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Ageing and cancer: psychosocial burdens

Cancer Council Australia Essay

Competition

Priya Maheshwari

UNSW IV

Word count: 2399 (excluding references)

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Table of Contents

Introduction ................................................................................................................................ 3

The older patient with cancer seen through a psychosocial lens ............................................... 4

Psychosocial support needs........................................................................................................ 6

Caring for the older patient with cancer .................................................................................... 8

Preparing the future medical workforce .................................................................................. 11

Conclusion ............................................................................................................................... 12

References ................................................................................................................................ 13

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Introduction

The ageing of the Australian population means that the issues related to cancer care in the

older patient will become more prominent, especially with the potential for increasing

numbers of cancer diagnoses and elderly cancer survivors. People diagnosed with cancer and

their loved ones can take some comfort from the knowledge that remarkable advances in

cancer treatment have dramatically increased the rates of survival from cancer. However,

these advances in biomedical care have not always been matched with progress in the

development of high-quality care to address the social and psychological consequences of a

cancer diagnosis, which can especially burden older patient groups.

This essay will examine the psychosocial effects of cancer and its treatment on older adults,

and the supportive care needs of the older patient. The ways in which practitioners can meet

those needs will be explored, as well as the importance of the medical school curriculum in

producing practitioners who are well-equipped with the skill set to do so.

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The older patient with cancer seen through a psychosocial lens

‘It is much more important to know what sort of a patient has a disease than what sort of a

disease a patient has.”

- Sir William Osler, Canadian physician.

In 2011-2012, approximately 1.5% of the Australian population had cancer, with the

prevalence of cancer increasing with age [1]. The highest rate of cancer was found to be for

the 75 years and over age group, and one in approximately 14 people in that age group had

cancer [1]. Prostate and breast cancer remain the most common cancers diagnosed in men

and women respectively [2].

The impact of cancer and its treatment is influenced by the patient’s age. However, the

elderly are not a homogenous population with respect to health, ability to cope with the

psychosocial and physical impacts of cancer and views about management [3]. The clinician

therefore must avoid making presumptions about the patient’s needs and attitudes stemming

from age-based stereotypes. The need to be mindful of this is illustrated by the fact that

health care providers have been found to generally underestimate the quality of life of older

patients with chronic disease [4].

Cancer can bring significant emotional upheaval, and people with cancer may experience a

range of social and emotional difficulties, including potent feelings of distress, fear and

anger. An individual’s level of psychological distress may vary depending on the extent to

which a person which cancer feels supported by family and friends [5]. Financial stress from

the cost of health care and reduced income and employment may also contribute to the stress

experienced by people living with cancer. Although the resolution of such financial and

social problems is beyond the capability of medical practitioners, an understanding of how

these problems can affect the psychosocial state of the patient with cancer is a vital part of

good-quality health care as it facilitates the addressing of these issues within the constraints

of clinical practice [6].

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Older people often have medical conditions in addition to cancer that are likely to affect

function, and the number of comorbid conditions increases with age. Cancer-induced

physical stressors include fatigue, pain and various disabilities which may create limitations

in the ability of patients with cancer to perform activities of daily living [6]. Older patients

with cancer are more likely to require functional assistance than those without cancer [7]. The

physical sequelae of cancer and cancer treatment can exacerbate emotional and mental health

problems.

Older people with cancer frequently have a slightly different set of concerns than other adults

with cancer, which can affect how they cope with their diagnosis and treatment. One of the

key concerns for many older adults with cancer is whether they will be able to maintain

independence and remain in control of their health and health-related decision-making [8].

For example, cancer treatment may limit the ability of people to perform independently

activities of daily living such as cooking, washing and accessing transportation [8].

Furthermore, older cancer patients are less likely to have social support systems in place,

especially as they may not live close to family or may have experienced the loss of family

members and friends [9]. Isolation increases the risk of depression and anxiety, the

development of which increases the difficulty of older adults to cope with cancer treatment

[10].

Older people have typically retired from paid employment and they may have reduced

opportunities to be involved in their local community. Older people may have a reduction in

the scope of their social lives especially if they are gradually spending more time at home

alone, which slowly narrows of their life-space [11]. For elderly patients with cancer, the

death of the primary wage earner, retirement and existing financial issues can be important

factors contributing to limitations on financial resources, especially to pay for costs

associated with cancer treatment [11]. Such concerns can contribute to feelings of anxiety and

depression in patients. Thus, a multitude of factors unique to the older patient demographic

result in cancer typically having psychosocial impacts significantly disparate to the impacts

of cancer on younger people.

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Psychosocial support needs

‘Mental pain is less dramatic than physical pain, but it is more common and also more hard

to bear. The frequent attempt to conceal mental pain increases the burden: it is easier to say

“My tooth is aching” than to say “My heart is broken”.’

- C.S. Lewis, English novelist and scholar.

There has been an increasing interest in formal needs assessments in Australia and abroad.

The first known study to explicitly examine the supportive care needs of people with cancer

was conducted over 30 years ago by the American Cancer Society [12]. Needs not addressed

and where additional support is required were classified as “unmet needs”. Growing evidence

points to the detrimental effects on patient wellbeing from unmet needs [6]. These unmet

needs include the domains of psychological and other forms of patient support, access to

health information and the ability to undertake activities of daily living.

A systematic review demonstrated that the level of unmet needs in older adults newly

diagnosed with cancer and undergoing active cancer treatment is high, with a wide-ranging

prevalence of between 40 and 90% because of the vast range of tools and definitions used to

assess unmet needs in various studies [13]. This systematic review found that the most

common unmet needs include psychological needs (typically fear of the spread or return of

cancer), information needs (most frequently regarding the likelihood of cure and the adverse

effects associated with treatment) and physical needs (most commonly with complaints of

tiredness and lack of energy) [13]. Older patient groups are more likely to be vulnerable to

unmet needs and treatment toxicities due to their comorbidities and decreased physiological

reserve capacity [13].

Failures to address psychosocial problems can result in suffering for both the patient and their

family, and potentially affect the course of the disease. Stress, social isolation and untreated

mental health problems can contribute to emotional distress and interfere with the ability to

perform social roles and adhere to treatment regimens [14]. These problems may cause

changes in the functioning of the endocrine, immune and other organ systems in the body,

which could then have implications for the course of the disease [14].

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One out of two cancer patients report psychiatric disorders, especially depression, and elderly

patients with cancer are at a particularly increased risk of depression [15]. Depression can be

difficult to identify in elderly patients because they may not manifest prominent anhedonia or

sad mood which are the main symptoms of unipolar mood disorders [16]. Unrecognised and

untreated mood disorders in aging people with cancer is a key cause of disability and

suffering for patients and their caregivers [17].

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Caring for the older patient with cancer

‘The physician should not treat the disease but the patient who is suffering from it.’

- Maimonides, 12th century scholar and physician.

Cancer and its treatment can lead to psychological distress, physical disabilities and increased

healthcare needs [13]. Supportive care is defined as care that helps people with cancer and

their families to cope with cancer and its treatment, beginning at diagnosis and continuing

throughout treatment to cure, continuing illness, or death and bereavement [18].

It is particularly important for medical practitioners to address practical issues of coping and

the limitations on home activities created by cancer diagnosis and treatment in older patient

groups [19]. This may not always be a straightforward process, as the psychosocial needs of

older patients can be hidden beneath a façade of stoicism and a wish to be compliant. Thus

clinicians may need to question older patients sensitively in order to fully understand their

patients’ psychosocial needs [19]. Specific concerns which may need to be explored include

body image concerns, interpersonal problems, existential concerns, anxiety and depression

[19].

Supportive care needs can be diverse. They may relate to coping with the physical impacts of

cancer and its treatment, or with its psychosocial and psychological effects in the form of

depression, anxiety and feeling isolated [20]. Practical measures such as assistance with

transportation and daily activities and the provision of prostheses and wigs are considered

important elements of supportive care and they can reduce the psychological distress

experienced by people with cancer [20]. Access to evidence-based information throughout

the cancer journey is also viewed as an essential aspect of supportive care [20]. It is important

to note that the goals of treatment for the older patient with cancer often differs from those

for younger patients. This is because the focus of treatment can shift from prolonging

survival to quality of life endpoints, and especially aiming to prolong the period during which

the person is independent (‘active life expectancy’) [21].

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The ageing of the Australian population has particularly driven the need for geriatric

oncology in order to identify and manage psychosocial and other health needs of older

patients with cancer. Over the last 10-15 years, oncologists and geriatricians have begun to

have a greater collaboration in order to integrate geriatric principles into oncology care [22].

Use of a comprehensive geriatric assessment (CGA) for assessment of older patients with

cancer is an example of such efforts in Australia. A CGA involves an evaluation of an older

person’s functional status, cognition, nutritional status, comorbidities, psychological state,

social support and a review of their medications [23]. The International Society of Geriatric

Oncology has arrived at recommendations regarding the use of CGA in older cancer patients

[23]. There is growing evidence that the variables examined in a CGA can predict mortality

and morbidity in older patients with cancer and expose problems relevant to cancer care that

would otherwise go unrecognised [22].

Although the CGA is a useful tool, it can be unsuitable for daily clinical practice because it is

time-consuming, as it can take between 45 minutes and 2 hours to complete a CGA for a

single patient [24]. There are a wide variety of other instruments that can be used to assess

the needs of cancer patients and their families in place of the CGA, of which two were

developed in Australia, namely the Cancer Patient Need Questionnaire and the Supportive

Care Needs Survey [25] [26].

Regardless of the specific tools used to do so, it is essential that a plan be developed by the

treating health care team to assist the person with cancer to manage their illness and maintain

the highest possible level of wellbeing and functioning [6]. The ‘Care Coordination for Older

Australians with Cancer’ project which is an initiative of Cancer Australia and funded by the

Australian government is an example of the type of initiatives which can assist Australian

medical practitioners to coordinate supportive care for older cancer patients [27].

It remains vital for medical practitioners to re-assess older people with cancer frequently in

order to ensure that their psychosocial needs are being addressed. This is especially important

given that there are a number of supportive care interventions available. Such interventions

include peer support programs, counselling and psychotherapy, family and caregiver

education and provision of comprehensive illness self-management and self-care programs

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[6]. As such, medical practitioners are well-placed to significantly assist elderly patients with

cancer to cope with their disease.

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Preparing the future medical workforce

‘There are two objects of medical education: to heal the sick and to advance the science.’

- Charles Mayo, American medical practitioner and co-founder of the Mayo Clinic.

The Cancer Council Australia’s Oncology Education Committee has stated the “psychosocial

and cultural significance of cancer” as a learning objective in its Ideal Oncology Curriculum

for Medical Schools [28]. Medical students who meet this objective are able to demonstrate

an ability to assess the psychosocial state of patients, the cultural and psychosocial factors

mediating the effect of cancer on the patient and can demonstrate an understanding of sources

of reliable patient support information [28]. The importance of this learning objective

becomes clear when we consider that the number of cases of cancer diagnosed in Australia

each year is projected to rise over the next decade for both men and women and it is

anticipated to reach about 150,000 cases in 2020 [2]. The medical practitioners of the future

therefore need to be equipped with the skills to manage the growing number of patients, and

particularly those from older age groups, who will present with the psychosocial issues

associated with cancer.

Health professionals may avoid discussion of emotional concerns with patients due to a fear

of causing unnecessary worry or distress, feeling out of their depth or assuming that the

spiritual elements of the cancer trajectory are not the domain of the medical practitioner [19].

A concerted effort by medical schools and those involved in developing medical curricula to

foster an improved understanding in medical students of the psychosocial needs of people

with cancer and particularly those of older patients will go some way towards removing these

barriers to high-quality psychosocial support for people with cancer.

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Conclusion

The older cancer patient has a set of psychosocial needs that can differ greatly from that of

the younger patient. A recognition of this fact is vital for the provision of individualised,

patient-centred care to elderly patients in order to assist those patients to maximise their

quality of life. The provision of adequate training to medical students in managing both the

biomedical and psychosocial aspects of care for elderly cancer patients is important

especially in the context of the ageing Australian population.

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References

1. Australian Bureau of Statistics, 4338.0 - Profiles of Health, Australia, 2011-13. 2012,

Australian Bureau of Statistics: Canberra.

2. AIHW, Cancer incidence projections, Australia 2011 to 2020. 2012, Cancer series no.

66, Cat. no. CAN 62. AIHW: Canberra.

3. Walker, L., et al., Psychosocial aspects of cancer in the elderly. European Journal of

Surgical Oncology, 1998. 24(5): p. 375-378.

4. Sprangers, M.A. and N.K. Aaronson, The role of health care providers and significant

others in evaluating the quality of life of patients with chronic disease: a review.

Journal of Clinical Epidemiology, 1992. 45(7): p. 743-760.

5. Parker, P.A., et al., Psychosocial and demographic predictors of quality of life in a

large sample of cancer patients. Psycho‐Oncology, 2003. 12(2): p. 183-193.

6. Institute of Medicine, Cancer care for the whole patient: meeting psychosocial

concerns. 2008, The National Academic Press: Washington DC.

7. Stafford, R.S. and P.L. Cyr, The impact of cancer on the physical function of the

elderly and their utilization of health care. Cancer, 1997. 80(10): p. 1973-1980.

8. American Society of Clinical Oncology, Cancer in Older Adults. 2012, American

Society of Clinical Oncology: Virginia, U.S.A.

9. Kroenke, C.H., et al., Social networks, social support, and survival after breast

cancer diagnosis. Journal of Clinical Oncology, 2006. 24(7): p. 1105-1111.

10. Hurria, A., et al., Distress in older patients with cancer. Journal of Clinical Oncology,

2009. 27(26): p. 4346-4351.

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11. Surbone, A., et al., The illness trajectory of elderly cancer patients across cultures:

SIOG position paper. Annals of Oncology, 2007. 18(4): p. 633-638.

12. American Cancer Society, Report on the social economic and psychological needs of

cancer patients in California. 1979, Greenleigh Associates: San Francisco, U.S.A.

13. Puts, M., et al., A systematic review of unmet needs of newly diagnosed older cancer

patients undergoing active cancer treatment. Supportive Care in Cancer, 2012. 20(7):

p. 1377-1394.

14. Bultz, B.D. and L.E. Carlson, Emotional distress: the sixth vital sign in cancer care.

Journal of Clinical Oncology, 2005. 23(26): p. 6440-6441.

15. Grassi, L., et al., Psychosocial morbidity and its correlates in cancer patients of the

Mediterranean area: findings from the Southern European Psycho-Oncology Study.

Journal of Affective Disorders, 2004. 83(2): p. 243-248.

16. Alexopoulos, G.S., et al., Comorbidity of late life depression: an opportunity for

research on mechanisms and treatment. Biological Psychiatry, 2002. 52(6): p. 543-

558.

17. Spoletini, I., et al., Depression and cancer: an unexplored and unresolved emergent

issue in elderly patients. Critical Reviews in Oncology/Hematology, 2008. 65(2): p.

143-155.

18. Gysels, M., et al., Improving supportive and palliative care for older adults with

cancer: research evidence. 2004, National Institutes of Clinical Excellence & Kings

College London: London.

19. National Breast Cancer Centre and National Cancer Control Initiative, Clinical

practice guidelines for the psychosocial care of adults with cancer. 2003, National

Breast Cancer Centre: Camperdown, NSW.

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20. Harrison, J.D., et al., What are the unmet supportive care needs of people with

cancer? A systematic review. Supportive Care in Cancer, 2009. 17(8): p. 1117-1128.

21. Hunter, C., K. Johnson, and I. Muss, Cancer in the Elderly. 2005, New York: Marcel

Dekker.

22. Extermann, M. and A. Hurria, Comprehensive geriatric assessment for older patients

with cancer. Journal of Clinical Oncology, 2007. 25(14): p. 1824-1831.

23. Extermann, M., et al., Use of comprehensive geriatric assessment in older cancer

patients:: Recommendations from the task force on CGA of the International Society

of Geriatric Oncology (SIOG). Critical Reviews in Oncology/Hematology, 2005.

55(3): p. 241-252.

24. Singhal, N. and A.V. Rao. Tools for assessing elderly cancer patients. 2008.

Accessed April 19, 2014; Available from:

http://www.cancerforum.org.au/Issues/2008/March/Forum/Tools_for_assessing_elder

ly_cancer_patients.htm#2.

25. Foot, G. and R. Sanson-Fisher. Measuring the unmet needs of people living with

cancer. in Cancer Forum. 1995.

26. Sanson‐Fisher, R., et al., The unmet supportive care needs of patients with cancer.

Cancer, 2000. 88(1): p. 226-237.

27. Hume RICS. Care Coordination for Older Australians with Cancer. 2014. Accessed

April 20, 2014; Available from: http://www.humerics.org.au/index.php?page=care-

coordination-for-older-australians-with-cancer.

28. The Cancer Council Australia, Ideal Oncology Curriculum for Medical Schools.

2007, The Cancer Council Australia: Sydney, NSW.