At what age are you too old to treat?
New research exposes a misconception that older people are more likely to refuse treatment following a cancer diagnosis. Nurses can play a role in obtaining more accurate assessments of older people and raising awareness that cancer risk rises with age.
Up until this point the 74-year-old retired lorry driver – a keen motorcyclist – had felt fit and active, having often been mistaken for a man in his early sixties.
He thought the GP did not take his symptoms seriously. ‘He said I needed to take more exercise, but I was always active and walked for miles. He accused me of sitting round all day watching TV – and I didn’t even have a TV,’ he says.
‘It was only some weeks later when I was screaming in pain and saw the emergency doctor at the hospital that I found out I had cancer.’
Mr Worthington’s experience is not a one-off. Research suggests that older people are more likely than their juniors to be diagnosed with cancer following an emergency presentation, when disease is at a more advanced stage.
Studies have also shown that older people are less likely to be given life-saving treatment. It was thought that this was because they are more likely to decline medical interventions.
However, an Ipsos Mori survey of 1,500 people, conducted for Macmillan Cancer Support, shows that older people are no more likely to refuse cancer treatment than younger patients. The survey also shows that older people are less likely to question decisions about what treatment might be best for them – leading the charity to warn that a new approach is needed.
Barry Worthington, like many older people, was diagnosed with cancer through an emergency consultation
‘What the research is pointing to is that the way that people aged over 65 are being treated is based on age, rather than physical capacity,’ says Macmillan Cancer Support head of inclusion Jagtar Dhanda.
‘We want to make sure that assessments of people are as holistic as they can be, and are based on people’s physical and mental health and wellbeing, so treatment decisions are based on the individual, and not on age alone.’
Nurses have a part in this, he adds. ‘We know that nurses play an important role in improving patient experience, and have great skills around listening and communication and much else. But we want to see better, more informed assessment: we need a better skills mix, including geriatricians as well as oncologists, and nurses can support both.’
Macmillan nurse specialist in acute oncology Philippa Jones sits on the Geriatric Oncology Expert Reference Group, set up by the charity and the British Geriatrics Society to inform the development of improved care and treatment for older people with cancer.
She says nurses should be aware of particular issues to consider around older people with cancer. ‘Often there can be comorbidities, and an older person might be more likely to be a carer, for a spouse or other family member,’ she says.
Around 30% of older people are diagnosed via emergency admission.
The new research shows that an overwhelming majority of people are not aware that the risks of getting cancer increase with age. They may not be seeking medical assistance with symptoms that could lead to early diagnosis – and nurses could help raise awareness of this, Ms Jones says.
‘Treatment should be offered based on holistic assessment of an individual patient,’ she adds. ‘What matters is that all health professionals should be working to get people diagnosed early and quickly enough, then make sure they get offered the right treatment, based on their circumstances, not on whether they are 56 or 76.’
12% of those aged 75 or over said they opted not to have certain types of treatment for cancer compared to 15% of those aged 55 to 64 and 14% of those aged 65 to 74.
The overwhelming majority of over-55s living with and without cancer (90% and 84% respectively) do not think that cancer is an age-related disease, despite evidence that shows that older people are at risk.
Most of those questioned feel there is at least some prejudice (among health professionals) against older people with cancer, but only one in nine felt that healthcare staff made decisions based on their age and not how fit they were.
Older people say they are willing to seek help but are not necessarily aware of services to support them.
Older people are no more concerned than younger people about the consequences of treatment, but are particularly concerned about maintaining independence.
Just over half of over-55s interviewed for the study believe that their life experience better equips them to cope with cancer.
Age UK charity director Caroline Abrahams says that making decisions on care on the basis of age alone is unacceptable.
‘There is a wealth of evidence that older people have poorer access to cancer treatment. We know from our own research that access to cancer treatment drops off dramatically after the age of 75, even though one third of all cancers are diagnosed above this age.
‘This report also shows that few older people would refuse treatment, demolishing the stereotype that fears about side effects or the effects of other health problems make older people especially inclined to turn down medical interventions for their cancer.
‘It is true that many older people have multiple medical conditions, but this is never a valid reason for excluding them. And to jump to the conclusion that someone is unsuitable for treatment on the basis of their age alone is just plain ageist and totally unacceptable.’
Mr Dhanda agrees. ‘We need to have better assessment and better services for older people because the survival rates are so poor in the UK that they lag behind similar countries in Europe. We need to change things so that our ratings improve.’
In Mr Worthington’s case, it was found that he had prostate cancer and the disease had caused a tumour on his spinal cord. It has been operated on successfully, and the prostate cancer is being managed with hormone therapy.
For Mr Worthington there was no question of refusing treatment because of his age. ‘I was told that while the operation was risky, without it I would be in a wheelchair in three months. There was no doubt that I’d go for it.
‘I’m not as mobile as I was, and I have good days and bad days. But I have never lived my life thinking I was an old man – and I’m not about to start now’.