Cancer in older adults, especially those occurring in individuals aged 65 years or older, presents unique considerations. And while the risk of cancers increases with age, the suitability of cancer treatments, like chemotherapy, surgery or radiation therapy, must be carefully evaluated based on older adults' health, fitness and psychosocial circumstances.

In this blog, we delve into cancer in older adults and cancer treatment options, addressing concerns and offering insights for informed decisions.

Chances of Getting Cancer by Age

A notable trend in recent years is the increase in life expectancy, due to advancements in healthcare, improved living conditions, and better access to medical care. While this is undoubtedly positive news, it also brings to light the challenges associated with an ageing population, including a higher incidence of cancer.

As we grow older, our likelihood of developing cancer increases, a fact that may come as a surprise to many, given the frequent media focus on cancer in younger populations. However, it is far less common for younger individuals to be diagnosed with cancer.

In fact, according to the Singapore Cancer Registry Annual Report 2021, the landscape of cancer diagnoses has shifted dramatically over several decades. From 1968-1972 to 2017-2021, there was a noticeable decline in cancer diagnoses among younger age groups, whereas diagnoses among the elderly groups saw a significant rise. Specifically, the proportion of individuals diagnosed with cancer at the age of 70 and above doubled from 16.3% to 39.2%. Additionally, the median age at diagnosis increased from 58.7 years to 66.4 years.

This shift is reflected in the patterns of the most common cancers. For instance:

• Males under 30: Lymphoid neoplasms are the most common.
• Males over 50: Colorectal and prostate cancers are more common.
• Males 80 and over: Lung cancer is the most prevalent.
• Females under 30: Lymphoid neoplasms are the most common.
• Females 30 to 79: Breast cancer is the most frequent diagnosis.
• Older females: Colorectal and lung cancers are more prevalent.

This demographic shift has significant implications for healthcare systems. It highlights the need for increased emphasis on geriatric oncology and the development of personalised treatment strategies that address the unique needs and circumstances of older adults.

Why Does the Risk of Cancer Increase with Age?

As individuals age, their risk of developing cancer increases due to various factors, such as cumulative exposure to environmental toxins, genetic predisposition, and age-related changes in the body's cells.

In general, the ageing process naturally leads to the accumulation of cellular damage. This damage often arises spontaneously from normal metabolic processes or from external sources like tobacco smoke, excessive alcohol consumption, and UV radiation exposure.

Our bodies are typically adept at repairing cellular damage or triggering the self-destruction of damaged cells. However, over time, with age, the efficiency of these repair mechanisms diminishes. If the cellular damage persists, these cells may begin to behave abnormally, which can sometimes lead to cancer. And the longer our cells are exposed to internal and external risk factors, the greater the likelihood of significant damage, making cancer more probable as we age.

Cancer In Older Adults: Unique Considerations

While treatment strategies for cancer are broadly consistent across different age groups, focusing on the type and stage of cancer, older adults present specific challenges and needs that differ from those of younger patients. Therefore, it is important that cancer treatment plans are tailored for older individuals by considering their overall health, existing comorbidities, and life circumstances.

Does Age Matter in Cancer Treatment?

Age-related factors can significantly influence treatment decisions. Older adults may have reduced tolerance for certain cancer treatments, such as chemotherapy, and diminished reserves to respond to disease and treatment-related complications.

They are more likely to have multiple medical problems, functional limitations, and variable access to transportation, social support, and financial resources. Balancing one’s quality of life and life expectancy becomes a crucial consideration for both older adults and their caregivers. Older adults are 11 times more likely to develop cancer in comparison to younger people, and approximately 60% of all cancer patients are 65 and older, it’s essential to learn more about how we can rationalise the use of the different types of cancer treatment in older adults.

Cancer Treatment Options

Cancer treatment encompasses a range of approaches, from traditional therapies like chemotherapy and radiation to other methods such as targeted therapies and immunotherapy.

Chemotherapy And Its Role In Cancer Treatment For Older Adults

Chemotherapy is a common cancer treatment that uses drugs to eliminate cancer cells. It can be given orally or through the veins, targeting cancer cells throughout the body. Depending on the stage and type of cancer, chemotherapy may be used alone or in combination with surgery or radiation therapy. In older adults with cancer, the decision to undergo chemotherapy takes into account the patient's overall health, functional status, and specific cancer characteristics.

Evaluating Chemotherapy In Cancer For Older Adults: Factors To Consider

Older adults are more likely to have other factors which may contribute to their overall health status. Therefore, when assessing an older adult’s suitability for chemotherapy, several unique factors should be carefully considered, such as:

• Treatment Duration: Chemotherapy often involves multiple sessions spread over weeks or months, which pose challenges for older adults with other medical appointments or limited transportation options. For example, coordinating caregiving support around multiple chemotherapy schedules can be difficult for older patients.
• Pre-Existing Medical Conditions: Chemotherapy may be associated with certain side effects such as neuropathy (nerve damage), renal impairment or liver dysfunction. Extra care should thus be taken in prescribing chemotherapy to older adults who already have multiple pre-existing medical conditions.
• Nutritional Status: Older adults may have swallowing difficulties, and poor dentition contributing to a suboptimal nutritional status. When coupled with cancer-related cachexia, it can be challenging for the patients to tolerate chemotherapy.
• Functional Status and Fall Risk: Some older adults may have functional limitations and be at risk of frequent falls. It is important to take this into consideration and prudent to ensure that these older adults are always accompanied by their caregivers when receiving chemotherapy.
• Polypharmacy: For older adults who are currently on multiple prescription medications, care should be taken to avoid drug interactions with their chemotherapy and to ensure medication compliance.

Radiation Therapy

Radiation therapy uses beams of intense energy to destroy cancer cells. It can be used alone or in combination with other treatments like surgery or chemotherapy.

For older adults, radiation therapy is often an option due to its non-invasive nature and minimal impact on the body as a whole. However, it's essential to consider potential side effects and discuss them with your doctor. Factors to consider include managing any existing health conditions, the demands of the treatment schedule, and ensuring adequate support to maintain independence.

Targeted Therapy

Targeted therapy uses drugs or other substances to specifically target and attack cancer cells while minimising damage to healthy cells. This approach can be used alone or with other treatments like chemotherapy, surgery, or radiation therapy.

And while targeted therapies are generally safe and effective for older adults, dosage adjustments may be necessary to ensure the best outcome.

Immunotherapy

Immunotherapy harnesses the body's own immune system to fight cancer. It works by stimulating or modifying the immune system to identify and eliminate cancer cells.

And while it is generally safe for older adults, studies suggest that they may experience slightly more side effects and may discontinue treatment earlier than younger patients. This highlights the importance of close monitoring and individualised care for older adults receiving immunotherapy.

Hormone Therapy

Hormone-sensitive cancers, like breast cancer, rely on hormones to grow. Hormone therapy aims to block or reduce hormone levels in the body, thus slowing or stopping cancer growth.

This treatment can be highly beneficial for older adults, as it is often as effective as chemotherapy but with fewer side effects. However, it's important to note that hormone therapy may not always provide a significant survival advantage in older patients.

Benefits Of Cancer Treatment In Older Adults

While treatment needs to be adapted to individual health profiles, and several factors must be considered before deciding on a specific treatment route, the potential benefits are significant. This is because appropriate cancer treatment is crucial for preventing the spread of cancer, slowing tumour growth, and targeting cancer cells that have metastasized in older adults.

It's important to recognise that cancer treatment can be beneficial for patients of any age. Additionally, advancements in cancer treatments, including chemotherapy, have demonstrated substantial benefits for older adults.

Studies have shown that targeted therapies, such as immunotherapy and molecularly targeted agents, can improve survival rates and quality of life for older adults with cancer. These treatments are designed to specifically target cancer cells while minimising damage to healthy tissues, thereby reducing the side effects commonly associated with traditional chemotherapy. These are more improved therapeutic options for older adults with cancer, offering them a better quality of life and improved overall outcomes.

It is still important to acknowledge the potential risks and side effects of cancer treatment, particularly in older adults with reduced physiologic reserves. Factors such as coexisting medical conditions, multiple medications, bone marrow changes, and other physical alterations can influence how cancer treatment affects older adults. Additionally, cognitive problems, including difficulties with thinking and memory, may impact treatment decisions. The decision to pursue cancer treatment should be a collaborative process, considering the potential benefits, weighing them against the risks, and taking into account the individual's state of health, goals and preferences.

There is increased awareness about the need to develop age-appropriate screening protocols, refine treatment strategies, and improve supportive care for older adults with cancer. These efforts would provide holistic cancer care to ensure optimal treatment outcomes while maintaining the quality of life in older adults.

Barriers To Cancer Treatment in Older Adults

However, despite these benefits, older adults may face a range of psychosocial challenges when making cancer-related treatment decisions.

• Societal norms: Many older adults and their loved ones may perceive their advanced age as a deterrent to them receiving cancer treatment and feel that they are unlikely to benefit from it because of their age.
• Family support: In our Asian setting, family members play an important role in making treatment decisions and caregivers for older adults during their cancer journey.
• Financial Constraints: As many older adults are retirees, they may be concerned about the costs of their cancer treatment and its affordability.

These diverse factors highlight the complex interplay between psychosocial factors that can influence geriatric patients' decisions regarding cancer treatment and their willingness to pursue it.

Benefits for Cancer Patients Over 65

While the focus often falls on older individuals, especially when it comes to financial constraints, financial aid from programmes like the Cancer Care Fund extends to cancer patients of all ages facing economic hardships soon after diagnosis. This fund is particularly aimed at Singaporeans or Permanent Residents, although non-residents with close familial ties to Singaporeans or Permanent Residents who have lived in Singapore for at least five years may also apply. Beneficiaries must be newly diagnosed within the first six months and must align with the income stipulations of the Blue/Orange Community Health Assist Scheme (CHAS).

The Cancer Treatment Fund further supports by subsidising part of the cancer treatment costs for patients in need. And eligibility extends to patients treated in subsidised wards of restructured hospitals, meeting both medical and means-test criteria set by the Singapore Cancer Society (SCS). Approved applicants can receive treatment subsidies up to 100% or $6,000 per treatment cycle, capped at $50,000 per individual.

Proactive Steps to Reduce Cancer Risk

But, of course, prevention is always better than cure. While cancer can impact anyone, certain lifestyle choices can significantly lower your risk, irrespective of your age.

Here’s how you can proactively safeguard your health:

• Quit Smoking and Avoid Tobacco: Tobacco use is linked to an array of cancers, including lung, throat, and bladder cancer. Avoiding tobacco or taking steps to quit can greatly reduce your risk.
• Adopt a Healthy Diet: Include fruits, vegetables, whole grains, and beans in your diet. Reducing consumption of refined sugars and high-calorie foods also lowers cancer risk, as does limiting alcohol and processed meats.
• Stay Active: Incorporating regular physical activity offers a double benefit, as it helps manage weight and independently reduces the risk of developing certain cancers.
• Sun Protection: Protect your skin from the sun to help prevent skin cancer. Wear protective clothing, use broad-spectrum sunscreen, and avoid tanning beds.
• Vaccinations: Vaccines reduce the risk of cancer by protecting against viral infections like Hepatitis B and HPV, which can lead to liver and cervical cancers, respectively.
• Regular Medical Checkups: Engage in regular screenings for various types of cancer, which can increase the likelihood of detecting cancer early and improving treatment success.

Consultation With A Cancer Specialist In Singapore

When it comes to cancer in older adults, consulting doctors in Singapore experienced with treating cancer in older adults, such as OncoCare, is crucial. Our oncology consultants have knowledge of managing cancer in older individuals and can provide personalised evaluation and guidance. If you or your loved one is facing the possibility of chemotherapy, it's important to consider the unique circumstances that come with cancer in older adults. Consulting with a cancer specialist will help you better understand the specific benefits and risks associated with chemotherapy in older adults. By involving healthcare providers and support networks, you can ensure that your decisions are personalised and well-informed.

At OncoCare, we embrace the opportunity to provide personalised cancer care that empowers older adults to thrive during their golden years. Our dedicated team is committed to ensuring that you receive the appropriate treatment while preserving your quality of life. Don't hesitate to reach out to us for compassionate and tailored assistance from our expert cancer specialists. Together, we can navigate the path to a brighter and healthier future.

“Expert knowledge means better care for cancer”

Written by:

Dr Angela Pang

MBBS (Singapore)

Grad Dip (GRM)

MRCP (UK)

M Med (Internal Med)