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Prepare for the Changes Happening Regarding the Treatment of Elderly People Diagnosed with Cancer

March 8, 2012 | AONN+ Blog
Featuring:
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Editor-in-Chief, JONS; Co-Founder, AONN+; University Distinguished Service Professor of Breast Cancer, Administrative Director, The Johns Hopkins Breast Center; Director, Johns Hopkins Cancer Survivorship Programs; Professor of Surgery and Oncology, JHU School of Medicine; Co-Creator, Work Stride-Managing Cancer at Work

There is a powerful movement afoot, and in the long run it will be for the better. However, while it gets implemented, it is going to feel incredibly strange. The movement is rethinking who needs screening and subsequent treatment for specific types of cancers.

Two important types of cancer that are very high volume are prostate cancer and breast cancer. The trend that we will see is elderly men who will no longer undergo prostate-specific antigen testing. Additionally, if they were to be diagnosed with prostate cancer, they will likely receive no treatment. The same will probably apply to elderly women with breast cancer. How is this possible? Does it sound as though they are just going to be left to suffer with these diseases?

Ironically, we’ve been having them suffer by treating them for these cancers. It is common for men to develop urinary incontinence, sexual dysfunction, and even bowel disorders as a result of receiving any of the common treatments—surgery, radiation therapy, or hormonal therapy. Therefore, an 80-year-old man with chronic obstructive pulmonary disease (COPD), heart disease, and diabetes diagnosed with prostate cancer will likely be told that no treatment is warranted. Why? Because prostate cancer in older men grows very slowly. So slowly that this gentleman will die as a result of his comorbid conditions before he dies of his prostate cancer progressing. Also, he will have better quality of life by not undergoing the cancer treatments.

The same scenario may play out for elderly women diagnosed with breast cancer. A woman who is bedridden, in a nursing home, with Alzheimer’s disease, congestive heart failure, and other illnesses and has a small lump noted by her granddaughter while helping her change her clothes would likely be diagnosed perhaps to confirm it is breast cancer. Pathology would be requested to do prognostic factors to determine its characteristics and if it proves to be hormone receptor positive and grade 1, then more than likely hormonal therapy will be recommended and no surgery performed at all. Keep in mind that just a few years ago research results verified that women aged 70 years and older who have estrogen receptor–positive breast cancer and undergo lumpectomy surgery can “skip radiation therapy” as long as they agree to hormonal therapy. These carefully thought-out changes in treatment planning were also based on the fact that these favorable prognostic factors of breast cancer enable the patient to have less treatment and still do well. And if recurrence were to happen, it would likely once again not be the cause of the woman’s death.

It’s probable that most elderly patients will feel comfortable with such medical decisions being made on their behalf. After all, we all took the oath, “to do no harm.” So treatment for the sake of making all people diagnosed undergo the same treatment based on stage of the disease and unrelated to age or comorbidities that already exist makes no sense. Patients will feel thankful. As a navigator for the elderly population, however, you have to deal with more than the patient to convince them this is okay. Who else? Their children and grandchildren. Offspring can feel guilty themselves that their mother/grandfather isn’t getting cancer treatment when it is known that their loved one in fact has cancer in their body. They may even feel that they are being “denied care” instead of being provided the most appropriate treatment option, which in many of these cases will be to do nothing more than to monitor the patient.

In anticipation of this becoming a growing trend, consider requesting that this topic be brought up at your tumor board meetings. Therefore, everyone involved with cancer patients of all ages at your cancer center can learn from one another and jointly develop the criteria for “treatment versus observation only.” Also discuss how such information will be conveyed to a patient and their family members, so that, again, everyone is taking the same approach. How this type of information is communicated will directly influence the reaction of the patient and their loved ones.

Here is a same-case scenario: The patient is 83 years of age and has lived with his daughter and son-in-law for 10 years. He has COPD and is oxygen dependent. During his routine physical, a digital examination showed an enlarged prostate with a hardened wall. A biopsy was performed, and it was confirmed he had prostate cancer.

Avoid this approach: You have prostate cancer. You are already 83 years of age, so there is no sense in bothering to treat this cancer you have. So don’t worry about it. I don’t know why anybody bothered to examine you anyway.

A better approach: Although the diagnosis is prostate cancer, I actually have good news for you and your family. Prostate cancer in older men is very slow growing. So slow growing, that yours won’t even require actual treatment. The treatment could result in your quality of life really being impaired by causing urinary incontinence, bowel problems, and other disorders like night sweats. We will follow you to make sure that it continues without any problems. You are a cancer survivor!

Anticipate seeing these types of changes happening more and more as the recommendations about the management of slower-growing cancers in elderly patients. Treatment going forward will be surveillance. They are cancer survivors however; that is important to acknowledge.

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