M.H. is an 87-year-old woman who has been a breast cancer survivor for several years. She had been diagnosed 6 years earlier with a 2.3 cm, node-positive, estrogen receptor-positive, infiltrating ductal carcinoma. She was originally treated with lumpectomy, followed by chemotherapy and radiation therapy, which she tolerated well. She has since completed almost 5 years of endocrine therapy with an aromatase inhibitor. Her coexisting illnesses include osteopenia, gastroesophageal reflux disease, and glaucoma. The patient is a retired pianist who continues to perform as an entertainer locally. She has a very supportive social network of friends in the area and two sons who live out-of-state. She is also active with swimming and bridge.
S.W. is a 79-year-old prostate cancer survivor. Eight years prior, he was referred for a prostate biopsy after his prostate specific antigen (PSA) level had risen to 5.4 ng/mL. The pathology revealed a Gleason 3+4=7 prostate cancer involving both the right and left lobes of the prostate with no capsular extension of disease. He underwent radical prostatectomy at that time and was followed with PSA measurements. Because of a rise in PSA level 3 years later, he was treated with external beam radiation. He is currently followed with yearly PSA measurements, which have been undetectable. The patient also has hypercholesterolemia, hypertension, aortic stenosis, congestive heart failure, multinodular goiter, osteoarthritis, and memory loss. The patient ambulates with a cane. He lives in an assisted living facility and has a caregiver during the day. He has a supportive family and they live close by.
With long-term survival from cancer rising, the number of cancer survivors is growing, and the majority (61%) of cancer survivors are aged 65 and older. According to a 2003 report of the National Cancer Institute (NCI) Office of Cancer Survivorship, there are over 10 million cancer survivors in the United States, representing 3.6% of the population. These numbers are expected to rise, given the increasing incidence of cancer and the aging of the population. Currently, an estimated one in every six people older than 65 years is a cancer survivor, highlighting the need to increase awareness and emphasize how to best care for this growing population in the oncology and geriatrics communities.
Because of improvements in cancer therapies, the 5-year and extended disease-free survival rates for early-stage breast, colorectal, and prostate cancer are over 90%. Likewise, early-stage melanoma, Hodgkin lymphoma, and cancers of the bladder, uterine cervix, and testes are associated with excellent survival outcomes. As a result, for most cancer survivors, death is more likely to occur from competing illnesses. However, cancer treatment modalities including surgery, radiotherapy, node evaluation, chemotherapy, and endocrine therapy have been shown to be associated with late effects that may persist for up to 20 years after initial treatment, including cognitive effects, physical effects, psychosocial adjustments, and functional decline. Many of these late effects overlap with physiological changes that occur with advancing age and with medical conditions associated with advancing age, making them an important focus in the care of the older cancer patient.
Definition of Cancer Survivor
According to a broad definition developed in 1986 by the National Coalition for Cancer Survivorship, any cancer patient or close family member of a cancer patient, from the time of diagnosis until death, may be considered a cancer survivor. More recently, the term survivor has been used to denote a more focused period of time beginning after the completion of initial treatment with curative intent, when the patient is being seen posttreatment and in follow-up (Ganz 2005). It is this period of time that will be the focus of this chapter. Important issues that arise in this period of time with respect to managing symptoms and late effects, as well as health care maintenance and screening in this population, will be addressed.
Heterogeneity of Aging Cancer Survivors
Cancer in patients older than 65 years is a heterogeneous process in a heterogeneous population. Heterogeneity arises in the number and severity of coexisting illnesses, cognitive function, physical activity and performance status, and social connectedness. (Balducci 2008) While one patient aged 95 may be skiing, another aged 67 may be bed-bound. Surviving and thriving while experiencing the impacts of cancer and its therapy is a personal and individualized process, especially in the older patient. The two cases described earlier highlight the dramatic individual differences that can be seen in the older population.
Palliation, Prevention and Health Promotion
The goals of care for survivors have been well summarized as the 3 Ps of survivorship: palliation, prevention, and health promotion. (Ganz) With palliation, the intention is to improve quality of life. This goal is especially important in older people with complex and chronic illness. Concentration is placed on reducing the severity of prolonged disease symptoms where there is no curative medical treatment. These symptoms include pain, fatigue, depression, physical limitations, cognitive changes, lymphedema, sexual dysfunction, and menopause-related symptoms.
The main focus of the second P, prevention, is providing systematic follow-up required to screen for late-onset complications of cancer and its treatment. Complications that can arise as a result of treatment, such as osteoporosis, heart disease, and cataracts, are often conditions that are also associated with aging. The goal of this screening is early detection and early intervention for these complications. Another goal of prevention is to screen for second malignancies, and to counsel patients on chemoprevention and lifestyle modification that may decrease risk of a second malignancy.
Finally, the goal of health promotion is to endorse risk reduction for common health problems. In the older patient, these problems include other chronic diseases, such as diabetes and heart disease, as well as functional decline. Therefore, the focus of this third P is on educating patients about the importance of increasing physical activity, avoiding weight gain, and avoiding exposures that are harmful. For example, one harmful exposure, alcohol consumption, in older adults is associated not only with risk of malignancy, but also with increased risk of falls, medication interaction, and depression.
Comprehensive Care for Survivors
A clinical program designed to meet the special health needs of cancer survivors should be multidisciplinary in nature. Under this concerted approach, the patient undergoes a nutritional evaluation, psychological evaluation, social work assessment, and evaluation by physical therapy and occupational therapy. Recommendations are discussed as a team and an integrated care plan is formulated together with the primary care physician. This comprehensive model has already been proven to be effective in geriatric medicine and is likely to be of great benefit for older cancer survivors. The shared care model that has been recently developed for survivor care will be discussed later in the chapter.
Late Effects of Cancer Treatment
Late effects have been attributed to chemotherapy, surgery, radiotherapy, and endocrine therapy; these effects can persist for decades. There is a great deal of overlap between late effects of cancer therapy and the physiological changes that occur with advancing age. Table 24-1 highlights this overlap and lists by system the late effects of therapy that commonly occur in cancer survivors alongside the potentially interacting age-related changes in that physiological system.
|System||Chemotherapy||Radiotherapy||Surgery||Endocrine Therapy||Age-Associated Physiologic Changes|
|Cardiovascular||Cardiomyopathy, congestive heart failure||Scarring, inflammation, pericardial effusion, pericarditis, coronary artery disease||—||Venous thrombotic events||Decreased cardiac output, decreased maximum oxygen consumption, increased inflammatory cytokines|
|Pulmonary||Pulmonary fibrosis, inflammation interstitial pneumonitis||Pulmonary fibrosis, decreased lung function||Shortness of breath||—||Decreased FEV1, decreased D L CO, decreased total lung capacity|
|Gastrointestinal||CASH, hepatic fibrosis, cirrhosis||Malabsorption, biliary stricture, liver failure||Intestinal obstruction, hernia, altered bowel function, nausea, vomiting||—||Impaired peristalsis, delayed gastric emptying time, impaired absorption, decreased liver blood flow|
|Genitourinary||Hemorrhagic cystitis||Bladder fibrosis, small bladder capacity||Incontinence||Vaginitis||Diminished bladder capacity, enlarged prostate|
|Renal||Decreased creatinine clearance, delayed-onset renal failure||Decreased creatinine clearance, hypertension||—||—||Increased blood pressure, decreased creatinine clearance|
|Hematologic||Myelodysplasia, acute leukemia||Myelodysplasia, cytopenias, acute leukemia||—||Anemia||Anemia|
|Musculoskeletal||Avascular necrosis||Osteonecrosis, fibrosis, atrophy, deformity||Accelerated arthritis||Osteopenia||Decreased bone density, decreased muscle strength and muscle volume|
|CNS||Problems with thinking, learning, memory; structural brain changes; paralysis, seizure; fatigue||Problems with thinking, learning, memory; structural brain changes; hemorrhage; fatigue||Impaired cognitive function, motor sensory function, vision, swallowing, language, bowel and bladder control, phantom pain (amputation), fatigue||Mood changes, fatigue, generalized weakness, hot flashes||Decreased brain weight, increased reaction times, diminished smell, decreased digit span and block span, impaired circadian rhythm and sleep|
|Peripheral nervous system||Peripheral neuropathy, hearing loss||—||Neuropathic pain||—||—|
|Pituitary||Diabetes||Growth hormone deficiency, other hormone deficiencies||—||—||Decreased growth hormone and DHEA, impaired insulin sensitivity|
|Thyroid||—||Hypothyroidism, thyroid nodules||—||—||Decreased thyroxine secretion|
|Gonadal||Sterility, early menopause||Sterility, ovarian failure, early menopause, Leydig cell dysfunction||Retrograde ejaculation, sexual dysfunction, testosterone deficiency||—||Decreased testosterone, decreased LH and FSH, decreased estradiol|
|Oral health||Tooth decay||Dry mouth, poor enamel, dental carries||—||—||Decrease in salivary flow rate|
|Ophthalmologic||Cataracts||Cataracts, dry eyes, visual impairment, retinopathy||—||Cataracts||Reduction in pupil size, loss of accommodation, impaired night vision|
|Skin||Rashes||Burn||Impaired wound healing, cosmetic effects||—||Epidermal atrophy, increased stiffness in dermal collagen, slower wound healing|
|Immune||Impaired immune function, immune suppression||Impaired immune function, immune suppression||Impaired immunity and risk of sepsis (splenectomy)||—||Impaired cell-mediated immunity|
|All tissues||Second cancer||Second cancer||—||Endometrial cancer||Increased risk of cancer|