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Around two in every hundred of the UK’s over-75s are diagnosed with cancer each year. And this accounts for around a third of the nation’s new cancer cases each year.

But because life expectancy in the UK is increasing, the number of older people living with cancer is growing. By 2020 there will be nearly two million people aged 65 and over alive following a diagnosis of cancer.

But are the UK’s cancer services geared up to support the older generation?

Today, a report exploring this question is launching at this year’s Britain Against Cancer Conference in London. It draws together evidence on what we know, and what we still need to understand, about cancer and older people in the UK. The report was commissioned by Sean Duffy, NHS England’s National Clinical Director for Cancer, and is published by the National Cancer Intelligence Network (NCIN) in association with Cancer Research UK and Macmillan Cancer Support among others.

So what were the report’s key findings and recommendations?

Healthy living is important at any age

When it comes to cancer risk, being a non-smoker, cutting back on alcohol, keeping a healthy weight and staying active are the best ways to stack the odds in your favour.

But – as the evidence in the report shows – older people are less aware of this than other age groups, despite the fact that being overweight and inactive is more common in older people than in the population as a whole.

And it’s not just about avoiding cancer. If you do get cancer, then the fitter you are in general, the better – it increases your chances of being able to have more aggressive (but more effective) cancer treatments.

Early diagnosis is a challenge in older people

Diagnosing cancer early saves lives – but the report shows that older people with cancer are more likely to be diagnosed via an emergency hospital visit, usually with a more advanced cancer

That’s probably due to a combination of factors. Research shows that older people are less aware that symptoms like a lump or sickness are possible cancer warning signs, so they may be less likely to tell their GP if they’re having those symptoms.

They also might have complex health needs to start with, so it’s harder for their GP to work out the root cause of a new or existing symptom – after all, many possible cancer symptoms stem from a range of other illnesses too.

Too old for treatment?

The report draws together the evidence that the use of surgery (as we also blogged about last week), chemotherapy and radiotherapy tails off as we get older. This is probably one reason (among others) why cancer survival is lower for older people. It’s tempting to interpret this as simple ageism, but there are plenty of good reasons why an older person mightn’t receive these treatments.

As we’ve covered already, older people may not be fit enough for aggressive treatments. Their cancer might be too advanced for certain treatments to work, or there might be other treatments which work better for their type of cancer. And, we mustn’t forget, sometimes quite understandably, older patients decide with their doctors that they just don’t want to put themselves through treatment.

But the variation in treatment by age suggests that decisions not to give older cancer patients active treatment are not always based on these good reasons. The report discusses the fact that, sometimes, doctors just don’t have the evidence to decide whether giving a certain treatment to an older person will benefit them, because trials of that treatment have excluded older people. And sometimes doctors might decide a patient is just ‘too old’ for a treatment, without really thinking about that patient’s individual circumstances – focusing on their chronological, rather than biological, age.

Although it’s possible that some older patients are missing out on effective and appropriate treatment, overall, it seems that older patients are still more likely to have confidence in their doctors and nurses and to feel that they were treated with dignity and respect. But they are also less likely to say they were told about side effects of their treatment.

Lots of factors might explain why older people report a different experience of cancer care compared with younger people – different cancer types, a different outlook on ‘people in authority’, or different information needs.  We need more research to understand these differences.

What can be done?

Of course age alone doesn’t define a person’s needs. These are also determined by the type of cancer they have, their level of social and economic deprivation, their sex, their ethnic group, and their general health apart from their cancer.

So a key message from the report is that understanding each older person’s unique circumstances is vital to providing the best support and care at every stage of their cancer journey.

But in his foreword, Sean Duffy homes in on several things that will improve that journey for older people:

  • Support for lifestyle changes to reduce their risk of developing cancer and to make them fitter for more aggressive (but more effective) treatments
  • Help in becoming more aware of possible cancer symptoms and encouragement to tell their GP if they have those symptoms
  • Help doctors make cancer treatment decisions based on fitness for treatment and patient preference, not patient age

And he promises that ‘…actions to tailor services to the needs of older people [will be] at the heart of [NHS England’s] efforts to further improve all aspects of cancer services in the coming years’.

We’re behind him all the way.

Katrina Brown is a senior cancer epidemiologist at Cancer Research UK

Image

Elderly couple image by Garry Knight, accessed via Flickr under a Creative Commons CC-BY-SA-2.0 license

Comments

Nick Peel January 12, 2015

Hi Val, thanks for your comment. As you say, elderly patients will be more likely to have a range of conditions that make it more challenging to have high-quality consultations with their doctors. As with patients of any age it’s vital that the NHS and its staff tailor services to elderly patients’ needs. So the problems you mention clearly need to be addressed both in the training and guidelines that healthcare staff, such as doctors, receive – and in the design of NHS services.

However, it’s important to consider that elderly patients are more likely to say they had a good experience of most areas of the NHS (see, e.g. chapter 5 of the NCIN report). Overall, elderly patients are more satisfied with their treatment and care, more likely to feel they were treated with dignity and respect and had greater confidence in their doctors and nurses. It’s not clear why this is, and it’s also clear that on issues where they do have poor experiences, older patients are ready to report them – such as the availability of Clinical Nurse Specialists.

There certainly will be some elderly patients that face challenges in communicating with their doctors. This must be effectively addressed and in some instances there is undoubtedly room for improvement. However, the findings from the patients’ experience survey highlighted in the report suggest that the challenges that most urgently need to be addressed, such as more difficulty in getting treatments to patients and late diagnosis, arise elsewhere.

Nick, Cancer Research UK

Alison Parker January 3, 2015

I lost my lovely aunt two years ago at 86. She had been suffering for at least a year with symptoms that she knew werent good. We believe now that her cancer must have started in her tummy somewhere. My aunt made several trips to her doctors but nothing was ever done which now we can only say must have been her decision because her sheer weight loss alone would have caused alarm in any doctor. Eventually she had a fall & fractured her hip. She was rushed into hospital where they operated on her. They were then going to discharge her but my cousins demanded that they keep her in for tests because their mum looked very ill. It was then that we all found out that she had cancer throughout her body it was way too advanced & sadly we lost her within two weeks. I do feel that she wasnt a typical 85 year old & that if she had wanted to she may have got through a course of treatment. But she must have decided to let it take its course because in hospital she said ‘she had had a good life’.We would love to have had her around longer but my aunt felt she had had her life. The elderly with cancer is a tricky area they are a stubborn generation & not always for their own good.

Val Alderson January 2, 2015

This is informative. How do you standardise advice? Some doctors appear to be only half-present during consultations; eager to move along the clinic list. Often older people’s hearing is poor, even with hearing aids. Foreign accents are difficult to understand.

Louise Godfrey January 2, 2015

My Grandmother is in her early 80s and was diagnosed with lung cancer almost a year ago. We are lucky that since she gave up smoking about 30 years ago she has led a healthy lifestyle, and that it was caught early. She has undergone surgery and is due for her last dose of chemo this month. Apart from one doctor, everyone involved in her recovery has been positive. She has lost a lot of weight through losing her appetite as a side effect of the chemo, but is getting better every day. I can’t express how grateful I am that she hasn’t been dismissed or denied treatment because of her age, as it gives me potentially many more years with an amazing woman who I love.

Chris Hiley December 10, 2014

We’ve finally spotted older men and women – in a disease of ageing. This report is very important, though I’m not sure it will turn out to be a game changer. I do so hope it does….

Men and women over the age of 75 with, and at risk of cancer (which means all over 75s) are a massive opportunity for some new charity thinking on collaboration within the cancer sector, collaboration with the ageing sector and collaboration with the wider health charity sector – because all those reflect the lives of the older people one is hoping to serve.

I hope the 2014 Britain Against Cancer conference started the job.

The idea that “it’s never too late for lifestyle gains” was a surprise to me but on reflection it’s a really interesting idea since the context – old people – does not demand that cancer is the main or sole point of such health promotion. In fact, the ‘story’ of a lifestyle gain tailored for old people would cover many health issues and would not need to concentrate on only cancer or, even worse, each cancer one by one, which really is daft! I wonder though, how strong the evidence is on outcomes, after achieving lifestyle change, in people in their 80s and 90s, one supposes after decades of earlier non-response?

It feels to me as if there is far more gain via campaigns on symptom recognition. Some idea of how many symptoms an elderly person is experiencing on a daily basis, from however many co-morbidities, side effects and impairments of ageing – plus supervising the same in a dependent spouse, for example – would show that whilst awareness might be poor, the solution is a long way away from being simple such as better distribution of a symptom leaflet – not that CR-UK is offering such a thin analysis. It’s far more complicated than that. How best to address it with solutions created thru’ up-to-date research by/with this population of men and women over 75 with co-morbidities and, perhaps, no firm belief that early symptom recognition makes any difference.

England will see a 51% rise in those aged 65+ from 2010 to 2030 (it’s already 2014) In the same period there will be a 101% increase in those aged 85+. One hundred and one percent! So says http://www.parliament.uk/business/committees/committees-a-z/lords-select/public-services-committee/report-ready-for-ageing/

This is a massive change. What is the third sector response going to be? ‘More of the same’ is not an option. Because this ageing population group has its unique facets, just like adolescents, just like people of working age, it too needs its own unique model of care and support.

Leadership is important. Single tumour organisations should put aside their single-condition orientation and work alongside each other to grow ‘whole sector’ expertise on ageing and cancer actively and strategically – learn about ageing, needs analyses, working with vulnerable populations, marketing, service uptake in this population ‘new’ to contact with cancer charities and at risk of frailty, complexity and neglect. Then see when other health charities representing co-morbidities might join? Heart disease, the neurological or respiratory disorders, mental ill-health, visual impairment….. If health charities really believe they are doing person centred care there is no excuse not to. Old people can be complicated. So working with them might be too. Get used to it.

The current stereotype of cancer charity working practice is built on the experiences of younger people – of working age. These have been the easier fundraising ask and the easiest with whom to engage.

We’re on the tough stuff now.

Ageism is what held up this Report. If there wasn’t any, we wouldn’t be looking at the effects of age, in a disease of ageing, quite so late in the demographic day.

Ageism is there because we all of us comply or collude with it. Well, let’s just stop! Take the ageism battle to the papers, just like racism, just like sexism. (Once one’s own house is in order, of course) Until the way ageing and the old people are represented in the usual broadsheet print and online media it must be challenged and challenged repeatedly; until it is always going to be the whiff of burden, demand and difficulty around old people and cancer – rather than their contribution and value.

The posited 51% rise in those aged 65+ and 101% increase in the number of men and women aged over 85 means far more new diagnoses of cancer a disease of ageing, far more recurrences and late effects in people treated for primary cancer earlier in life, far more people with more co-morbidities and more impairments of ageing, and in more people in more complicated and potentially isolating social circumstances. The conventional narrative of cancer, beloved by charities and the media is early detection, intervention and life saved. This is, for quite a lot of older men and women, overly simple or just plain wrong.

There is no Awareness Month big enough or long enough to cope with these demographic changes. The demand from ageing men and women will be different; the supply of support from cancer charities cannot remain the same. Charity activism must be junked for the new reality of demographic demand – and the demand for the sector, should they pause to consider it, is, I believe, a big cogent idea about the huge task of caring for men and women over the age of 75 who have co-morbidities, frailties and impairments alongside their cancer.

It’s not just about treatment, though it is a good place for this Report to start.

The underdeveloped clinical research agenda in elderly people with cancer is matched by the underdeveloped social research agenda in elderly people with cancer. What do patients think/do about delay? What is their perception of cancer? What are the cancer related lay beliefs in this age group, and what effect does cultural background have? What effects good and bad, do proxy information seekers have on older people e.g. daughter seeking information for her Dad. Does Dad always land up with what helps him?

Do carry on with your efforts to discuss policy and cancer for old people. Discuss, lead….and diffuse.