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Cancer screening rates ‘unexpectedly high’ among adults aged 85 years and older
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Individuals aged 85 years and older underwent cancer screening at “unexpectedly high” rates even though it is generally not recommended for this age group, according to a report published in CA: A Cancer Journal for Clinicians.
Cancer incidence and mortality trends among this patient demographic — known as the “oldest old” — appeared similar to those for individuals aged 65 to 84 years. However, the older group had lower survival rates, results showed.
“There is essentially no data on how to treat these patients, because clinical trials implicitly or explicitly make it almost impossible for people in this group to be enrolled,” co-author William Dale, MD, PhD, Arthur M. Coppola family chair in supportive care medicine at City of Hope, told HemOnc Today. “The challenge with these older adults is that we either overtreat or undertreat them. We rarely know exactly what to do.”
Incidence and mortality
The number of adults aged 85 years and older is projected to nearly triple — from 6.4 million in 2016 to 19 million by 2060 — as less smoking, improved screening and treatment advances reduce all-cause mortality.
Dale and colleagues sought to better understand the cancer burden among this oldest age group by collecting data from the SEER database, North American Association of Central Cancer Registries and National Center for Health Statistics.
They found that, although adults aged 85 years and older comprise 2% of the U.S. population, they account for 8% of all new cancer diagnoses. This is equivalent to about 140,690 new diagnoses (61,830 male, 78,860 female) projected for 2019. Men in this age group with no history of cancer face a 16.4% risk for an invasive cancer diagnosis in their remaining lifetime, compared with a 12.8% risk among women.
Overall risk for cancer increases with age until roughly ages 80 to 84 years for women, and ages 85 to 89 years for men. Although the reasons for the reduction in risk beyond these ages are not fully understood, the report suggested it may be a result of genetic factors or natural aging processes that suppress tumor growth.
Cancer rates among adults aged 85 years and older reached a peak in 1990 but declined rapidly since then. Researchers noted this trend reflects decreases in colorectal and prostate cancers, as well as more recent reductions in lung cancer among men and breast cancer among women.
Still, cancer is the second leading cause of death after heart disease for this age group.
Approximately 103,350 cancer deaths (49,040 men, 54,210 women) are expected to occur among this population in 2019, representing 17% of total U.S. cancer mortality. The remaining lifetime risk for cancer mortality by age 85 years is 14.4% for men and 9.6% for women.
Prostate and lung cancers are the most prevalent causes of cancer death among men aged 85 years and older; these cancers combined account for 40% of cancer deaths. The leading cause of cancer death among women aged 85 years and older is lung cancer (19%), followed by breast cancer (13%). Colorectal cancer is the third leading cause of cancer mortality among both men (9%) and women (13%) in this age group.
Researchers observed different trends in certain cancers — such as melanoma and lung cancer — between the oldest group and those aged 65 to 84 years, likely an indication of elevated risks among the oldest old.
Moreover, patients aged 85 years and older had greater disease progression at diagnosis than patients aged 65 to 84 years, with smaller proportions of the oldest old presenting with local-stage breast cancer (57% vs. 68%) and local-stage prostate cancer (41% vs. 77%). The researchers noted this disparity likely is attributable to lower rates of screening among patients aged 85 years and older. Screening typically is not recommended for the oldest old due to decreased life expectancy, higher rates of serious comorbidities and limited evidence of survival benefit.
“For most individuals in this age group, the small potential benefit of extending life is outweighed by the possible harms,” Dale and colleagues wrote.
Screening the elderly
Despite the limited likely benefit, many of the oldest old underwent some form of cancer screening, according to data from the National Health Interview Survey.
More than a third of women aged 85 years and older reported in 2015 that they underwent a mammogram during the prior 2 years, and 18% received cervical cancer screening tests. Meanwhile, more than half of individuals aged 85 years and older reported undergoing a stool screening test within the past year, or a sigmoidoscopy or colonoscopy within the previous 5 to 10 years. Almost 30% of men in this age group were tested for PSA levels during the prior year.
“For some people, screening is what I will call a ‘moral imperative,’” Dale said. “They feel like they are not a good person if they don’t get their regular screenings. They might think, ‘I’ve always gotten my mammogram’ or ‘I’ve always gotten my PSA screening,’ and they feel obligated to keep doing it.”
Treatment decisions
The report’s authors also concluded that the oldest old patients with cancer are less likely than younger patients to undergo surgical treatment.
They found “the most striking difference” in breast cancer.
Only 65% of patients aged 85 years or older with breast cancer received surgery, compared with 89% of those aged 65 to 84 years.
Age alone is not a reason to forego surgery; instead, clinicians who treat older adults must take several factors into account to avoid undertreatment or overtreatment, Dale said.
“If someone is older but still has good health status and a reasonable life expectancy, not treating the cancer is really just discrimination,” Dale told HemOnc Today. “Instead of drawing lines that are relatively arbitrary based on chronological age, we need a measure of functional and physiological age.”
Conversely, if a patient is frail or otherwise unfit, clinicians must weigh the benefits and risks of a particular treatment.
“We can consider whether to do a full dose or follow the geriatric principle of ‘start low, go slow,’ inching up the dose as high as we can,” Dale said. “On the other hand, maybe we should talk to the patient about their overall life goals and discuss the risks in an appropriate way before we blindly treat them.”
Physician-patient communication is essential, Dale added.
“We need to discuss what the patient wants,” he said. “I treat World War II veterans who will say, ‘You know, I charged the machine gun nest. I’m a go-for-it kind of person, and I want to go for it,” he said. “On the other hand, you might have a patient whose family [favors treatment] but the patient is thinking, ‘I’ve had a good life, I don’t want to go through this.’ It’s mistreatment not to talk to them about it.”
The report’s authors concluded that more research on the cancer burden among the oldest Americans is necessary to appropriately address their complex health care needs and improve outcomes.
A deeper understanding of this age group will require more creative approaches to clinical trial design and a decreased emphasis on chronological age, Dale added.
“Older patients can get quite advanced cancers and, just because a patient is aged older than 85 years doesn’t automatically mean they should be treated differently,” he said. “We really need to pay better attention to their health status rather than their age so that we can treat an increasingly healthy older population in a nonageist, nondiscriminatory way.” – by Jennifer Byrne
For more information:
William Dale, MD, PhD, can be reached at City of Hope Comprehensive Cancer Center, 1500 E. Duarte Road, Duarte, CA 91010.
Disclosures: Dale reports no relevant financial disclosures. Please see the report for all other authors’ relevant financial disclosures.
Perspective
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Selina Chow, MD
This report by DeSantis and colleagues has provided greater insight on the “oldest old” cancer population. Very little is known about cancer adults aged 85 years and older, for whom cancer clinical trial data are limited. Historically, these older adults were excluded from trials due to rigid eligibility or enrollment criteria. This article revealed the national trends that we’re seeing in this population of patients along the entire cancer care continuum.
Although it was unsurprising that cancer incidence and prevalence among patients aged 85 years or older have decreased over time and that the most common cancers in these adults are similar to their younger cohorts, it was unexpected to see the high rates of breast, colorectal and prostate cancer screening in this age group where considerations of comorbid conditions, physical function and overall life expectancy may have a greater role in a patient’s medical care. This finding may need further exploration as to what is guiding older patients or physicians to continue cancer prevention screening in this patient group.
The trends found by the authors that patients with cancer in this age group are more likely to be diagnosed at an advanced stage or are less likely to accept surgical treatment may be a reflection of the unintended biases that patients or clinicians may have when it pertains to older age. Rather than focusing on a person’s chronologic age, wider education and implementation of geriatric assessment may help determine a patient’s functional and physiologic age that clinicians and patients can use to better inform cancer treatment decisions. Ultimately, we must strike a balance to providing appropriate cancer-directed treatment without overtreatment that may lead to increased side effects, or undertreating patients leading to shortened survival.
As the “silver tsunami” wave rises over the next few decades, clinicians will likely see more patients in their clinics who may have been treated for cancer in the past. Issues related to survivorship, such as the impact of prior cancer treatments on a patient’s function, cognition or psychologic state may need to be addressed during routine medical care. Additional research into cancer survivorship for the older patient population is needed to help ensure successful aging.
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