Cancer in old age: planning treatment and care individually

What role does life expectancy play in treatment choice??

Average life expectancy is rising in almost all industrialized countries. But the risk of cancer increases with age. The latest cancer statistics for Germany show: Among those diagnosed for the first time in 2012, more than 90 were.000 patients eighty years and older.
What role does age play in the choice of treatment, and what influence do concomitant diseases have?? Can very old people still be expected to undergo therapy at all?? And who makes important decisions when a patient can no longer do so himself or herself??

The following text offers those affected and their relatives an initial overview of treatment and care options, as well as tips for talking to the doctors treating them.

Note: Information from the Internet can provide an overview. However, they are not suitable as a substitute for advice from a doctor.

Cancer and age: An overview of the situation in Germany

Elderly couple in the woods with walking sticks © pershinghks/ThinkstockMany older people consciously keep fit © pershinghks/Thinkstock

Cancer can occur at any age. However, the majority of patients in Germany are already of retirement age when the diagnosis is made.
Many of those affected still feel fit and full of plans at this stage of life.

  • "old" Equal to "sick": This equation is a misconception. This is also confirmed by current data from German health research.

However, the statistics also show: in old age, most people actually have to struggle with one or another health restriction. The likelihood of high blood pressure and other cardiovascular diseases or kidney problems already increases sharply from the age of 60. Many have joint and bone problems, such as arthritis or osteoporosis. Quite a few older people in Germany are diabetic.
As a result, sufferers need appropriate medication, often several at the same time.

The older patients become, the greater the likelihood that these health restrictions will have an effect on everyday life and that they will be dependent on help. This is especially true when dementia also begins to emerge.

But what is the situation if cancer only appears at an actually advanced age?? When other diseases have already limited health and life expectancy is noticeably limited?

Cancer registry statistics show: The proportion of cancer patients who are not diagnosed with a tumor until they are 80 or 85 and older is not small. About one fifth of the total 478.000 new cases affected this age group in 2012.

  • What are the consequences of these facts for those affected?

Therapy planning: date of birth and biological age

A Uniform Definition of "Being Old does not exist. Culture, society and also the country you live in play a role. In Germany, the retirement age is often used as a limit. The WHO does not define the life stage "old age also start at the age of 60 to 65. Many physicians, however, tend to focus on physical and mental condition rather than date of birth.

Does cancer really grow more slowly with age and remain harmless? There is no robust evidence for this assumption so far. When planning treatment, the only thing that counts is how those affected actually feel.

Not infrequently, doctors are confronted with the fear that too much is expected of an elderly person during treatment: such a major operation, a stressful chemotherapy – is that really necessary at this age?? This is one of the typical questions asked by patients and their relatives. Often, this question is also justified by the fact that cancer in "seniors" is not a serious problem is not growing so aggressively and very slowly anyway – therefore no treatment is necessary.
But is this concern really always justified?? Here, too, doctors advise taking a close look before refusing treatment on the grounds of age alone.

They warn against being rigidly oriented only to the date of birth: The so-called biological age is more informative when it comes to treatment planning. What should one pay attention to overall? The following factors are particularly important.

Expected course of the disease and start of treatment

The examinations and findings will show what is in store for those affected. From this, it can be roughly estimated how aggressive the disease really is and how quickly therapy must begin.
Tumors do not always grow more slowly in older people than in younger ones. Pain and other distressing symptoms can also develop very quickly in older patients – and must then be treated as soon as possible.

However, there are some situations in which older cancer patients are not recommended any therapy – at least not immediate therapy.

One example is prostate cancer: Many patients with a prostate tumor can live a relatively long time without treatment. For older patients whose expected remaining life span is less than ten years, the question arises as to whether they will benefit from therapy at all. After all, surgery is stressful and can entail risks and side effects. As long as the tumor does not cause any symptoms, patients can therefore decide "only" to undergo treatment to go for regular check-ups. The doctor then examines the personal state of health, but not the tumor. If symptoms occur, the doctor treats them, but not the cancer itself.

Therapy options, quality of life and life expectancy

Should one absolutely try everything to achieve a cure even with elderly cancer patients?? Here, too, there is no general answer. The general state of health and thus indirectly the further life expectancy are important for the assessment.

Does the patient feel fit and do the general examination findings show a similar picture?? In this case, physicians are unlikely to treat older patients any differently than younger people.
There are only a few exceptions to this recommendation: They occur, for example, when it comes to very long-term consequences of cancer, which would not affect older patients purely statistically.

The situation is different if the patient’s age is compounded by poor health:
Could their cancer be cured only at the cost of many side effects, without measurably prolonging their lives?? In this case, the quality of life is in the foreground, not the cure by all means.
What this means? Patients and physicians can decide together not to use every possible therapy option; they forego therapy options that are particularly lengthy, organizationally complex and physically stressful.

It is important to weigh what will cause more problems in the foreseeable future: the disease with its consequences? Or the treatment with its side effects and burdens?
Such deliberate restrictions in treatment or the complete abandonment of therapy are, however, a very personal decision. Each patient can only make this decision individually with the doctors and, if necessary, together with relatives.

Adaptation of cancer therapy to the health situation

If other diseases are already present? For many elderly patients, physicians must then also adapt the delivery of treatment to their health situation, from the selection of therapeutic procedures to the dosage of medications.

An example of this is again older men with prostate cancer: If an operation is out of the question, for example because of a serious heart condition, then the costs of the operation must be taken into account? In such cases, radiation therapy can be a largely equivalent alternative, with good long-term chances of cure. The situation is similar for patients with a form of light skin cancer, a squamous cell carcinoma: they too may be treated with radiation instead of surgery.

Necessary adjustments to medications are even comparatively common:
Patients with one or more other diseases were usually already dependent on medication before their cancer diagnosis. Doctors therefore also need to be aware of possible interactions between these agents and cancer therapy.
In addition, many people show changes in metabolism or slight restrictions in organ function at an older age. These do not in themselves constitute a disease. But they must be taken into account in cancer therapy.
For example, patients on blood thinners to prevent strokes may need to stop taking these drugs before tissue removal or surgery. Or they may be switched to other drugs and closely monitored to avoid unwanted bleeding.
Another example: Many older people have kidney or liver function problems that they have not noticed in their daily lives. Some cancer drugs may need to be dosed differently than in younger people

Support in getting well

Not only the planning of the actual cancer therapy is important, but also the time afterwards should be considered.
Older patients may need longer to recover. A long stay in hospital can in itself lead to a further decline in performance. Those affected may find it difficult to return to their previous daily routine immediately after therapy.

What reasons can there be for this, and what do doctors pay particular attention to??

Statistically, problems with the defense against infections become more likely with increasing age. Wound healing may also be slower in some cases. However, neither of these is necessarily a typical "sign of old age". It is not uncommon for this to be due to previously unrecognized malnutrition, which can be further exacerbated by the cancer itself. Those affected can then benefit from targeted nutritional therapy, possibly even before the start of treatment.

General physical performance, such as muscle strength, is also not infrequently limited in older people: Under these conditions, prolonged bed rest can do more harm than good. Physiotherapy can be used to counteract this – usually while the patient is still in the hospital. Even in the long term, adapted exercise and possibly even sport remain important.

Age as a cost factor? Is everything still paid for at all in the case of old people?

There is another fear that doctors occasionally hear from their patients or their relatives: that savings are being made on older cancer patients, and that insurance companies will no longer pay for everything that is taken for granted in the case of young adults.

  • In principle, however, the date of birth alone is not a decisive factor in the decision for or against cancer therapy.
  • Insurance companies in Germany do not specify age limits for cancer treatment.

However, there is one restriction that elderly cancer patients may encounter even in Germany, especially if their general condition was already limited before they developed cancer: participation in clinical trials in which new cancer drugs are tested for the first time.

There may be several reasons for this:

  • One of them is in the realm of ethics: in many clinical trials, people with dementia are excluded because they don’t understand what the tests are about. Therefore, they cannot make an independent decision whether or not to expose themselves to the risks of a study.
  • Another reason: very early studies with agents about which little is yet known are often tested on subjects who were healthy before they developed cancer. This makes it easier for cancer researchers to understand what the new drugs trigger in the metabolism.

However, cancer researchers and cancer physicians know that such data are then of only limited use in practice. This is why more and more studies no longer have an age limit. Other studies are even carried out specifically with patients who are older or suffer from one or the other health restriction.

Preparing for medical consultations: important questions for patients and relatives

In the following sections, the Cancer Information Service has compiled questions and overviews: They are intended to help patients and family members prepare for conversations with their treating physicians.

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