An Evidence-Based Approach to the Treatment and Care of the Older Adult With Cancer

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Foreward

In 1980, I assumed my first oncology clinical nurse specialist position in a large tertiary care medical center in Phoenix. We had weekly interdisciplinary rounds that proved instructive as well as effective in addressing unmet patient needs and readying families for discharge. Following one such round, I had one of those "ah-ha" moments. Almost every patient we discussed that morning was an older person. Makes sense, I thought, living in the epicenter of retirement. Yet this revelation fostered my curiosity. If this was the case, Arizona must be unique in its cancer and aging affiliation.

With the help of a dedicated librarian colleague, we began searching multiple databases to analyze Arizona's cancer incidence and prevalence rates specific to older adults. What we found was both revealing and disconcerting. Arizona was characterized by a comparable predominance of cancer in older adults to the rest of the nation. Regardless of geography, cancer was a disease of the aging, with the majority of malignancies diagnosed in Americans older than 65. Additionally, cancer was disproportionately diagnosed in a relatively small subset of Americans. More than half of all malignancies occurred in only 12% of the populace (Lew, 1976; Peterson & Kennedy, 1979). Never in my 12 years of clinical practice nor graduation from an oncology-specific clinical nurse specialist program had I heard these statistics. Why was this the case? I could not be only one of a handful of professionals specializing in oncology who was aware of this reality. Yet, in truth, it seemed I was.

In the early 1980s, the late and esteemed Dr. Paul Carbone from the University of Wisconsin and colleague Dr. Colin Begg were credited with revealing widespread ageism, particularly within the ranks of medical oncology. Their critique of 21 Eastern Cooperative Oncology Group clinical trials in eight different cancer primary sites affirmed extensive bias toward the older adult based solely on chronologic age (Begg & Carbone, 1983). Stereotyping prevailed and physiologic age was not considered in decision making about appropriateness of antineoplastic therapies for the older adult. Exclusion, underdosing, and therapy substitution predominated when cancer treatment for the older adult was scrutinized. These findings soon were followed by comparable examples within the ranks of surgical and radiation oncology.

Shortly following this time, a collaborative effort to plan a working conference to synthesize existing data on cancer in the older adult and to identify knowledge gaps relative to this special population was initiated. In concert with medical oncologist Dr. Paul Carbone and surgical oncologist Dr. W. Bradford Patterson, Rosemary Yancik, PhD, formerly with the National Cancer Institute (NCI) and now with the National Institute on Aging (NIA), organized the conference "Perspectives on Prevention and Treatment of Cancer in the Elderly." What resulted was a significant initial effort to educate cancer professionals about the knowledge gap characteristic of cancer in the older adult. The first edited text on this topic was hence published in 1983 (Yancik, Carbone, Patterson, Steel, & Terry, 1983).

Around this same time, I remember submitting an abstract for the 1982 Oncology Nursing Society (ONS) Congress in St. Louis, MO, on the application of the ONS Standards of Practice to the care of the older adult with cancer. Although it was not accepted, this exercise further heightened my sense of concern over the global avoidance of these patients. Speaking and writing on the subject enhanced my sense of empowerment to champion the older adult agenda. During the late 1980s and 1990s, various nursing authors began to publish on topics related to cancer and the older adult (Kagan, 2004). In 1992, ONS supported this much-needed advocacy stance by becoming the first professional specialty organization to take a position on the unmet needs of the older adult with or at risk for cancer (Boyle et al., 1992).

Twenty-five years have passed since my initial inquiries in this area, and this reality in cancer care is only beginning to garner focused attention. In 2001, NIA and NCI organized a workshop to provide a forum for leaders to address research priorities in the integration of aging and cancer research focused on people aged 65 and older (NIA, 2005). In 2003, ONS received a grant from the John A. Hartford Foundation to assist with a needs assessment to determine possibilities for inclusion of an older adult focus within the organization. That same year, the American Society of Clinical Oncology developed a gero-oncology continuing education curriculum for medical oncologists. They also funded several fellowships in gero-oncology coordinated and taught by geriatricians and oncologists. Recently, ONS updated its position statement on cancer in the older adult and collaborated on such with the Geriatric Oncology Consortium (Oncology Nursing Society and Geriatric Oncology Consortium, 2004). Kagan (2004) proposed a working definition of gero-oncology as reference to the assessment, management, and evaluation of the unique needs of the older adult with, or at risk for, cancer. Based on the premise of heterogeneity and the deliberative consideration of the interface between the aging process and cancer, this special focus was noted to "occur within the contextual paradigm of a life mostly lived" (Kagan). Yet, advances in technology and supportive care have contributed to the fact that older adults are living longer with cancer and other chronic illnesses and may have several years of life ahead. Kagan called for shifting the perspective from individual level research in cancer and aging to family and community level research to address an aging society's needs in cancer care and break down the ageism bias in healthcare disparities.

Finally, a more secure base was being established to support the growing voices of activism and more concerted efforts to counter bias and prejudice. Proof of moving forward is substantiated by this significant text, spearheaded by two champions of caring for older adults with cancer, Diane Cope and Anne Reb, with contributions by many dedicated colleagues with well-established interests in gero-oncology. As readers of this text, I implore you to do one of the following. Take at least one key new piece of information and make it yours. In patient care discussions, force the integration of this new knowledge into care planning. Use these chapters in journal club forums. Access an article referenced in this text, and post it for colleagues to read. Ask new questions of older adult patients and their caregivers that you have never asked before. Share these findings in charting, interdisciplinary deliberations, and scholarly writing. Make competency in gero-oncology nursing mandatory in your setting. Realize its necessity for your professional growth now and in the future.

I consider oncology nurses to be ambassadors for older adults. Patient advocacy responsibilities abound in considering the silence of elder-specific articulated need in cancer care. Become determined to foster activism in the public health venue. Engagement also can occur at home, in your community, within work, through professional education, via the media, and by having a political voice. As we give newfound recognition to this evolving epidemic of aging, we must be cognizant of our roots and our own sensitivity deficits. Although well intended in our plans for nursing care, remember that older patients have been young, but the majority of caregivers have never been old. Highly specialized and individually tailored older adult care represents a new frontier in the field of oncology. Let it be known that geriatric oncology nursing is finally coming of age.

References

Begg, C.B., & Carbone, P.P. (1983). Clinical trials and drug toxicity in the elderly: The experience of the Eastern Cooperative Oncology Group. Cancer, 52, 1986-1992.

Boyle, D.A., Engelking, C., Blesch, K., Dodge, J., Sarna, L., & Weinrich, S. (1992). Oncology Nursing Society position paper on cancer and aging: The mandate for oncology nursing. Oncology Nursing Forum, 19, 913-933.

Kagan, S. (2004). Gero-oncology nursing research. Oncology Nursing Forum, 31, 293-299.

Lew, E.A. (1976). Cancer in old age. CA: A Cancer Journal for Clinicians, 28, 2-6.

National Institute on Aging. (2005). Cancer burden for persons 65 years and older. Retrieved June 21, 2005, from http://www.nia.nih.gov/ResearchInformation/ConferencesAndMeetings/WorkshopReport/ExecutiveSummary.htm

Oncology Nursing Society and Geriatric Oncology Consortium. (2004). Oncology Nursing Society and Geriatric Oncology Consortium joint position on cancer care in the older adult. Retrieved June 28, 2005, from http://www.ons.org/publications/positions/Geriatric.shtml

Peterson, B.A., & Kennedy, B.J. (1979). Aging and cancer management: Clinical observations. Cancer, 29, 322-332.

Yancik, R., Carbone, P.P., Patterson, W.B., Steel, K., & Terry, W.D. (1983). Perspectives on prevention and treatment of cancer in the elderly. New York: Raven Press.

Deborah A. Boyle, RN, MSN, AOCN^®, FAAN
Practice Outcomes Nurse Specialist
Coordinator, Senior Cancer Care Nursing Studies Program
Banner Good Samaritan Medical Center
Phoenix, Arizona