We have an aging population, which is a good thing since people are living longer. [But] cancer is a disease that tends to occur most frequently in older people, so the combination of those two events will lead to many more older people with cancer, a larger cancer population in general, and a larger number of cancer survivors.
Both of those issues present a number of problems. It wouldn’t be a problem if older people were just the same as younger people, but we know from a number of studies that the very elderly differ from younger people regarding the number of comorbidities, physiology, and social and financial situations. So many of these properties will lead to the need for different approaches to their cancer treatment.
What social problems are associated with these issues?
For one, older people [often] live alone, and when they don’t live alone they often live with an older spouse. We often rely on caregivers for help in the care of patients, and in these situations you are dealing with an older caregiver as well as an older patient, which can result in substantial difficulties in management.
There are also financial issues [to contend with]. In the United States, for example, we think of older people being covered by Medicare, and while that is true, there are substantial copays required [in association with the program] and for many of the new cancer treatments, which are very, very expensive, those copays can exceed people’s ability to pay.
So I think there are many different issues that are going to have to be dealt with.
Are these problems being addressed in the United States?
People are starting to be more and more aware of them. I think the dynamics of the population change is finally beginning to dawn on people. People in both the oncology and geriatric communities have been recognizing these problems and are starting to work together to approach these issues.
This issue came to the attention of the Institute of Medicine (IOM), which recently issued a report1 specifically dealing with the issues that are going to come about as a consequence of an aging population.
Do you work as part of a multidisciplinary team?
Unfortunately, there aren’t as many of these types of clinical teams as are needed. But ideally (and in our program), we have geriatricians who work with oncologists who work with nurses and social workers and pharmacists, all of whom are geared to the care of the older patient. Everybody can weigh in with their expertise and come up with the best plan for both the medical treatment and social treatment [needed] in the care of the patient.
Do nurses need to be specialized when working with older patients?
It’s much like medicine in general. Certainly, in theory, all physicians should be able to deal with older patients as well, but many physicians haven’t been trained to be alert to specific characteristics. [For example,] older people may need specific attention to the disorders they get. And the same is true in nursing. So ideally we would like to have at least some people on these teams who have geriatric nursing experience as well as oncology nursing experience. Unfortunately, the workforce in those areas is diminishing, so that’s another cause of substantial concern: having the appropriate workforce and the appropriately trained workforce.
Do you see a change in the number of older patients in clinical trials?
Traditionally, older people have not been [enrolled] in [clinical trials] because of age exclusions. More recently, those exclusions have been removed, but there are still relatively few [older patients] represented, in part because they just aren’t referred for entry into these trials. Many older people don’t get to the oncologist, who is usually the route for entry into these trials. This is something that is of substantial concern and one of the actions that the IOM called for—that is, increased attention to enrolling older people, roughly in proportion to their presence in the population in clinical trials. Hopefully, there will be some change on the horizon, but we will have to wait and see. ■
Disclosure: Dr. Cohen reported no potential conflicts of interest.
Harvey J. Cohen, MD, is Walter Kemper Professor of Medicine, Director of the Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
1. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Institute of Medicine. September 10, 2013. Available at www.iom.edu.
aAdapted with permission from an interview conducted by eCancer Conferences at the 2013 International Society of Geriatric Oncology conference in October. To view the full interview and others, visit ecancer at http://www.ecancer.org.
ecancer is an online oncology channel supported by the ECMS Foundation (ecancermedicalscience). The Foundation was established by Professor Umberto Veronesi and Professor Gordon McVie as an independent, not-for-profit organisation with charitable status to fund the speedy dissemination of cancer information. ecancer is Published by Cancer Intelligence Ltd, England and Wales.