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What an Aging Population Means for Cancer Treatment

TON - April 2019, Vol 12, No 2 - Geriatric Cancer, Supportive Care
Saima Iqbal
Ishmam Khan

Between 2014 and 2060, the population of Americans aged ≥65 years is projected to more than double, ushering in a transformation of our workforce, healthcare system, and understanding of aging.1 This generation, and those following, are expected to live longer and remain more active. Every day, the average life span increases by >5 hours, and a growing number of Americans at retirement age choose to continue working full-time.2,3 Unfortunately, with age comes higher rates of chronic illness, including cancer.4 In 2016, individuals aged ≥65 years represented 62% of all 15.5 million cancer survivors in the United States, and by 2040, they are expected to represent 73% of a projected 26.1 million cancer survivors.5

Improving the quality of medical and psychosocial care for older cancer survivors requires recognition of their heterogeneity.6 Scientific journals divide the older population into those aged 65 to 75 years (the young-old), those aged 75 to 85 years (the middle-old), and those aged ≥85 years (the old-old). Each cohort varies by physical health and psychological development.6

Whereas chronologic age does not always dictate physical ability, older adults are more susceptible to everyday wear-and-tear as well as other comorbidities.7 Likewise, current psychological models reject Erik Erikson’s theory that all adults aged ≥65 years withdraw from society and search for “ego integrity” or a stable sense of self.8 Rather, our personalities continue to develop as we age. Some studies suggest older adults find new purpose, are more willing to take risks, and want to give back to others. Others indicate that they become more able to transcend fear, as they can rely on a life’s worth of lessons and losses to adapt to challenges—including cancer.9 Indeed, older survivors tend to better manage their symptoms and fears compared with their younger counterparts and are less likely to develop mood or anxiety disorders.10

Understanding what older survivors expect from life and what social challenges they face can help nurses better communicate information about treatments and improve adherence to therapy.

Facilitating Communication with Patients

Each patient has a different relationship to care. In a study of 38 elderly patients with cancer, some prioritized quality of life and independence over a longer life span; others wanted the most effective treatment regardless of side effects, duration of hospital stays, or travel distances.11 Of these patients, 27 preferred to play a part in their treatment or end-of-life care, whereas the remainder of the cohort chose to leave decision-making to physicians or deities.

Although often overlooked, some elderly patients with cancer have strong sexual health needs. Some common side effects of treatment and specific cancers can stifle patients’ self-esteem and sexuality.12 Although these patients may be reticent to discuss erectile dysfunction or loss of sexual desire, it is vital for nurses to initiate discussions regarding all they need from care.13

A patient’s expectations for care are tempered by their ability to obtain and understand healthcare information and services. Patients with poor health literacy skills are more likely to believe that the progress of their cancer is inevitable, misunderstand the purpose of screening, and avoid physician visits. Although patients rely on information about cancer prevention and screening from healthcare professionals, they are less likely to ask physicians to clarify or repeat information, which puts them at a higher risk for hospitalization, which can be a financial burden.14,15

The old-old tend to have the lowest health literacy rates and greatest unease with Internet use.16 Many patients in this cohort, often referred to as the “Silent Generation,” are embarrassed to ask their physicians questions, or lived during an era when few physicians communicated with patients about diagnoses.17 They expect a certain rapport with primary care physicians. By contrast, survivors in the young-old cohort, often referred to as the “Baby Boomer Generation,” are more financially secure, educated, healthier, and in control of their care.18 These individuals are more likely to use vitamins, diet, meditation, and exercise to maintain their health. They tend to ask fellow cancer survivors for support in decision-making, refer to the Internet for health-related information, and report poor mental health.19

Regardless of health literacy skills, older cancer survivors find it harder to process and remember health-related information compared with younger cancer survivors.20 Healthcare providers can address this issue by speaking slowly and using less jargon. Older individuals remember information better when it is personalized and delivered with empathy. Summarizing and repeating personal relevant information, engaging survivors’ caregivers in discussions, and being aware of one’s tone of voice when speaking can help.

Improving Adherence

Caregiver strain, stigmas about cancer, and the cost of treatment can pre­sent obstacles to patient treatment adherence. Because many older cancer survivors cope with additional chronic illnesses, 43% need help completing daily tasks and 63% rely on informal caregivers.12,21 Unfortunately, the average caregiver is aged 63 years and has a 36% chance of being in fair to poor health as well.21 Whereas many caregivers find their roles valuable, they also report feeling distressed, unsupported, and overwhelmed.22 The risk for caregiver strain and depression increases as the caregivers age or fall into poor health and as the cancer survivors start needing help with daily tasks.23 Older cancer survivors are thus highly susceptible to caregiver strain and loss.

Individuals whose caregivers have moved away, or died, may struggle to travel to and from appointments, especially in areas with fewer forms of accessible transportation. The resulting social isolation is not only distressing, but also linked to lower patient treatment adherence, underreporting of side effects, and depression.24

In a society that values self-reliance, older cancer survivors who rely on caregivers may feel as though they are burdens to their family members, especially if their cancers are linked to lifestyle choices.25 For instance, many members of the old-old cohort with lung cancer smoked cigarettes when it was considered a dignified pastime.26 Patients with low self-esteem often believe they do not deserve treatment and fail to adhere to it.

It does not help that cancer treatments are becoming increasingly expensive.27 The resulting financial strain can bury patients in debt and cause them to delay, reject, or ration their treatment. Cancer survivors have higher out-of-pocket costs for years after their diagnosis and are 2.7 times more likely to file for bankruptcy compared with individuals of the same age without cancer. Of those who are employed and relatively financially stable, 14% and 25% say they are unable to focus on and complete tasks at work, respectively, and have missed 22.3 more workdays per year than their cancer-free peers.28 Older cancer survivors appear less able to pay for care than their younger counterparts. Patients who rely on fixed incomes or part-time pay often receive less aid from their employer’s health insurance.28 The old-old are especially more likely to lose the “breadwinners” of their families and to have low incomes, a high amount of debt, and minimal savings.29

As members of the multidisciplinary team, oncology nurses play a crucial role in the well-being of older cancer survivors. Addressing these patients’ unique psychosocial challenges will ensure that nurses continue providing meaningful support.

References

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  2. Dovey C. What old age is really like. October 1, 2015. www.newyorker.com/culture/cultural-comment/what-old-age-is-really-like. Accessed August 9, 2018.
  3. DeSilver D. More older Americans are working, and working more than they used to. June 20, 2016. www.pewresearch.org/fact-tank/2016/06/20/more-older-americans-are-working-and-working-more-than-they-used-to. Accessed August 9, 2018.
  4. Marosi C, Köller M. Challenge of cancer in the elderly. ESMO Open. 2016;1:e0000020.
  5. Bluethmann SM, Mariotto AB, Rowland JH. Anticipating the “silver tsunami”: prevalence trajectories and co-morbidity burden among older cancer survivors in the United States. Cancer Epidemiol Biomarkers Prev. 2016;25:1029-1036.
  6. Little W, McGivern R. Aging and the elderly. In: Little W, McGivern R, eds. Introduction to Sociology. 1st Canadian ed. British Columbia, Canada: OpenStax College; 2014:397-438.
  7. Kowal PR, Wolfson LJ, Dowd JE. Creating a minimum data set on ageing in sub-Saharan Africa. Southern African Journal of Gerontology. 2000;9:18-23.
  8. Erikson E. Identity and the Life Cycle. New York, NY: W.W. Norton & Company; 1980.
  9. Alon S. Psychosocial challenges of elderly patients coping with cancer. J Pediatr Hematol Oncol. 2011;33(suppl 2):S112-S114.
  10. Lang MJ, Giese-Davis J, Patton SB, Campbell DJT. Does age matter? Comparing post-treatment psycho­social outcomes in young adult and older adult cancer survivors with their cancer-free peers. Psychooncology. 2018;27:1404-1411.
  11. Kelner M. Activists and delegators: elderly patients’ preferences about control at the end of life. Soc Sci Med. 1995;41:537-545.
  12. Schapmire T, Faul A. Cancer and older adults (65 plus). In: Christ G, Messner C, Behar L, eds. Handbook of Oncology Social Work: Psychosocial Care for People with Cancer. Oxford, United Kingdom: Oxford University Press; 2015:527-535.
  13. Legg MJ. What is psychosocial care and how can nurses better provide it to adult oncology patients. Austral J Adv Nursing. 2011;28:61-67.
  14. Morris NS, Field TS, Wagner JL, et al. The association between health literacy and cancer-related attitudes, behaviors, and knowledge. J Health Commun. 2013;18(suppl 1):223-241.
  15. Cartwright LA, Dumenci L, Cassel JB, et al. Health literacy is an independent predictor of cancer patients’ hospitalizations. HLRP: Health Literacy Research and Practice. 2017;1:e153-e162.
  16. Coursera. Perceptions of Old Age - What Is Old? [Video]. www.coursera.org/lecture/ageing/1-perceptions of-old-age-what-is-old-sgW3L. Accessed August 8, 2018.
  17. Sontag S. Illness as Metaphor. New York, NY: Farrar, Straus, and Giroux; 1978.
  18. Fry R, Igielnik R, Patten E. How millennials today compare with their grandparents 50 years ago. March 16, 2018. www.pewresearch.org/fact-tank/2018/03/16/how-millennials-compare-with-their-grandparents/. Accessed August 13, 2018.
  19. Rose JH, Bowman KF, Deimling GT, Stoller EP. Health maintenance activities and lay decision-making support: a comparison of young-old and old-old long-term cancer survivors. J Psychosoc Oncol. 2005;22:21-44.
  20. Posma ER, van Weert JC, Jansen J, Bensing JM. Older cancer patients’ information and support needs surrounding treatment: an evaluation through the eyes of patients, relatives, and professionals. BMC Nurs. 2009;8:1-15.
  21. Jayani R, Hurria A. Caregivers of older adults with cancer. Semin Oncol Nurs. 2012;28:221-225.
  22. Applebaum AJ, Buda KL, Schofield E, et al. Exploring the cancer caregiver’s journey through web-based meaning-centered psychotherapy. Psychooncology. 2018;27:847-856.
  23. Goldzweig G, Merims S, Ganon R, et al. Informal caregiving to older cancer patients: preliminary research outcomes and implications. Ann Oncol. 2013;24:2635-2640.
  24. Payne S, Jarrett N, Jeffs D, Brown L. Implications of social isolation during cancer treatment. The implications of residence away from home during cancer treatment on patients’ experiences: a comparative study. Health Place. 2001;7:273-282.
  25. Applewhite A. Let’s End Ageism [Video]. Vancouver, Canada: TED, 2017. www.ted.com/talks/ashton_applewhite_let_s_end_ageism?referrer=playlist-how_can_we_better_treat_our_elders&language=en. Accessed August 9, 2018.
  26. Knapp S, Marziliano A, Moyer A. Identity threat and stigma in cancer patients. Health Psychol Open. 2014;1:2055102914552281.
  27. National Cancer Institute. Cancer trends progress report: financial burden of cancer care. Updated February 2019. https://progressreport.cancer.gov/after/economic_burden. Accessed August 14, 2018.
  28. National Cancer Institute. Financial toxicity and cancer treatment (PDQ)-health professional version. Updated January 25, 2019. www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq. Accessed August 14, 2018.
  29. Gillers H, Tergesen A, Scism L. A generation of Americans is entering old age the least prepared in decades. June 22, 2018. www.wsj.com/articles/a-generation-of-americans-is-entering-old-age-the-least-prepared-in-decades-1529676033. Accessed August 14, 2018.
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Last modified: August 6, 2019