FACET - European Journal of Cancer Care December 2004

1. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners Forte, D.1 McGregor, R.2 • Population ageing in United Kingdom • Currently over one fifth of the population is over 60 years • By 2025 those over 80 years will increase by almost 50% • By 2025 those over ninety will have doubled • Estimated percentage of older people 65 years or more in population in 2004 is 15% Slide One *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

2. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Incidence of cancer in older people • Cancer generally increases with age • Incidence of most malignant cancers increase with age up to 85 years • Decline in these cancers after 95 years • 12% of newly diagnosed breast cancer patients are 80 years or more Slide Two *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

3. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Link between cancer and old age • The link between old age and cancer is the result of three main factors according to Repetto & Balducci (2002) • Substantial length of time required for carcinogenesis • The occurrence of age related molecular changes that mimic carcinogenesis • Changes in bodily environment that favour cancer progression Slide Three *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

4. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) What do we mean by ageing? “The universality of ageing places it outside the realm of pathologic study. The changes that occur are normal for all people but take place at different rates and depend on accompanying circumstances in an individual’s life”. (Ebersole & Hess 1998, p85) Slide Four *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

5. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Challenges of chronological ageing versus biological ageing • Ageing varies not only among individuals but within different systems of the same person” (Eliopoulos 1997 p45) • “Aging is a highly individualised process, demonstrated by the differences between persons of similar ages” (Eliopoulos 1997 p45) • Chronological ageing is an indicator of the number of years lived but is only a crude indicator for ageing Slide Five *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

6. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Loss of function in old age and implications for cancer (1) • Nervous system 10% • Basal metabolic rate 15% • Cardiovascular system 30% • Pulmonary system 50% • Renal system 30% Slide Six *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

7. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Loss of function in old age and implications for cancer (2) • Bone marrow • Reduced tissue repair • Changes to sensory system Slide Seven *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

8. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Are cancer services inherently ageist? • Often older people receive less screening for cancer • They are less likely to be referred to a main cancer centre • Once diagnosed, often receive less aggressive treatment leading to an increase in mortality from the cancer rather than comorbidities • Problems related to early detection of cancer Slide Eight *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

9. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) The National Service Framework for Older People (DoH, 2001) has as its first standard, the need to root out age discrimination in the health service. It states that: “NHS services will be provided; regardless of age, on the basis of clinical needs alone” Slide Nine *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

10. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Older people and access to clinical trials (1) • Researchers indicate that for all cancers, older people are under-represented in clinical trials. This is due to • The strict exclusion criteria built into many research protocols Slide Ten *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

11. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Older people and access to clinical trials (2) • Older people often present with comorbidity which pre dates the diagnosis of cancer and which many clinicians feel makes the older person too vulnerable for the more aggressive forms of treatment • Misconceptions about ageing and cancer may have a negative effect when it comes to influencing clinical decisions about treatment Slide Eleven *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

12. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Problems related to early detection and access to treatment • Effects of ageism on early presentation of symptoms • Signs and symptoms of cancer can be vague and non specific • Clinical presentation may be slow to develop and be masked by other age related physical changes and comorbidities • Importance of raising awareness of early detection in older people. • Need for comprehensive assessment by multiprofessional team Slide Twelve *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

13. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Screening (1) • Breast • A 30% reduction in mortality from breast cancer in the last 10 years in the United Kingdom • The figures are similar in the USA but have remained static in Europe (Rosin, Cancer Services Collaborative 2001) • By the end of 2004 all women in the United Kingdom will be offered routine breast screening Slide Thirteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

14. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Screening (2) • Cervical • Screening is estimated to save around 1,300 lives per year • Primarily aimed at people under 65 years • Need for older women to be included in routine screening • Prostate • The evidence for prostate screening is less clear than for other cancers • PSA testing fails to differentiate between slow and fast growing prostate cancers Slide Fourteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

15. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Screening (3) • Bowel • The incidence increases with age and is mainly a disease that affects older people • In 2000 the National Cancer Plan announced that it would implement a pilot study to look at the population most likely to benefit from bowel cancer screening Slide Fifteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

16. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Comprehensive assessment • Needs to include: • Biographical data • Physical assessment • Psycho/social assessment • Cultural preferences • Multidisciplinary input • Patient and carer involvement Slide Sixteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

17. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Single assessment • Should facilitate better communication within and between teams, and other service providers with whom the older person has contact • Reduces the need for the older person to repeat the same assessment information to a variety of service providers at a time when they are feeling vulnerable Slide Seventeen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

18. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Key assessment areas for older people at risk of cancer • Physical • Psychological • Social • Spiritual • Financial support Slide Eighteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

19. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Key assessment areas for older people at risk of cancer • Comorbidity • Natural ageing process • Understanding of the impact of multi-pathology/chronic illness/cognitive impairment • Thorough assessment of past medical history and medication • Identifying risk factors including smoking, nutritional status Slide Nineteen *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

20. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Key assessment areas for older people at risk of cancer • Psychological state (1) • Impact of cancer on the older person’s sense of wellbeing • Motivation and adjustment to the situation • Quality of life Slide Twenty *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

21. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Key assessment areas for older people at risk of cancer • Psychological state (2) • Psychological support • Cognitive function • Sexuality and self image Slide Twenty one *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

22. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Key assessment areas for older people at risk of cancer • Social assessment needs to consider: • Social support networks • Carer support • Housing • Finance • The older person’s perception of health Slide Twenty two *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

23. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • Summary • Need for more research • Greater consideration of the impact of ‘normal’ ageing changes • Rights of older people to being told their diagnosis and the options available to them Slide Twenty three *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

24. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • References and further reading • Bouchardy C., Rapiti E., Fioretta G., Laissue P., Neyroud-Caspar I., Schäfer P., Kurtz J., Sapprino A. & Vlastos G. (2003) Undertreatment strongly decreases prognosis of breast cancer in elderly women. Journal of Clinical Oncology. 21 (19): 3580-3587. • Cooley C. & Coventry G. (2003) Cancer and Older People.Nursing Older People. 15(2): 22-26. • Cunningham S. (1996) The biological basis of cancer. British Journal of Nursing. 5:14 869-874. • Department of Health (2000) NHS Cancer Plan for England. Department of Health. London. www.doh.gov.uk/cancer/cancerplan.htm • Department of Health (2001) National Service Framework for Older People. Department of Health. London • Ebersole P. & Hess P. (1998) Towards Healthy Ageing, 5th edition, Mosby. Missouri. • Eliopoulos C. (1997) Gerontological Nursing. 4th edition ch.4:p44-52; ch.7:p74-94. Lippincott. Philadelphia. Slide Twenty four *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

25. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • References(continued) • Fee L., Cronin A., Simmons R. & Choudry S. (1999) Assessing older people’s health and social needs. Health Education Authority. London. • Gearing B. & Coleman P. (1996) Biographical Assessment in Community Care, in Birren J.; Kenyon G.; Ruth J.; Schroots J. & Svenson T. (1996) Ageing & Biography: Explanations in Adult Development. Springer. New York. Chapter 15:265-282. • Girotto J., Schreiber J. & Nahabedian M. (2003) Breast Reconstruction in Older Women: Preserving Excellent Quality of Life. Annals of Plastic Surgery. 50(6): 572-578. • Heflin MT, Cohen HJ. (2001) Cancer screening in the elderly. Hospital Practice. 36(3): 61-9. • Lewis J., Kilgore M., Goldman D., Trimble E., Kaplan R., Montello M., Houseman M. & Escarce J. (2003) Participation of Patients 65 Years of Age or Older in Cancer Clinical Trials. Journal of Clinical Oncology. 21:1383-1389. Slide Twenty five *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

26. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • References(continued) • Lichtman S. & Zaheer W. (1996) Breast cancer screening is underused, although clearly beneficial, in elderly women. Primary Cancer Care. 16(5): 5-6. • Matsushita I., Hanai H., Kajimura M., Tamakoshi K., Nakajima T & Matsubayashi Y. (2002) Should Gastric cancer Patients More Than 80 Years of Age Undergo Surgery? Journal of Clinical Gastroenterology. 35(1): 29-34. • Nolan M. & Caldock K. (1996) Assessment: identifying the barriers to good practice. Health & Social Care in the Community. 4(2): 77-85. • Patel S. & Zenilman M. (2001) Outcomes in Older People Undergoing Operative Interventions for Colorectal Cancer: Surgery for Colorectal Cancer in Older Patients: A Systematic Review. Journal of the American Geriatrics Society. 49(11): 1561-1564. • Posner R. (1995) Ageing and Old Age. The University of Chicago Press, Chicago. Slide Twenty six *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

27. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • References(continued) • Reinbart Ayres M. (2004) Cancer and the Older Population: Considerations for Healthcare Professionals. Topics in Geriatric Rehabilitation. 20(2): 75-80. • Repetto L. & Balducci L. (2002) A case for geriatric oncology. The Lancet Oncology. 3(5): 289-297. • Robinson J. & Turnock T. (1998) Investing in Rehabilitation. Review Findings. Kings Fund. London. • Rosin D. (2001) Breast Cancer – Cancer Services Collaborative http://www.nelh.nhs.uk/nsf/cancer/breast_sig/summary/summary-intro.htm • Schmitt C. (2004) Treatment Strategies for Colorectal Cancer in Older People. Journal of Clinical Gastroenterology. 38(5): 387-389. • Thomé B., Dykes A., Gunnars B. & Hallberg I. (2003) The Experience of Older People Living With Cancer, Cancer Nursing, 26(2): 85-96. Slide Twenty seven *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc

28. FACET - European Journal of Cancer Care December 2004 Older People and Cancer: Considerations for Healthcare Practitioners(continued) • References(continued) • Turner N., Haward R., Mulley G. & Selby P. (1999) Cancer in old age – is it adequately investigated and treated? British Medical Journal. 319: 309-312. • Vardaxis N. (1995) Pathology for the Health Sciences. Churchill Livingstone. Edinburgh. • Westin E. & Longo D. (2004) Lymphoma and myeloma in older patients. Seminars in Oncology. 31(2): 198-205. • Wyld L., Garg D., Kumar I., Brown H. & Reed M. (2004) Stage and treatment variations with age in postmenopausal women with breast cancer: compliance with guideline. British Journal of Cancer. 90(8): 1486-91. • Yancik R., Wesley M., Reis L., Havlik R., Edwards B. & Yates J. (2001) Effects of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA. 285(7): 885-92. Slide Twenty eight *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc