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Older and wiser about cancer


The population of Northern Europe is aging and this means an increase in cancer diagnoses. Is this good news or bad?

People over age 65 have a ten-fold higher risk of cancer than people under age 65. But cancer in older people is more complex than that number. For example, some leukemias are more aggressive but breast cancer appears to be less aggressive in older people. In addition, under treatment of elderly patients is a known problem that affects cancer mortality statistics. The complicated issue of cancer in older people is a priority for researchers, clinicians, and social scientists as the population ages in developed countries.

“The demographic shift is good news, in a way,” says Christoffer Johansen. “It’s the result of success in treating cardiovascular disease, diabetes and other chronic conditions.” Johansen is a professor of oncology at Rigshospitalet and head of the Survivorship Research Unit at the Danish Cancer Society. The flip side of a longer lifespan, however, is more cancer patients with comorbidities, which is the clinician’s term for pre-existing conditions. Comorbidities influence cancer therapy because the drugs for other conditions can interact with cancer treatments and vice versa. In addition, some elderly patients are deemed too frail to tolerate cancer medications, complicating their treatment decisions.

In fact, developing cancer guidelines for older people is particularly complex, not only because of frailty and comorbidities. Few clinical trials measure the effectiveness of drugs and devices in older people so knowledge about therapies in this population is poor. Arvid Widenlou Nordmark is a program officer for the Swedish National Board of Health and Welfare. He manages the development of evidence-based treatment guidelines based on expert review of the clinical literature. Widenlou Nordmark says his goal is quality care for everyone regardless of age, sex or other factors, including providing guidelines about cancer screening and care for older people. “However,” he says, “most studies are done in relatively healthy younger people so it is hard to get evidence for recommendations about older people.”

Research solutions

Widenlou Nordmark suggests, “The medical industry could do more studies on how different age groups tolerate drugs, on the balance between effects and harms in this population.” Randomized controlled clinical trials in older populations face a catch-22, though. We need evidence about treatment in older patients because they are likely to have comorbidities, but comorbidities complicate clinical trials because the analyses must consider the effects of pre-existing conditions. One solution, says Widenlou Nordmark, is studies that get data from medical records and registries, for example the clinical notes that providers use to track a patient’s treatment. Researchers can conduct observational studies using these data to see what happens when, for example, patients over age 65 receive a particular treatment. However, since these studies do not control who gets a certain treatment, their results can be biased if patients tend to get or avoid a treatment based on factors other than those considered in the study.

Social solutions

Widenlou Nordmark offers another solution: prevention. “Society can do a lot to reduce the expected increase in cancer,” he says. ”We can try to prevent smoking, get people to eat the right food and be more active.” This is an area where Johansen has expertise. Some of his research is in rehabilitation for cancer patients, which often involves lifestyle changes. Older people can already have a complicated program of chronic disease management, he says. “And life gets even harder if you’re also expected to change your diet, not smoke, and moderate your alcohol intake.” Any health programs that involve lifestyle changes, says Johansen, must consider the patient’s point of view. Too often, he says, clinical researchers designing health interventions don’t consider challenges for older people, for example, the difficulty of using a fitness center where everyone is young and fit. “Health programs won’t be effective unless patients comply with them,” he says.

The aging population and the trend for people of all ages to live alone, which reduces family support for medical care, means it is time for a major cultural shift, says Johansen: “We must get away from thinking that we can prescribe our way out of disease. We have a new situation with the aging population that requires more patient engagement.” The need for patient involvement fits the current demographic, he says. As people who grew up in the activist 1960s and1970s age, they are likely to demand participation in medical decisions. This trend will require good communication by both patients and doctors. Widenlou Nordmark seconds the need for patient-centered programs. “Age on paper,” he says, “should not decide a person’s treatment. That should be based on potential effects and harms for that person.”