Cancer may drive health problems as people age

A new study indicates that cancer may have negative impacts on both the physical and mental health of individuals as they age. Published in CANCER, a peer-reviewed journal of the American Cancer Society, the study suggests that cancer increases the risk for certain health issues above and beyond normal ageing. This is likely due, in part, to decreased physical activity and stress associated with cancer diagnosis and treatment.

As the population of older adults grows, it is increasingly important for clinicians to understand the unique impact of cancer on the health of individuals as they age. To investigate, Corinne Leach, MS, PhD, MPH, of the American Cancer Society in Atlanta, and her colleagues analysed cancer registry data that were linked to Medicare surveys. The analysis included 921 Medicare beneficiaries with a breast, colorectal, lung, or prostate cancer diagnosis who completed initial surveys in 1998 and 2001 and follow-up surveys two years later. These patients were matched to 4605 controls without cancer.

Cancer groups demonstrated greater declines in activities of daily living and physical function compared with controls, with the greatest change for lung cancer patients. Having a cancer diagnosis increased risk for depression but did not increase the likelihood of developing arthritis, incontinence (except for prostate cancer), or vision/hearing problems. Having a cancer diagnosis also did not exacerbate the severity of arthritis or foot neuropathy.

This prospective analysis used a propensity score matched control group to cancer cases that enabled us to tease apart the effects of cancer and ageing in a novel way,” said Dr. Leach. “Decreased physical functioning among older cancer patients compared with older adults without cancer is an important finding for clinicians because it is also actionable. Clinicians need to prepare patients and families for this change in functioning levels and provide interventions that preserve physical function to limit the declines for older cancer patients.”

Leach et al. “Is it my cancer or am I just getting older?: Impact of cancer on age-related health conditions of older cancer survivors.” Cancer, 2016; DOI: 10.1002/cncr.29914 [Abstract]

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Older people not receiving adequate access to cancer care

Older people all around the globe are being denied proper access to cancer care, according to an editorial by Queen’s University Belfast academic, Professor Mark Lawler of the Centre for Cancer Research and Cell Biology.

In an editorial in the BMJ (British Medical Journal) Professor Lawler said: “there is increasing evidence from around the world that elderly patients are being ‘undertreated’, leading to a ‘survival gap’ between older and younger patients.

We need a fundamental change in cancer policy for the elderly patient. Our current practices are essentially ageist, as we are making judgements based on how old the patient is rather than on their capacity to be entered into clinical trials or to receive potentially curative therapy. It is disappointing that we see different principles being applied for older patients when compared to younger patients, with these differences leading to poorer outcomes in the elderly patient population.”

Professor Lawler’s findings are published in an editorial in the BMJ entitled, ‘Ageism In Cancer Care: We Need to Change The Mindset‘. It states the need to redress the disparities in the policy on cancer for older patients, citing a recent position paper from the European Organisation for Research and Treatment of Cancer, the Alliance for Clinical Trials in Oncology and the International Society of Geriatric Oncology recommending that clinical trials should be without an upper age limit.

A high proportion of older women with a certain form of breast cancer (‘triple negative’) receive less chemotherapy than their younger counterparts – despite evidence of the treatment’s efficacy in this patient cohort, the authors claim.

They also point out that more than 70 per cent of deaths caused by prostate cancer occur in men aged over 75 years, who usually have more aggressive disease. Few older patients, however, receive treatment for localised prostate cancer, and in most cases they are denied access to chemotherapy for advanced disease, they add.

Colorectal cancer is another disease of older people, yet the evidence again suggests that optimal treatment is not being provided to this patient cohort,” Professor Lawler continues.

The paper sets its argument within the context of an ageing society – both locally and globally. Estimates for the UK suggest that 76 per cent of cancers in men and 70 per cent of cancers in women will occur in the over-65 population by 2030.

In the US, the number of over-65s is set to double at least, from around 40 million in 2009 to 89 million in 2050. Cancer is mainly a disease of the elderly. Given our ageing demographic, the paper argues, this will lead to an exponential increase in the number of cancer deaths unless we change our approach towards the elderly cancer patient.

The International Cancer Benchmarking Partnership – a collaboration that compares clinical outcomes between Australia, Canada, Denmark, England, Northern Ireland, Norway, Sweden and Wales – has indicated decreased survival for patients older than 65 years. A EUROCARE 5 study confirmed this trend, suggesting that the survival gap was widening between older and younger patients in Europe.

The evidence provided highlights the ‘urgent need’ for a ‘geriacentric’ strategy that maximises clinical trial activity in older patients, makes existing treatments more available and develops new approaches that are well tolerated in older people, the paper says in its closing comments.

Professor Lawler concludes: “Such a strategy will also have to ensure that the principle of early diagnosis (underpinning more effective and less aggressive treatment) is applied in older patients as well as in their younger counterparts. Only then can we truly deliver a comprehensive cancer service to the elderly population in our society.

Lawler et al., (2014). Ageism in cancer care: We need to change our mindset. BMJ348:g16  doi: http://dx.doi.org/10.1136/bmj.g1614 [Abstract]

Guidelines for stem cell transplants in older patients with myelodysplastic syndromes

A new study by an international team led by Dana-Farber Cancer Institute scientists provides the first statistically-based guidelines for determining whether a stem cell transplant is appropriate for older patients with myelodysplastic syndromes (MDS) – the most common blood disorders in people over 60 years of age, and frequently a precursor for leukemia.

Using mathematical models to analyze hundreds of MDS cases from around the world, the researchers found reduced intensity transplants of donor stem cells are advisable for patients aged 60-70 who have higher-risk forms of MDS that are likely to turn into leukemia in the near future. For patients with lower-risk MDS, non-transplant treatments are preferable, the model indicates. The research was reported online today in the Journal of Clinical Oncology.

“Our study helps inform older MDS patients and their doctors whether a stem cell transplant is preferred or whether it makes more sense to pursue other options,” says John Koreth, MBBS, DPhil, medical oncologist in the Division of Hematologic Malignancies at Dana-Farber, who is the study’s lead author and co-principal investigator (with Joseph Pidala, MD, MS, of the H. Lee Moffitt Cancer & Research Institute, and senior author Corey Cutler, MD, MPH, of the Division of Hematologic Malignancies at Dana-Farber). “Until now, there haven’t been statistically-quantified guidelines for making these decisions for older patients, who are most impacted by the disease.”

MDS arises in the blood-forming cells of the bone marrow, causing a drop in the number of healthy white and red blood cells and of platelets needed for blood clotting. Depending on which type of cells are in short supply, the result can be fatigue, shortness of breath, easy bruising and bleeding, or infection and fever. An estimated 12,000 people in the United States are diagnosed with MDS each year, and more than 80 percent of whom are over age 60. (Some researchers believe MDS to be widely under-diagnosed, so the number of people affected may be much larger.)

In some cases, MDS produces only mild symptoms that don’t worsen for years. In others, the symptoms can be severe, leading to the development of a fast-growing form of leukemia. The most common tool for predicting the course of MDS is the International Prognostic Scoring System (IPSS), which is based on a patient’s blood counts, percentage of immature “blast” cells in the blood or bone marrow, and occurrence of chromosomal abnormalities in these cells. Based on IPSS scores, the disease is classified as low risk, intermediate-1 or -2 risk, or high risk.

Patients in the first two categories, with lower-risk disease, usually receive treatments such as antibiotics, transfusions, blood cell growth-promoting agents, or other supportive therapies to alleviate their specific symptoms. Patients in the latter two categories, with higher-risk disease, often receive chemotherapy.

While these treatments are often helpful, they cannot cure the disease. The only potentially curative treatment is a donor stem cell transplant, which can, in principle, be used for patients with any stage of MDS. But because even reduced-intensity transplants are fatal in a significant minority of cases, there has been some uncertainty over the use of transplantation for older patients with MDS.

“It hasn’t been clear for which older patient groups the benefits of transplant outweigh the risks,” Koreth says. To find out, researchers collected data on 514 patients, age 60-70, who were newly diagnosed with MDS. For both lower- and higher-risk groups, they built separate mathematical models to compare treatment outcomes in patients who received reduced-intensity donor stem cell transplants with outcomes in patients who received non-transplant therapies. They analyzed not only length of survival but also the quality of life of patients in those groups.

Patients in the lower-risk groups who underwent transplant lived an average of 38 months after treatment, less than the 77 months for those who were treated without transplant. For patients in the higher-risk groups, by contrast, average life expectancy was 36 months for those receiving transplants, better than the 28 months for those receiving non-transplant therapies. Adjusting for patients’ quality of life did not change the conclusions regarding the relative merits of the treatments.

“The clear result is that, on balance, reduced-intensity stem cell transplantation offers a survival benefit for patients with higher-risk MDS, but not for those with lower-risk disease,” Koreth says. “The findings should offer useful guidance for older patients with MDS on deciding the best course of treatment.”

Koreth et al., (2013). Role of reduced-intensity conditioning allogeneic hematopoietic stem-cell transplantation in older patients with de novo myelodysplastic syndromes: An international collaborative decision analysis. J. Clin. Oncol., EPub Ahead of Print [Abstract]