Malignancy
Malignancy in older people
Cancer is a disease of the elderly population, being relatively rare in people under 35 years of age, and increasing in incidence with each decade.
Why is there more cancer in older people?
As more people avoid death from infection and vascular events, so they remain alive to develop cancer
Some cancers are caused by cumulative exposure to environmental agents. A good example would be sunlight and skin cancer, or smoke and lung cancer, but dietary factors and exposure to other carcinogens are also likely to contribute over time
The process of cell replication may senesce, increasing the chance of malignant change
Is cancer different in older people?
Development of metastases may appear to be slower, the cancer overall having a more indolent course, possibly due to altered immune or hormonal responses
In contrast, some cancers appear to be more aggressive in older people (eg acute myeloid leukaemia, Hodgkin’s disease, ovarian carcinoma)
Overall, age itself has limited influence over disease progression and prognosis—factors such as comorbidity and performance status (Table 25.1) are much more important
The impact of cancer may be different in an older person. Non-cancer deaths are common in frail elderly people with malignancy, so cancer control by non-invasive means (eg tamoxifen for breast cancer) may be a better option than cancer cure by more unpleasant treatments (eg surgery)
Never underestimate the psychological impact of a cancer diagnosis, whatever the age. Heart failure carries a worse prognosis than many cancers, yet news of its diagnosis rarely has such an impact. Whatever your assessment of a person’s quality of life, they may see things very differently—you will not know until you ask. The adverse reaction to the diagnosis is often tied up with fears about a slow and painful death (rather than death itself) and careful explanation about symptom control measures may allay some concerns
HOW TO … Describe performance status
Table 25.1 Performance status scoring | ||||||||||
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An approach to malignancy
Make the diagnosis
Even if no curative treatment is possible, a diagnosis allows targeted symptom control and gives an idea about the likely course of the disease and the expected prognosis
Many people find ‘not knowing what is wrong’ very hard, and may find a diagnosis a relief, as it allows the future to be planned
Sometimes a frail patient is obviously dying, and investigations can be an additional burden, without hope of finding reversible pathology. In this case, blind palliation of symptoms is the best course. This should be combined with careful explanation to the patient and family
There are many shades of grey in between these two extremes. In some cases, finding multiple metastases on a scan may be enough to plan management. In others, a histological diagnosis by biopsy is required to fully balance risks and benefits of treatment. Each individual should have benefits of diagnosis weighed up against discomfort (and cost) of investigation
Once diagnosis is made, attempt to stage the disease
This allows accurate prognostication and gives the patient better information on which to base treatment decisions. Again, there are exceptions to this (eg the very frail who are likely to die from other causes), and each individual should be considered separately.
Assess patient factors that will influence outcome
▶Age is not one of these factors
Comorbidity will adversely affect both disease prognosis and tolerance to treatment
Functional status is the other main predictor—is the patient active and asymptomatic, active but with symptoms, slowed down by symptoms or incapacitated by them? Oncologists use performance status (see Table 25.1) as an indicator of functional ability and a score of ≤3 correlates with a median survival of 3 months. Comorbid conditions and poorer functional status will be more common in older people, but not universal, so purely age-related treatment decisions are unwise.
Utilize a specialist multidisciplinary approach
Cancer care changes rapidly, and it is hard for the generalist to keep up to date, so specialist referral is usually needed. Many different specialists work together in MDTs to provide cancer management, determining the best options individually. Specialist nurses often perform a coordinating role in the patient’s journey through the system, providing consistent, non-threatening support, allowing fears to be discussed and providing practical help (eg arranging additional help at home).
Discuss decisions carefully with the patient
Some patients who have led a long and healthy life (and so would potentially do well from therapy) may wish simply to die without being ‘messed about’. Other patients with multiple problems and poorer outlook may take any chance at a prolongation of life whatever the cost.
Presentation of malignancy
In a cognitively intact and physically fit older patient with a malignancy, presentation is often typical—eg a breast lump, a thyroid nodule, altered bowel habit with an iron deficiency anaemia. In these cases, there is little dilemma—management is as for all patients with such a complaint.
In the frail elderly person, the presentation is often less clear. Cancer may be found incidentally (eg a mass on a routine CXR) or there may be a highly suggestive clinical scenario. Judging how hard to look and to what end is a common challenge in geriatric practice.
Common presenting scenarios include
Weight loss without apparent cause
Always check a dietary history (and corroborate it with family or friend), measure thyroid function, screen for depression, and assess cognitive state
If there are no localizing symptoms or signs on careful history or examination, then check screening investigations (see
‘HOW TO … Screen for malignancy’, p.631)
If these are normal, then malignancy is relatively unlikely, and dietary support with reassessment at an interval may be appropriate (see
‘HOW TO … Manage weight loss in older patients’, p.357)
Following up hints offered in a systems enquiry (eg admits to occasional loose stool) will depend on the individual patient—whether they would tolerate bowel investigation, whether they would be fit for treatment if malignancy is found and, crucially, what they wish to do
Elevated inflammatory markers (ESR, CRP)
This is a relatively common scenario
Begin with the screening history, examination and investigations
An important differential diagnosis is sepsis, and this should be actively sought with cultures and appropriate tests such as echocardiogram
Consider giving the patient a thermometer and temperature chart to fill in
Look at joints and bones as a possible source (gout, septic arthritis, discitis, osteomyelitis, etc.)
Remember diverticular and sub-diaphragmatic abscesses
Have a low threshold for thinking of endocarditis (see
‘Overview of infection in older people’, p.608)Related posts:
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