, cumulative lifetime risk of cancer and the impact of cancer in the rapidly growing, older population suggest a forthcoming major health care problem.
In the past 20 yr, the incidences of lung, breast, and prostate cancer; malignant melanoma; and non-Hodgkin’s lymphoma have increased. Until age 50, the incidence of cancer is higher in women, but after age 60, the incidence increases remarkably among men (see FIG. 13-1). However, lung cancer, common in elderly men, is becoming increasingly common in women. In the USA, it is the leading cause of death from cancer among women, killing more women than breast cancer.
Because of the increased incidence and prevalence of cancer in older persons and the high mortality rate from cancer, some have implied that little progress has been made in the fight against cancer in the USA. This is not true. But the major advances have benefited children and younger adults. The cure rates are high for acute leukemia in children, testicular cancer, and Hodgkin’s disease; among persons < 55 yr, all cancer mortality has decreased by 23%. In contrast, among persons > 55 yr, cancer mortality has increased by 17%. Survival rates are lower in older adults than in younger adults for most types of cancer, even within the same stage at diagnosis.