60 is not the new 30 for cancer

Cancer is one of the leading causes of death in India after the age of 60, says Dr Vineet Gupta

Cancer, Ageing Population Numbers, Ageing, United Nations Population Fund, UNFPA, Cancer A Disease of Aging, Aging

As one ages the treatment strategy for cancer is often tweaked depending upon whether a patient is frail or not. In old age, frail is not merely an adjective. A syndrome marked by slowness, weakness, fatigue and often weight loss, frailty tells doctors a lot about their patients’ likely futures. It can, for example, predict how well older patients rebound from physical stresses — like that of chemotherapy, radiation and surgery.

Ageing Population Numbers

Ageing does not just affect the elderly (defined as 60 years or more); it affects everyone in society in one way or the other. Globally, the elderly population constitutes about 12% of the total population of 7.3 billion. The number of elderlies will be double by 2050, reaching 2 billion and accounting for 22% of the global population, outnumbering those under the age of 15 for the first time in history.

According to United Nations Population Fund (UNFPA) report states that in India too, the size and percentage of elderly population have been increasing in recent years and this trend is likely to continue in the coming decades. The elderly population has increased from 77 million in 2001 to 104 million 2011. By 2050, the elderly population is likely to increase by three times to reach around 300 million, according for 20% of the total population of the county. The relatively young India of today will turn into a rapidly greying society in the coming decades.

Why Is Cancer A Disease of Aging?

Live long enough, and chances are about 40 percent that you will develop a potentially life-threatening malignancy. Although cancer certainly can and does strike young people, it is, by and large, a disease of aging—and one of the leading causes of death in India after the age of 60.

Risks for most types of cancer increase as we grow older for at least three reasons. First, we experience more cumulative exposure to the things that mess with DNA in ways that can lead to malignant growth: sunlight, radiation, environmental toxins and noxious by-products of metabolism. Second, older cells are more vulnerable to this damage—or less able to repair themselves. Third, the various housekeeping systems—such as the immune defenses—that keep our tissues healthy begin to break down with age, the equivalent of watchdogs falling asleep.

What are the barriers for the treatment of elderly with cancer?

This soon-to-erupt tsunami of elderly patients with cancer require adequate treatment, for which guidelines and evidence-based data are still scarce, given the long-lasting under-representation of elderly patients with cancer in cancer trials. In elderly, we are always having to extrapolate from treatment guidelines based on younger people, but the gap is most extreme in cancer care.

Secondly, with advancing age all organ systems are affected and accumulate changes leading to age-related diseases and ultimately to organ failures. The gap between the numerical and the biological ages of an individual might be significant, and explains why considering only the numerical age in an elderly person may lead to insufficient estimates of organ functions in a given individual.

Thirdly, older adults present not only with the physiological decreases of organ functions related to age, but also with an individual burden of other diseases, other impairments and social factors that might impact on their potential for undergoing cancer care.

Finally, some cancer treatments can be adapted for those not strong enough for a full dose. But until now that’s usually been done in a somewhat haphazard way in the sense that - it’s normally clinical experience, rather than scientific evidence that guides these decisions. A young patient may be willing to tolerate extreme side effects and long hospitalisations for a chance to live longer. For an elderly patient, having to enter a nursing home because of side effects might seem like a fate worse than dying

There’s a worry that if you give low dose treatment, you’re giving inferior treatment, but a new study presented at the annual American Society of Clinical Oncology meeting in 2019, suggests otherwise. This study included 514 people all over the UK, at an average age of 76, who had advanced stomach or oesophageal cancer. Their doctors knew they wanted to offer chemo, but they weren’t sure of the best dose. They randomly allocated patients one of three different doses of chemo, instead of the usual trio of chemotherapy drugs that fitter patients receive, people on the trial were given two of the three drugs at the different doses.

Patients were randomly allocated to receive these two drugs at either full strength, medium-dose or low-dose.

Lowering the dose of treatment didn’t make the chemo any worse at controlling the cancers, or affect how long the patients lived. And when the researchers investigated patients’ experience of treatment, considering factors like the side effects or impromptu hospital visits, and the patients’ own view of how worthwhile their treatment was, the lowest dose chemo group fared best of the three.

What this trial says is that to give substantially lower dose is not only okay, but it’s absolutely the right thing to do.

It means doctors can confidently know that they’re not compromising their patient’s survival and are actually giving them a kinder treatment, which will improve their quality of life.

Bottom Line

-         Engage in a conversation with your doctor, spend about equal amounts of time discussing the treatment choice and risk of the proposed treatment
-         Take a second opinion
-         Discuss your life goals with your doctor
-         Soft treatment is as effective in older patients- more is not always better.

Dr Vineet Gupta is Senior Consultant & Head - Medical Oncology & Haematology, Sakra World Hospital.