By Dr. Fredrick Ashbury, PhD and Dr. Ellie Berger, PhD
Cancer and Age
In 2021, nearly 1.9 million Americans will be diagnosed with some form of Cancer and more than 608,000 people will die. As we know, half of all cancer diagnoses occur in people age 66 or older.1 Older cancer patients are more likely to have several comorbid conditions, to be frailer, to be taking prescription medications for these additional diagnoses, to have functional challenges and to present with nutrition problems. In fact, the American Society of Clinical Oncology and the International Society of Geriatric Oncology have recommended that cancer patients who are 70 years of age and older and for whom treatment is being contemplated should first have a comprehensive geriatric assessment.2 Having comorbidities and increased dependency can increase the risk of elder abuse, and thus it has been recommended that cancer assessments include screening for elder abuse.3
Ageism in Cancer Care?
The International Geriatric Radiotherapy Group has acknowledged that older patients can face “unconscious discrimination bias” from cancer specialists, and this bias relates to the chronological age of the patients.4 Ageism is defined as any discriminatory attitude, behavior, or policy based on age.5 It has even been regarded as a “social disease”, which can spread among people.6
Specifically, beyond biases in the presentation and discussion of treatment options, ageism bias has been shown to exist in communication styles during direct patient encounters, such as clinicians displaying dismissive attitudes, in which older patients are “talked over, talked down to, or outright ignored”. There is no question that cancer treatments take their toll on a person’s body, and older people can experience more severe toxicities associated with organ declines compared to younger patients. Thus, treatment and care management options
should always be considered in this context. Nevertheless, the need to ensure communication styles are effective and non-biased to prevent ageism and ensure older patients receive appropriate care is real.
We also know that older cancer patients (particularly age 70 and older) are under-represented in cancer trials, and this bias occurs in trials where sponsors have not indicated any specific age ceiling. The obvious concern is the challenge under-representation by age means for generalizing the results to the larger population of cancer patients. Hence more studies are needed to establish dosing options for older patients, including both treatment and supportive drugs. Real-world data on outcomes of patients age 70 and over are also sorely lacking, thereby denying the opportunity to make more effective decisions regarding treatment and supportive care options for older cancer patients.
Reducing Ageism in Cancer
Overcoming ageism requires a paradigm change. This shift is not limited solely to clinicians, but also third-party payers, trialists, and policy makers.7 Not only does communication with older cancer patients need to change, but intervention research is needed to determine which treatments and supportive care strategies are effective in this population.
With the aging of the population and the improvements in cancer treatment, there is enormous potential to improve the health outcomes for a wider portion of the population. However, this can only come about if we do proper geriatric assessments and address ageism in the cancer care setting. Older patients require access to and delivery of appropriate cancer care, including survivorship. In fact, recent research shows that the response rates of chemotherapy are not dependent on age.8 Thus, health equity demands that we consider and adjust where required how we communicate with older cancer patients and the policies affecting their treatment, supportive and follow-up care options and implementation.
1 National Cancer Institute. Available from: https://www.cancer.gov/about-cancer/causes-prevention/risk/age
2 Mohile SG et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 2018;36:2326-2347.
3 Akagunduz B et al. Assessment of abuse and related factors in older patients with cancer. Supp Care Cancer 2021; Jul 2. doi: 10.1007/s00520-021-06391-7
4 Popescu T et al. Challenges facing radiation oncologists in the management of older cancer patients: Consensus of the International Geriatric Radiotherapy Group. Cancers 2019, 11(3), 371; https://doi.org/10.3390/cancers11030371
5 Butler R. Ageism: Another form of bigotry. Gerontologist 1969;9:243-46.
6 Palmore EB. Ageism comes of age. Journals of Gerontology: Psychological Sciences & Social Sciences 2015;70(6):873-5.
7 Dharmarajan KV, Presley CJ and Wyld L. Care disparities across the healthcare continuum for older adults: Lessons from multidisciplinary perspectives. ASCO Educational Book 2021 :41, e215-e224
8 Olver I. Chemotherapy for elderly patients with advanced cancer: is it worth it? Aust Prescr 2000;23:80-2
Fredrick D. Ashbury, PhD
Chief Scientific Officer, VieCure Professor (Adj), Department of Oncology University of Calgary Professor (Adj), DLSPH, University of Toronto
Ellie Berger, PhD
Associate Professor, Department of Sociology & Anthropology, Nipissing University