Older People with Cancer

Cancer is primarily a disease of elder adults. As the population ages, cases of cancer in the elderly have also been on the rise. In 2021, 21,150 new cases of cancers were diagnosed among the elderly in Hong Kong, with half of the patients aged over 65.

For older adults aged 65-74 years, prostate cancer (21.5%) and lung cancer (18.6%) were the two commonest cancers for males, while breast cancer (25.0%) and lung cancer (15.9%) were the top two cancers for females.

For elderlies aged 75 or older, lung cancer (21.2% in male; 18.3% in female) and colorectal cancer (18.1% in male; 17.7% in female) were the two commonest cancers in both sex.   

Why older patients are more prone to have cancer?

• Older people experience more cumulative exposure to things that can damage DNA, such as sunlight and environmental toxins. 
• DNA damage can lead to uncontrolled cell division followed by abnormal cell growth. 
• The immune system acts as a line of defence and eliminates abnormal cells. When the immune system deteriorates with age, its ability to eliminate abnormal cells will decline. As a result, the abnormal cells will continue to grow, proliferate and develop into cancer.  

The principles of cancer treatment in older patients are essentially same as in younger patients. While both have similar responses to these types of therapies, older patients experience more frequent and potentiated side effects, often called “toxicities”.

There are several reasons for higher toxicities in older patients:

1. Age-related organ function decline:

• Bone marrow function: 
  • The stem cell stores gradually deplete with age, slowing the recovery of blood cells. This causes a greater risk of severe and prolonged chemotherapy-related low blood cell count.
• Kidney: 
  • The kidney is responsible for removing cancer drugs from the body, so that they do not accumulate and leave behind too many toxicities. When the kidney function deteriorates with age, cancer drugs cannot be removed from the body quick enough, causing toxicities to build up. 
• Liver: 
  • The functions of our liver are drug metabolism and elimination of waste. As one ages, the liver function deteriorates while liver volume and liver blood flow decline, potentially causing higher drug concentrations in the body for a longer period of time.  
  • In patients with other comorbidities, such as alcoholism, multiple liver metastasis or history of viral hepatitis, their liver function may be affected, leading to higher risks of drug toxicities.
• Heart:
  • With age, the risks of coronary artery disease and valvular heart disease increase while the ventricular ejection function decreases. The use of cardiotoxic drugs (which potentially cause heart problems) should be carefully considered, given the possibility of exacerbating age-related abnormalities.
• Bowel:
  • The absorption of oral drugs depends on the ability of the intestines to digest and absorb the drugs, which tends to decline with age. 
• Muscle:
  • Muscle mass will gradually decrease as one ages. The effect of cancer and anti-cancer treatment will also cause loss of muscle mass, which in turn reduces mobility and functional status.

2. Comorbid conditions

• Older patients usually have multiple medical conditions apart from cancer. Some common examples include anemia, hypertension, diabetes, heart disease, cognitive impairment or gastrointestinal diagnosis.
• These comorbidities increase the risk of anti-cancer treatment toxicity. 
• Furthermore, drugs for treating comorbidities may interact with chemotherapeutic drugs, potentially increasing toxicity in elderly patients.

3. Social support 

• Older patients with insufficient social support, financial difficulties, lower education or health literacy may face difficulties in taking access to supportive care and better medications, and may adhere to to medical recommendations (which are self-financed items). These may lead to higher risks for increased toxicity.

1. Cancer and treatment options

Causes of cancer and treatment plans should be discussed with the doctor. Try to obtain a clear picture about the type of cancer and the options available:

• Detailed information: cancer type, any site of metastasis (when the cancer spreads to other sites)
• Treatment options: benefits and risks of each treatment option 
• Other medical conditions: Any other medical conditions that may affect the effectiveness of treatments or increase risks of treatment-related toxicities

2. Impact of treatment

Apart from the above details, it is important to understand how cancer treatment will affect one’s physical, mental, and social health. Side effects may affect different aspects of life. Please carefully consider:

• Who can provide assistance and support during this challenging period
• If there are any financial difficulties, and if any care funds are available
• How the treatment will affect quality of life and relationships, self-care ability, or to what extent does it prevents one from living a meaningful life; and one’s opinion on a dignified and peaceful death 

3. Goal of treatment

Clarifying treatment goals are especially important for senior patients. Unlike younger patients who may have stronger desires to be cured despite difficult and radical treatments, older patients may value independence and comfort. Some may consider to only manage symptoms and live with cancer instead of paying high hopes for a cure, whereas some with high future prospects or value health may opt for more aggressive treatment. Below are examples that can be taken into reference for evaluating one’s treatment goal:

• Being cancer free
• Extending life
• Suffering less from cancer and its treatment
• Maintaining physical and/or emotional independence
• Maximising quality of life

4. Opinions of family members

Opinions of family members may be into consideration in setting treatment goals or making future plans. Expressing thoughts can help the family reach consensus on a preferred treatment. Below are examples of matter to be discussed among the patient and their family members:

• Opinion on the patient’s wishes
• Agreement on treatment plans

A healthcare team will assess the patient’s overall health. Besides cancer, one’s activeness, nutritional status, eating habits, vision and hearing, cognitive functions, memory, other medical problems, current list of medications, history of falling over, emotional health, whom one lives with and their financial status are also into evaluation. 

A multidisciplinary team consisting of oncologists, geriatricians, pharmacists, nurses, physiotherapists, occupational therapists and dieticians from some cancer centres also conduct an assessment called the Comprehensive Geriatric Assessment (CGA). CGA is a systematic process to identify physical, cognitive, affective, social, financial, environmental, and spiritual components that influence an older adult's health, in order to develop a coordinated plan to optimise their health as they age. A variety of treatable illnesses will also be identified during CGA.

1. Principles of communicating

For a caregiver, family member, or friend, learning that a loved one is diagnosed with cancer can be difficult, frightening and stressful. If help can be offered and communication with the patient is longed for, below are some suggestions:

• Listen
  • Try to listen and understand how the patient feels. Expressing their feelings is an important part of coping emotionally with the disease. 
• Ask open ended questions to encourage patients to open up
  • This allows them to express their anxieties and fears. Try to express encouragement or offer support. Examples include:
    • "How are you doing?"
    • "I am here for you if you wish to talk."
    • "Please let me know if I can help".
    • "I will keep you in my thoughts".
    • "Please know that I care."
    • "I am sorry to hear that you are going through this."
  • Things to avoid:
    • False positivity and optimism
    • Sharing others’ experiences in coping and convincing the patient to follow, as one’s experience may not be applicable to others.
• Show empathy
  • Uncertainty and fear are common emotions. Patients may feel angry, depressed or withdrawn, which is a normal process of grief. Most of them are able to adapt to their new lifestyle and move forward over time.
• Avoid judgement and reassurance   
  • Patients may regret what are thought to have caused cancer. Reassure them by saying that the past cannot be changed, but they can control the future. 
  • At a certain stage, some may wish to withdraw from treatment as if they are giving up. Disagreeing with their decision may be upsetting. It is important to support them and let them decide what is best.
• Not to avoid conversations on death.
  • Patients may bring up their worries about death, such as the futures of their loved ones. Listening in poses a form of relief.
• Be there
  • When the treatment stops helping, it can be frightening for people. It is important to accompany the patient, comfort and reassure them under all circumstances.

2. Practical ways to improve communication with older patients 

Verbal cues are the cornerstone of effective communication. Below are ways to appropriately converse with older patients:

• Talking in an appropriate speed and tone. For example, talking slowly with patients with dementia and louder to those with hearing problems. An appropriate tone is also recommended.
• Letting them speak without dominating the conversation
• Establishing a natural and comfortable pace
• Changing the topic proactively when needed
• Appreciating and understanding them from their perspectives
• Avoiding hidden biases
• Reducing distractions under a comfortable environment 

Non-verbal cues can also go a long way in establishing a calming and comfortable atmosphere. 

• Eye contact, nodding and gesturing as signs of attention
• Appropriate physical contact
• Accommodate for any hearing, visual, or other disabilities

Hospital Authority Hong Kong Cancer Registry, 2020

American Society of Clinical Oncology (ASCO): Cancer and Aging

Special thanks to Mr. Jeffrey Yan-Ho Lau  (Class M24), Mr. Thomas Siu-Long Yik (Class M24), medical student of Li Ka Shing Faculty of Medicine, the University of Hong Kong, and Dr. Wendy Wing-Lok Chan, Department of Clinical Oncology, the University of Hong Kong for authoring and editing this article.

Last updated on 18th Dec, 2023.