Cancer Treatment Decision-Making in Older Adults
It is widely accepted that the single greatest risk factor for cancer is age. Sixty percent of cancers and two-thirds of cancer deaths occur over the age of 65 years.
Jeannette Kates, MSN, RN, GNP-BC
PhD Candidate, Duquesne University, Pittsburgh, PA
It is widely accepted that the single greatest risk factor for cancer is age. Sixty percent of cancers and two-thirds of cancer deaths occur over the age of 65 years.1 This proportion is expected to increase markedly in the near future due to the aging of the population. The incidence of comorbid illness also increases with age. On average, people 65 years of age and over with cancer suffer from three additional diseases.2,3 Comorbidity is associated with reduced life expectancy and increased risk for treatment complications, while also having the potential to negatively affect the natural history of cancer.4-7
Although the goals of cancer treatment in cancer patients who are older—namely cure, prolongation of survival, and effective symptom management— are the same as those for cancer patients of other ages, there are unique factors to consider with this population.4
Balancing Risks and Benefits
Functional, physiologic, and psychosocial factors must be considered when treating older patients. Clinicians must balance the implications of the cancer diagnosis with the risks and benefits of cancer treatment on every aspect of a patient’s life.
Regardless of age, cancer treatment-related decisions can be exceedingly complex. Individuals have varying levels of desire for participating in their decision-making, which may be influenced by their age and disease progression.8-11 Additionally, there are a variety of psychological, physical, functional, and social factors that influence decisions.12-15
With an increasing number of cancer treatments available, patients are presented with increasingly difficult decisions. These decisions can lead to decisional conflict, which can be described as “a state of uncertainty about which course of action to take when choices among competing actions involve risk, loss, regret, or challenge to personal life values.”16,17
Physiologic and psychological factors can be the basis for patients’ decision-making. For older adults, decisions regarding treatment may be considered in the context of physical function. People sometimes choose to forgo treatment explicitly within the context of their age and comorbidities.18 Careful thought precedes decision making, influenced by a broad perspective of older adults’ values and their perceptions of their whole life situation.19,20
Quality of Life Considerations
Quality of life (QOL) is a concept that is central to the care of cancer patients. QOL is generally described as being subjective and multidimensional.21 QOL can be understood only from the patient’s perspective and can only be assessed appropriately by asking the patient about it directly.
Patient’s responses are influenced by their current set of expectations surrounding their actual functional level, as well as their perceptions about the treatment environment.21 QOL also has many dimensions, including physical functioning or well-being, psychological well-being, social role functioning or well-being, disease- and treatment-related symptoms, and spiritual well-being.21-23
Box. Cancer Management in Older Adults4
Is the patient going to die of cancer or with cancer?
Is the patient going to live long enough to suffer the consequences of cancer?
Is the patient able to tolerate the treatment?
Are some complications of cancer treatment more common in older adults?
Is the social network of the patient adequate to support him or her during the treatment?
As the proportion of older adults increases so too, will the prevalence of cancer. Cancer treatment-related decisions are multifactorial and complex for both healthcare providers and patients. Physicians use clinical tools to make decisions about treatment, yet little is known about how older adults make their own decisions regarding treatment and whether they experience decisional conflict regarding those decisions.
As a PhD Candidate at Duquesne University School of Nursing, I have had the opportunity to address the gaps in the literature related to decision making in older adults with cancer. With the guidance and support of Duquesne University School of Nursing faculty (Dissertation Committee Chair Linda Goodfellow, PhD, RN, and Committee Member Joan Such Lockhart, PhD, RN, CORLN, AOCN, CNE, FAAN), my dissertation study will be an important first step towards understanding the unique interplay of age, cancer, comorbid illness, QOL, and decisional conflict.
The diagnosis of cancer is a life-altering event that has the potential to cause significant emotional and psychological distress. Oncology nurses are charged with the responsibility of assessing the psychosocial needs of their patients and collaborating with other disciplines to design and implement plans to provide patients with the needed support.24-27
Feeling conflicted about decisions related to the diagnosis and its treatment may lead patients to have further distress. By knowing how much decisional conflict occurs, nurses and other healthcare providers can develop and implement strategies to minimize it.
- National Cancer Institute. Surveillance, Epidemiology, and End Results (SEER) Program. Turning Cancer Data Into Discovery. SEER Stat Fact Sheets: Breast Cancer. http://seer.cancer.gov/statfacts/html/breast.html. Accessed November 4, 2013.
- Extermann M. Measurement and impact of comorbidity in older cancer patients. Crit Rev Oncol Hematol. 2000;35(3):181-200.
- Marenco D, Marinello R, Berruti A, Gaspari F, Stasi MF, Rosato R, et al. Multidimensional geriatric assessment in treatment decision in elderly cancer patients: 6-year experience in an outpatient geriatric oncology service. Crit Rev Oncol Hematol. 2008;68(2):157-164.
- Balducci, L. Supportive care in elderly cancer patients. Curr Opin Oncol. 2009;21(4):310-317.
- Extermann, M. Interactions of cancer and comorbidity. Cancer Control. 2007 Jan;14(1):13-22.
- Muss, HB. Cancer in the elderly: A societal perspective from the United States. Clin Oncol (R Coll Radiol). 2009;21(2):92-98.
- Zeber, JE, Copeland, LA, Hosek BJ, Karnad AB, Lawrence VA, Sanchez-Reilly SE. Cancer rates, medical comorbidities, and treatment modalities in the oldest patients. Crit Rev Oncol Hematol. 2008;67(3):237-242.
- Barry B, Henderson A. Nature of decision-making in the terminally ill patient. Cancer Nurs. 1996;19(5):384-391.
- Degner LF, Sloan JA. Decision making during serious illness: What role do patients really want to play? J Clin Epidemiol.1992;45(9):941.
- Petrisek AC, Laliberte LL, Allen SM, Mor, V. The treatment decision-making process: Age differences in a sample of women recently diagnosed with nonrecurrent early-stage breast cancer. Gerontologist. 1997;37(5):598-608.
- Yogaparan T, Panju A, Minden M, Brandwein J, Mohamedali H Z, Alibhai, SMH. Information needs of adult patients 50 or older with newly diagnosed acute myeloid leukemia. Leuk Res. 2009;33(9):1288-1290.
- Chen H, Haley WE, Robinson BE, Schonwetter RS. Decisions for hospice care in patients with advanced cancer. J Am Geriatr Soc. 2003;51(6):789-797.
- Gauthier DM, Swigart VA. The contextual nature of decision making near the end of life: Hospice patients' perspectives. Am J Hosp Palliat Care. 2003;20(2):121-128.
- Kelly-Powell ML. Personalizing choices: Patients' experiences with making treatment decisions. Res Nurs Health. 1997;20(3):219-227.
- Kohara, I, Inoue T. Searching for a way to live to the end: Decision-making process in patients considering participation in cancer phase I clinical trials. Oncol Nurs Forum. 2010;37(2):E124-E132.
- Legare F, O'Connor AM, Graham ID, Wells, GA, Tremblay S. Impact of the Ottawa decision support framework on the agreement and the difference between patients' and physicians' decisional conflict. Med Decis Making. 2006;26(4):373-390.
- O'Connor AM. Validation of a decisional conflict scale. Med Decis Making. 1995;15(1):25-30.
- Sinding C, Wiernikowski J, Aaronson J. Cancer care from the perspective of older women. Oncol Nurs Forum. 2005;32(6):1169-1175.
- Hughes N, Closs SJ, Clark D. Experiencing cancer in old age: A qualitative systematic review. Qual Health Res. 2009;19(8):1139-1153.
- Thome B, Dykes AK, Gunnars B, Hallberg IR. The experiences of older people living with cancer. Cancer Nurs. 2003;26(2):85-96.
- Cella DF. Quality of life: the concept. J Palliat Care. 1992;8(3):8-13.
- Dunn J, Lynch B, Aitken J, Leggett B, Pakenham K, Newman B. Quality of life and colorectal cancer: a review. Aust N Z J Public Health. 2003;27(1):41-53.
- Ferrans CE. Quality of life: Conceptual issues. Semin Oncol Nurs. 1990;6(4):248-254.
- Institute of Medicine. Cancer in Elderly People: Workshop Proceedings. http://bit.ly/1cGWOhW. Accessed November 4, 2013.
- Kagan SH. Shifting perspectives: Gero-oncology nursing research. Oncol Nurs Forum. 2004;31(2):293-299.
- Lichtman SM, Balducci L, Aapro, M. Geriatric oncology: A field coming of age. J Clin Oncol. 2007;25(14):1821-1823.
- Oncology Nursing Society and Geriatric Oncology Consortium. Joint position on cancer care for older adults. Oncol Nurs Forum. 2007;34(3):623-624.