The Vulnerable Zone: Adjusting Care for Older Patients With Cancer

Jim O’Connell was pushing 88 when he realized something might be amiss. Though he walked to church every day and was healthy enough to do his own yard work, his gut wasn’t quite right. And he was losing weight.

But the unnerving thing that happened next at the doctor’s office was not a diagnosis. It was that his doctor — without a clear explanation — refused to perform the colonoscopy that could have helped determine what was wrong. In O’Connell’s opinion, he was simply sent away, presumably because of his age.

He’d been treated for prostate cancer in 1999 and had acquired a pacemaker, but the retired phone company lifer was otherwise quite fit. Now 91, he still does all of his own yard work. Three times a week, he and Ann — his wife of 66 years — head to Centennial Park near their home in Ellicott City, Maryland, for a more strenuous amble. Ann O’Connell now calls their decision to see a geriatric specialist “the best choice we ever made.” Jim had a real problem — or, more accurately, two: a pair of cancers, one in his esophagus, the other in his rectum. But while his previous doctor wouldn’t even risk a thorough examination, his new team quickly moved on the esophageal cancer, excising the tumor. When he recovered quickly from that surgery, they moved directly on to remove the rectal tumor.

“I was prepared for the worst,” O’Connell says now, almost three years later. He knows that not everybody in his situation would consent to such aggressive steps. “But I don’t think that I ever thought that I would not do treatment.”

O’Connell is part of a growing American population of older people that demographers are calling the Silver Tsunami. Now entering that group are the oldest members of the Baby Boom generation, who are nearing the age of 70. Baby Boomers have remodeled major sectors of the American economy, from education to housing, as they have hit new life milestones. Now, it’s oncology’s turn.

The math is fairly straightforward: Half of cancers — and 70 percent of cancer-related deaths — occur in patients 65 years of age or older. And over the next decade, the number of Americans over 65 is expected to swell from 47 million to 65 million.

“Medical care — cancer care — is going to be overwhelmed by the number of older people coming into the system,” says Jimmie Holland, 87 and still a practicing psychiatrist at Memorial Sloan Kettering Cancer Center in New York City.

Even as shortages of geriatricians and oncologists are expected, current researchers are actively seeking to transform cancer care for the elderly — with a little help from patients like Jim O’Connell. Twenty years ago, doctors hesitated before using aggressive treatments like chemotherapy on patients in their 70s. Although studies show that there’s still some reluctance about giving such treatments to older patients, that threshold has generally been moved back a decade.

The trend has not been driven much by research from clinical trials, in which people over age 70 are underrepresented, but researchers have been tracking trends in the treatments given to older patients, along with the resulting health outcomes. And the engagement of older patients in their own care has certainly helped.

The Vulnerable Zone

“The older population used to be on the back burner, kept quiet,” says Ilene Browner, a geriatric oncologist at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University. Now they’re “very proactive, very educated, very motivated. They come into the office with piles of papers and research trials. It’s a very different population. They self-advocate.”Cancer is a disease of aging, but there are other common health conditions that accumulate as the decades tick by: The likelihood of developing hypertension, heart problems and diabetes all tend to increase with age. Among Americans aged 60 to 79 years, more than 70 percent have some form of cardiovascular disease. “When you get into the late 70s and 80s, it’s rare to find somebody who has cancer and nothing else,” says Martine Extermann, a specialist in geriatric oncology at the H. Lee Moffitt Cancer Center at the University of South Florida. On average, she says, a patient in his or her 70s has three diseases, not including cancer.

There are always outliers, like John Glenn, who was healthy enough to soar into space at age 77. And there are the obviously frail elderly, confined to a wheelchair. “For that person, going to the bathroom is a space expedition,” says Extermann.

In between is the vulnerable zone. These patients are still functioning pretty well, but their reserve is decreased. Subject their body to the stress of chemotherapy or major surgery and you may risk revealing these thin stockpiles. Recognizing such patients, and tailoring treatment to avoid a crash, is the challenge. Doctors have a special term for a patient’s collection of ailments: comorbidities. Generally, these present a special challenge to cancer treatment. Most important is the severity of the conditions. But bring three or more comorbidities to the table and your chances for a good outcome start to erode — regardless of the severity of those problems.

Recent studies show that doctors’ long-held reservations about using aggressive cancer treatments on patients strictly due to their advanced age were, in general, unnecessary. Older patients who are fit withstand these treatments just as well as their younger counterparts — perhaps with a bit more monitoring for toxicities — and experience similar health outcomes, Extermann and colleagues explained in one 2012 study. And 2013 research out of Harvard University showed that people are not only living longer lives than they did in previous decades, but are remaining healthier for longer — until a couple of years before their deaths.

Nevertheless, older age is much more likely to lead to undertreatment for cancer than is the presence of an additional illness, according to a study from the same year, led by Sunny Wang of the San Francisco Veterans Affairs Medical Center.

That doesn’t mean, though, that comorbidities are ignored in decisions about how aggressively to treat patients for cancer.

According to a review paper by researchers in Denmark that was published in 2013, which looked at the results of 2,500 studies, people with both cancer and comorbidities had a survival rate one to six times worse than that of people with cancer and no comorbidities. The studies found that those with comorbidities were less likely to be treated with surgery, chemotherapy or radiation or to finish a course of cancer treatment, but it wasn’t clear whether that was the result of patient preference, poor clinical care or careful consideration of toxicities.

From a doctor’s perspective, Browner says, it doesn’t always make sense to use treatments that will cause more physical problems in people whose daily activities are already compromised. Further, patients with many or severe comorbidities are not as likely to benefit from aggressive treatments, Extermann and colleagues found in their 2012 study.

Jim O’Connell was in his late 80s when he successfully weathered two surgeries to remove cancer. [Photo by Brian Schneider]

Imagine a patient with hypertension, a little diabetes, some arthritis and some gastroesophageal reflux disease. By and large, the conditions may be well-controlled, with careful attention to lifestyle factors like diet and exercise, and perhaps a prescription or two.

But pile onto that the stress of a cancer diagnosis, the shock of surgery and the challenge of follow-up chemotherapy. “When you perturb the system, suddenly those comorbidities may have less control,” says Browner.

For example, patients with diabetes may already have peripheral neuropathy — a loss of some feeling or precise control in their extremities. Many cancer medications can also induce neuropathy. Suddenly, the patient can’t get as much done around the house, can’t move as well and may be at an increased risk for falls. “In an older patient, these issues become much more pertinent,” says Browner.

On the other hand, an older patient who is fit and motivated to undergo treatment can be a good candidate for standard therapy.

Extermann recalls a recent visit with an older patient who had severe diabetes and had recently lost a foot to amputation. After reviewing the patient’s full record, she’d concluded that she wouldn’t be recommending aggressive treatment. But when Extermann entered the room, she was greeted by a woman who couldn’t wait to learn to walk again on her prosthesis. “I want to live until I’m 120,” she declared.

“Time to re-adjust,” Extermann says. “Age is only a number. You have to figure out what the patient wants. What is their objective in life?”

The more relevant number to factor into treatment decisions is life expectancy. Most people think about life expectancy as a number that you get at birth. But it’s really a moving target — the older you get, the older you’re likely to get.

“When somebody reaches the age of 70, they are survivors and, as a group, they have a better prognosis,” she explains. “When I tell my 80-year-old patients that, if they are healthy, in most cases they’ll live past 90, they are very surprised, usually.”

The Emotional Component

Ultimately, a simple interplay between life expectancy and comorbidities governs many decisions. If a man has low-grade prostate cancer that, if left untreated, might cause problems in 10 years, and a heart condition likely to kill him in five, there is simply no reason to treat the cancer.In 1969, Mary Andrade fled a bad marriage for the promise of New York. “I came here with two babies and three suitcases,” she says. It’s a line she’s clearly said many times, but still, it comes across with genuine pride. She took a job in City Hall, but while tidying up at the tail end of the Ed Koch era, she had a run-in with a wet floor and suffered a serious spinal cord injury.

She rehabbed, recovered and was in the midst of a second career when her first breast cancer came, at age 58. When her surgeon balked at performing a double mastectomy, she fired him and found one who would.

A decade passed relatively uneventfully, but in the last few years she’s endured a rash of cancer surgeries: robotic procedures on both lungs, and a finger reconstruction. There was a surprise hepatitis C diagnosis. Then she damaged her knee in, of all things, a cancer fundraising walk, and needed still further repair.

After all this, she’s unbowed. “I’m 73, but I feel like 43,” she says. “Out of all of this darkness comes sunshine. I don’t need much. I’m grateful for my life.”

Andrade’s unflagging attitude, says Jimmie Holland, is an example of the paradox of the U bend. Put happiness under the microscope and you’ll find, not surprisingly, that people in their 20s are pretty high on life. This slips as responsibilities pile on, bottoming out at around 55. “That’s when you wonder,” she says. “Is your career going to make it? Your parents are aging, children are launching.” Make it to 60, and happiness starts rising again. You realize you’re not going to live forever, and that you’d better live in the now and make the most of it. “People begin to appreciate life more,” Holland says. “You become grateful just to live, to enjoy the simpler things of life.”

And so, when something like cancer comes along, you’re not terribly surprised. “Older people modulate their emotions better,” she says. “They handle things better.”

Still, Holland says, a cancer diagnosis for older patients often precipitates hard questions about whether they can still live as they are accustomed. “Those are big, big losses of independence that are very painful for people to have to face.”

A pioneer in advocating for the psychosocial support of cancer patients, Holland says psychological support for the elderly has been neglected. She’s been helping develop a counseling plan that can be delivered via phone, including a general life review and sections on coping with illness and dealing with loneliness and existential concerns such as death. Holland and her colleagues have shown that, after only five sessions, depression, anxiety and loneliness all decrease for participants in the program, while their sense that they are able to solve problems goes up.

Tailored Techniques Gaining Ground

Holland also sees a need to train health care professionals to set aside age bias and communicate better. “Younger people haven’t often had an opportunity to get to know someone who is old because we put them off in assisted living,” she says. “More communication across generations would be tremendously helpful.”Given the general shortage of geriatricians and geriatric oncologists, patients may find it difficult to get one officially involved in their treatment. And that sometimes means their needs will be overlooked.

“I often get patients who say, ‘My doctor won’t treat me because I’m 92 years old,’” Browner reports. “Sometimes that’s the right recommendation, and sometimes it’s not.”

The good news is that the techniques and perspectives developed in geriatric oncology are gaining ground.

Doctors are growing increasingly comfortable giving treatment to older cancer patients, and they’re gathering even more evidence to make even sounder treatment decisions. Better drugs with fewer side effects are coming online. Moffitt is even testing a system that will allow quick access to its huge database of patient records, giving the institution’s doctors instant access to both the promise and peril of various treatment options.

“If we can give the oncologists the right tool for assessing risks and benefits, then you empower both the oncologist and the patient,” says Extermann.

Does every older patient need a geriatrician? “Maybe, maybe not,” says Browner. “If they feel that they have special needs, or that their needs are not being met — ask,” she encourages.

There is clear evidence that a team approach can make a difference, suggesting that older patients may benefit from an assessment at a multidisciplinary clinic — most often found within larger academic cancer centers — even if the treatment that stems from that visit is carried out by a different facility closer to home. One study, for instance, found that when a multidisciplinary team re-evaluated a diagnosis and treatment plan developed by a single oncologist, the diagnosis and subsequent treatments were changed about a fourth of the time.

“We live in a world of complex medicine, and sometimes you need to do that by teams,” explains Extermann.

Browner agrees — she has one surgeon in particular she works with often. He’ll tackle the cases of patients that other surgeons refuse to operate on, but also won’t hesitate to say no when the risk is too great. “It’s that synergy that brings the patients the best care,” she says.

“Having the patient as part of that multidisciplinary ethic is critically important,” Browner adds. The key is in the conversation, in shared decision making. “Not everybody wants treatment, even if we recommend it. And sometimes we don’t recommend it and patients request it,” she says. “That dance of education and respect for mutual input allows us to make proper decisions.”

From where Browner sits, geriatric oncology is a field on the verge of blossoming. “As we evolve as a society and as a medical community, we’re going to have to rethink how we approach these patients,” she says. “They are so incredible and so valuable to our population. As a society, we are finally recognizing that.”