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Cancer Facts and Aging Introduction
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Introduction
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1. One in five Americans will be at least age 65 or older by the year 2030, and the incidence of cancer is 11-fold higher in persons over age 65.
2. About 3.5% of the American population are cancer survivors - meaning many people suffer the consequences of cancer and its treatment.
3. There is now proven efficacy for aggressive chemotherapy in elderly patients with cancer. Thus, chronological age is no longer a factor that would limit aggressive treatment.
4. About 400 thousand new patients a year develop bone metastases, requiring therapeutic options, either via surgery, chemotherapy, radiation therapy, or the use of bisphosphonates. Zometa (Zoledronic acid) has been shown to reduce the progression of metastases with a 30-40% risk reduction.1 -
The colorectal cancer incidence is over 50 times as high among people aged 60-79 than those younger than 40.
It has been noted that elderly colorectal cancer patients often receive less adequate lymph node sampling and are therefore often under-diagnosed, which could leave to a less favorable survival. Often, patients over 70 are less likely to receive chemotherapy.
Thus, those with a reasonable life expectancy should receive the same type of therapy given to younger patients. Comorbid conditions with age should be taken into account for treatment decisions, depending on what the comorbidity is and its severity in relation to prognosis.
Thus, treatment, in part, depends on one's physical function, clinical condition, comorbidities and ability to tolerate some of the many side effects of therapy. Part of the problem is physicians‚ reluctance to treat despite the evidence and benefits. It could be a wise move to offer some of the full and wide range of treatments available in hopes of obtaining a remission, cure and prolonged longevity. - 1. A lot depends on age related comorbidities, psychological, spiritual, and physical aspects of the patient.
2. Improved ways of patient follow up to prevent and/or treat late recurrences and long-term side effects related to the cancer and/or its treatment.
3. Ways of improving education provided for patients and caregivers in respect to survivorship.
Barriers and Outcomes in the Management of Cancer Survivors
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There are now over 10 million cancer survivors in the United States, and a great deal of attention is now being directed to assist and support them after a diagnosis of cancer is made.
Most cancer patients are cared for in a community setting rather than major cancer centers. It has been noted that additional information is needed for follow-up care after treatment has been completed. This could be done by primary physicians, nurses, or by specialized survivor clinics and programs.2
With the new emphasis on cancer survivors, how best to follow them is currently under study, and programs are being evaluated and implemented. The primary goal is to help in the shift from acute care to chronic care and follow up, emphasizing quality of life and wellness. Guidelines are now being developed to promote optimal quality care.
Symptom management is very important as well as providing the tools not only for cancer prevention, screening post-treatment for recurrent or new cancers, as well as controlling for optimal symptom management. This, of course, will differs depending on the age, sex, and physical condition of the patient, as well the available support from family, friends, and community.
There is also a need for improved analysis of different cultures, as well as cultural beliefs as the support and care of the cancer patient varies greatly in diverse parts of the world
- Some of the barriers for survivors involve:
- 1. Awareness and knowledge about cancer during and following treatment are vital pieces of information for support of the cancer patients and their caregivers. Many resources are now available through survivorship groups as well as the National Cancer Institute survivorship office, the National Coalition for Cancer Survivors and the American Cancer Society.
2. Courses for physicians, nurses and caregivers can be very helpful in providing state-of-the-art support for cancer survivors.
3. Knowledge of potential long-term latent side effects of cancer and its treatment need to be provided, as well as a medical record of the survivors diagnosis and treatment side effects.
4. Knowledge deficits lead to misunderstanding which often appear as depression, and also its cognitive problems which evolve not only from the cancer but its treatment.
5. A major barrier is the inefficiency and inadequacy of the health care system at the present time, whether in regards to cost of medications, inefficient follow up, or other health care obstacles. With more information and improvements in the survivorship follow-up programs, hopefully some of these problems will be solved.
6. A shift toward a wellness approach with diet, exercise and supportive care as part of the survivorship's lifeline helps survivors gain the best quality of life.
7. The emphasis on long-term follow up is now more appreciated and is being emphasized. Of note is that it is estimated that 80% of cancer care is delivered in the community; thus knowing about community services are vital. This will include screening and supportive care (exercise, nutrition, psychological support and education).
8. There are several health studies ongoing and providing information, such as the Nurses‚ Health Study and Women's Interventional Nutrition Study (WINS). This data will helps provide a framework for improved care.
9. Financial barriers, despite insurance policies, are a major consideration. A great proportion of the American population does not have adequate health insurance. What insurance many do have is often inadequate to cover the expenses of long-term treatment and follow up. Innovative ways of obtaining funding are now being evaluated and hopefully better solutions can be implemented in the near future. -
Thus, in conclusion, with medical advances in therapy, there will continue to be an increasing number of survivors who merit specialized care to help remove barriers currently in place.
The Wellness Plan - Exercise
Nutrition
Psychological
Education
Support
It appears that the nurse practitioner will be playing a central role not only in the treatment but in the follow up of cancer survivors. Promotion of wellness with good nutrition, exercise, psychological/emotional support, and patient education during and following treatment is essential.
After completion of therapy, the patient has to be prepared for long-term follow up of ten to twenty plus years. Follow-up care has changed because of the improved diagnoses and treatments. Thus new coping changes in medical care, lifestyle, social relationships, as well as solving and adjusting to medical problems have become paramount.
Side effects of the cancer or its treatment have to be controlled, such as pain, distress, fatigue, sexual concerns, as well as maintaining and promoting optimal physical functioning.
By developing a comprehensive program following diagnosis and treatment one can provide optimal care and promote wellness. A wellness plan should be provided for each patient and family, which encourage a positive attitude. Open discussions with physicians, nurses and the medical team are vital to promote knowledge, education and obtain realistic projections for the future.
Deconditioning: A Major Problem with Cancer Patients
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For many reasons - the diagnosis of cancer, its treatments and age - present a complex problem, where a person over even a short period of time can become weak and fatigued and deconditioned. This differs from fatigue. Deconditioning is frequently seen in ill patients, elderly, and the obese. Fatigue has many factors including chemical reactions, such as that of tumor necrosis factor, Interleukin-1, -6, and others, as well as cognitive, emotional and physiological components. It has been estimated to be present in 40% of cancer patients. 3
Deconditioning with debility and bed rest, muscles decline by an estimated 10% per week. Thus, in approximately five weeks, you could lose up to a quarter of your muscle strength, as well as getting joint capsule contracture.
Respirations change when supine as the diaphragm moves upward when recumbent, often leading to atelectasis.
Hypoxia when it occurs is often associated with hypertension, cardiovascular disease, and anemia.
When a person becomes partially or fully incapacitated with a loss of independence it can be looked upon as a rapid aging process, leading to frailty, which also goes along with the loss of vital capacity. It becomes harder to maintain daily functions, such as ambulation, with an altered oxygen capacity and increased lactic acid production affecting muscle strength and function. Normal activities of daily living, such as walking, increase the demands of oxygen consumption, leading to fatigue through deconditioning.
Cancer treatments also reduce functional status, especially when there are increased side effects of chemotherapy, radiation therapy, or surgery. Those with chronic obstructive pulmonary disease (COPD) or neurological problems have difficulty just walking or climbing stairs and doing daily functional tasks.
Aerobic exercises, such as bicycling, walking, or using a treadmill at least three times a week for twenty to thirty minutes can make a major difference with improved skeletal muscle strength, as well as cardiac muscle strength, with an improved stroke volume and cardiac output. It is difficult to get cancer patients, who are becoming more and more deconditioned, to exercise to help neutralize this problem as much as possible.
Cardiac and pulmonary rehabilitation programs have shown success but should be initiated as early as possible. Often, the problem is that reimbursements are lacking for many programs. Friends and family often say just taking it easy. But too much resting is the wrong message. With the use of a positive rehabilitation program, attitude and supportive guidance, it is possible to regain strength and improve quality of life.
There are often late side effects, including cardiovascular, gastrointestinal, hematologic, dental, pulmonary, renal, ophthmalogic, and bone and soft tissue damage early or as late side effects.
Heart failure, radiation, fibrosis, fatigue and cognitive, sexual, and urinary problems secondary to chemotherapy and hormonal therapy are not uncommon. 4
There are also problems with late side effects, including depression and psychological and cognitive effects, loss of fertility or potency, and concerns about one's future health and risk of a new cancer or a cancer recurrence and/or death.
Fatigue is a common problem and often goes along with cognitive changes and body deconditioning. There are chemical and biological changes, as well as emotional changes related to fatigue. Sleep problems are not uncommon and current studies are in progress to block tumor necrosis factor-alpha using imfliximab (Remicade).
Cancer survivors need follow-up examinations and reevaluations. This is best done in specialty clinics with nurses specially trained about survivorship and its problems. A treatment summary plan is also helpful for patients to better understand the disease process and possible consequences of the cancer and its therapy.
Remedies, as best as are available, should be provided for hot flashes, fatigue, shortness of breath, pain, and other cancer or treatment related problems.
A relationship has been shown between excess weight at diagnosis with an increased risk of cancer recurrence and death. Twenty-six of thirty-four studies showed increased body mass index (BMI) led to a poorer prognosis with larger tumors and more positive lymph nodes. An increase in recurrence and death was noted.5
There is some conflicting evidence showing that overweight might be protective for premenopausal women with adverse effects in postmenopausal women. 6
Of note is that following a diagnosis of breast cancer, those receiving chemotherapy typically gain two to six kilograms on anthracycline-based treatments. There is commonly a decrease in physical activity, which contributes to weight gain, which often continues post-treatment.
A healthy diet is essential. Diet and exercise also play a key role. Exercise can also make people not only feel better but increase muscle strength and produce other positive benefits.
Of note is in that the Nurses‚ Health Study of 2000 of 987 breast cancer patients followed over two years showed that three hours of moderate exercise per week was associated with a 50% reduction in cancer recurrence, breast cancer death, and total death rates.
Dietary factors are still under study, and the Women's Interventional Nutrition Study (WINS), which randomized early stage breast cancer patients to a low-fat diet or a usual diet control group, found they were able to decrease fat intake from 33% to about 20% over five years. Approximately five pounds were lost during this period, and although results are still under study, it appears that there is a decrease of breast cancer recurrence in the women on the low-fat diet.7 Of note is that the greatest benefits were in the estrogen receptor negative tumors.
Further results are being awaited.
1 Gammon, M. D., et al., J Natl Cancer Inst, 1998; 90: 100-117.
2 Lewis, L., Discussion and Recommendations: Addressing Barriers in the Management of Cancer Survivors. The AJN, March 2006; vol. 106: #3 supplement, pg. 91-95.
3 Gillis, T. A., Graham, H. F., "Watch for Deconditioning in Cancer Patients and Prescribe, Exercise," Journal of Supportive Oncology, vol. 5, #2, February 2007, pg. 94-95.
4 Ganz, P., "Cancer Survivors: Issues in Symptom Management," Journal of Supportive Oncology, vol. 5, #2, February, 2007, pg. 73-75.
5 Chlebowski, R., et. al., J Clin Onc, 2002; 20: 1128-1143.
6 Michels, K. B., et. al., Arch Intern Med, 2006; 166: 2395-2401.
7 Chlebowski, R. T., et. al., Journ Natl Cancer Inst, 2006; 98: 1767-1776 - an ASCO presentation, 2006.
First appeared April 19, 2007; updated February 20, 2008