Cancer in the context of aging: Health characteristics, function and caregiving needs prior to a new cancer diagnosis in a national sample of older adults

Abstract

Introduction

As cancer trajectories change due to screening, earlier diagnoses, living longer with illnesses, and new successful treatments, cancer is increasingly a disease of older adults. While cancer diagnoses themselves are very stressful for patients and families, little is known about the health status, functional limitations, and social resources of older patients before they face a new cancer diagnosis.

Materials and Methods

Using the National Health and Aging Trends Study (NHATS), a national survey of older Medicare beneficiaries linked to Medicare claims data, we examined the health characteristics, functional limitations and social and financial resources of older adults before a new diagnosis of lung, breast, prostate or colorectal cancer and how these factors vary by race/ethnicity.

Results

We identified 274 community-dwelling older adults with incident cancer diagnoses: lung (30.6%), breast (20.3%), prostate (30.8%), and colorectal (18.3%) representing 1,202,920 older Medicare beneficiaries. The sample was 81% Non-Hispanic White, 10% Non-Hispanic Black, and 9% Hispanic/Other. Before diagnosis, patients had an average of three comorbidities and 29% of patients reported poor/fair health. Almost one-third were living alone, 13% received help with at least one activity of daily living (ADL), 11% had probable dementia and nearly one in ten already received financial help from family members.

Discussion

Before an older adult has ever been diagnosed with a major cancer, many face significant health and financial challenges and are dependent on others for care. These needs vary based on cancer type and race/ethnicity and must be considered as clinicians develop individualized care plans for patients alongside caregivers.

Introduction

Cancer is increasingly a disease of older adults, with persons over 65 years accounting for 60% of newly diagnosed malignancies and 70% of all cancer deaths [1,2]. As the population of individuals in the United States age 65 years or older is projected to nearly double from 2000 to 2050 [1], and with improved cancer survival, a substantial number of older adults will be living with cancer. Treatment of older adults with cancer is complex [3]. The benefit of treatment to prolong survival must be weighed against potential treatment toxicity and reductions in quality of life (QoL) [2]. Yet minimal effort has been dedicated to developing guidelines for cancer treatment in older adults. Even though there is an increase in clinical trials evaluating patients above the age of 65 years, they are usually excluded and thus not well represented. Thus, new treatments are not effectively being tested in the segment of the population with the highest cancer incidence [4].

In 2018 the American Society of Clinical Oncology (ASCO) released new guidelines recommending geriatric assessment (e.g. function, comorbidity, falls, depression, and cognition) for older adults [5] with the goal of enabling providers to develop an integrated and individualized plan that informs cancer management. Because of their advanced age, many older adults receiving a new cancer diagnosis may already have significant functional and cognitive impairment, and suffer from one or multiple serious illnesses that require support from paid and family caregivers. In addition to physical and mental health conditions, older adults may face social isolation, reduced QoL, financial strain and significant unmet care needs that should be assessed in routine primary care. Such factors may complicate cancer decision-making and treatment adherence and outcomes [1,6]. Patients and families must decide whether to even engage in cancer-directed treatment in the face of competing prognoses, and need to weigh costs versus benefits of treatment (e.g., considering the effect of treatment toxicity [7] on a patient with reduced cognitive function [2,8]). Family caregivers may be faced with increased responsibility for decision-making and associated stress as they are confronted with the intersection of cancer in the context of other health and social challenges.

New cancer diagnoses themselves are highly stressful, and are associated with a decrease in QoL and an increase in depression symptoms and financial strain [[9], [10], [11], [12], [13]]. Yet surprisingly little is known about the health and well-being of older adults at the time of an incident cancer diagnosis. The intersection of these complex issues may necessitate additional support for older patients with cancer and their families. This may be especially true for racial/ethnic minorities who are increasingly burdened with multimorbidity, a more advanced stage at diagnosis and financial strain [14,15].

This study sought to determine the health, well-being and existing challenges faced by patients immediately prior to the diagnosis of the four most common cancers in the United States (lung, breast, prostate, colorectal) [16,17], using a longitudinal dataset consisting of a nationally representative sample of Medicare beneficiaries with detailed data on health status, functional limitations, and caregiving. The specific objectives are to: 1) identify Medicare beneficiaries with incident cancer diagnoses; 2) examine health, functional, financial, and caregiving status for these patients immediately prior to a cancer diagnosis; and 3) examine disparities in pre-diagnosis status based on race.