Cancer in the Elderly: Challenges and Barriers

The aging population implies important changes at various levels. From the ancient years to the 19^th century, human life expectancy doubled from 20 years to 40 years. However, this life expectancy doubled fast to 80 years from the 19^th century to the 20^th century and continuously increased in the 21^st century.[1] This fact implies important socioeconomic and health challenges. Aging entails a greater need to care for aspects related to primary aging (physical changes due to aging) and to secondary aging (ailments with risks increase in old age).[2] Undoubtedly, cancer risk increases exponentially with age. About 60% of cancers occur in people 65 years of age or older. Furthermore, about 70% of the deaths caused by cancers occur in this stage. Therefore, cancer is a disease of old age.[3] Taking into account the increase in cancer occurrence and the quality of life among the elderly population, a special approach is necessary for the diagnosis, treatment, and survival of elderly patients with cancer.

Cancer of the elderly exhibits slower growth because their body already has a slower rate of cell development than those of young ones. However, some data show that elderly with tumors have worse prognosis because of delayed diagnosis.[1] Thus, the elderly should learn about the right attitude and knowledge to combat cancer. Older people have cancer-related experiences in the Big C era when little information about cancer was still available. Personal and family experiences are of fear and concealment, and terminal phases are painful and full of suffering. People often retain these emotional memories and become immune to new information. Therefore, a number of cures or changes regarding what cancer means today sometimes do not arrive as clearly as their own experience to which they often give an assessment of the only truth. Meanwhile, old people tend to label themselves as part of the elderly population. Thus, any health concern or distress is quickly attributed to old age. This case occurs because of the attitude not only of older people but also of their relatives and friends including health staff.[1,4]

Psychosocial reactions to cancer are related to many personal aspects, including society, culture, education, and family. Age is associated with different ways of coping with the disease. We defend that more than talking about age, we should start tackling about life cycle because some aspects are not related to the numerical age but to moments and facts of the person's life.[1] Cancer is a complex disease that must be analyzed from several points of view, and special aspects need to be emphasized for the elderly.

Attitudes toward and Knowledge about Cancer in Older People

In this study, we interviewed 874 people 60 years of age or older regarding their beliefs and attitudes toward cancer. This work finally counted 814 valid surveys. This research also provides valuable information for the future related works and for the elderly to have the appropriate attitude toward health.[4]

Psychosocial Barriers

As aforementioned, cancer is not just a physical disease. It is associated with wrong beliefs due to its relation to death, pain, and suffering. Cancer has to do with historical aspects that are difficult to suddenly change.[1,4] This phenomenon is especially true to older people. Possible attributions to cancer causes and cure are often detected. Our data show that about 2% of people still believe that cancer is a contagious disease, and 5% believe it is a punishment for people who did something bad in their life. Older people have low health literacy[5] because they came from a time when health was only considered when one was sick, and the doctor only decided on what to do. As expected, only 28% of our elderly respondents are aware of their greater risk of developing cancer. Thus, persuading the elderly who experience physical problems to immediately consult a doctor is difficult. Older people often do not recognize the usefulness of early detection or initiate healthy behavior because they consider that at their age is no longer worthwhile.

Attitudes toward Prevention and Early Diagnosis

We found that older people do not have proactive attitudes and often do not see the need to change lifestyles or to visit the doctor before certain changes or discomforts. Although 53% of elderly believes that cancer can be prevented based on our study, they have little knowledge of the European code against cancer. Only 6% of these people claim that they know this code. When asked about some cancer postulates, the figures increased, especially regarding harmful tobacco (95%) and excessive sunbathing (90.6%). About 58% accounted for excessive alcohol intake, 48% for unhealthy diet, and 38% for overweight status as risk factors.

Regarding early detection, 74% indicated that it is possible and effective, but 21% confused it with prevention. Mammography is known as an early detection tool (84%), whereas only 44% of the sample knows PSA (Prostate-Specific Antigen) as a prostate cancer marker.

Treatments

Anticancer treatments are sometimes devastating. To the elderly, treatments may not be considered necessary because certain therapies may seriously affect their quality of life, and many consider their at age not anymore worthwhile.[4] In our data, 29% of elderly affirmed that the treatment for cancer is worse than the disease itself, and 34% preferred not to receive any treatment in case of developing cancer. The most feared treatment is chemotherapy, which was indicated by 58% of the sample as something deleterious, and 51% believe that the treatment could not be resisted if they would receive it. Meanwhile, 48.3% believe that radiotherapy is dangerous. As the side effects of these treatments, 54% stated that anesthesia is a very risky procedure, and 29% indicated that vomiting due to chemotherapy is unavoidable. In addition, 6% remarked that alopecia as a side effect is irreversible. These attitudes can restrain older persons to have an early diagnosis because of fear of the consequences of treatments. We must remember that older people have other physical conditions that sometimes make them more fragile or complex, and doctors should carefully analyze this general state before choosing a treatment.[3]

Psychological Reactions and Coping

The most frequent psychological reactions to cancer are anxiety and depression.[4] Age is inversely related to anxiety level while directly related to the degree of depression. Thus, older people with cancer score higher in depression than young people. Their psychosocial characteristics can lead to confusion with a diagnosis of depression, which is related to feelings of loneliness, little desire to make plans, little prospect of future, fatigue, and physical discomforts. Associating cancer with existential aspects (for instance, related to end life) increases depression risk. Regarding anxiety, age possibly leads to less extreme reactions to stimuli that lead to nervousness, surprise, discomfort, or tension. Accepting cancer diagnosis as a part of something consistent with age and the end of life can yield lower anxiety levels than in younger cancer patients. However, this case may be taken with caution because sometimes a less extreme physiological reaction does not imply that no alteration at the cognitive level must be treated.

Religious coping is a special coping mechanism common among the elderly with cancer. Patients with this coping mechanism attribute the cause and the course of their disease to religious aspects (usually expressed with phrases like “what God wants” or “I put myself in the hands of God”). Some studies show that this type of coping implies an important psychological advantage to those who exhibit it.[1,4]

Information, Attitudes in the Environment, and Quality of Life

Older people came from a time when diagnosis details are not completely disclosed. For instance, doctors in the past do not explain to patients their actual condition and fatal prognosis. Although these approaches are changing, a tendency of not disclosing the diagnosis to elderly may still be experienced. In this sense, families who have contact with a doctor become sometimes reluctant. This condition suggests that the patient seems returning to the stage of pediatrics in which he/she is only on the sidelines.[1,4] The families, especially in Latin countries, have a protectionist attitude. This attitude, which is to a good end, sometimes implies an obstacle in communication. Our data show that 77.2% of older people prefer to know their cancer diagnosis and prognosis. In this same sense, 74% would explain it to family and friends. These findings indicate a tendency contrary to that supposed in principle. Some studies show that oncologists deal more to the patients’ relatives than to the elderly patients.[1,4]

In the generation of older people, psychologists are only considered as professionals related to mentally ill people. About 67% of our respondents cited that a cancer patient might need psychological help and 58% expressed that the disease could alter relationships. These results indicate a certain change of tendency because these cases do not merely mean physical aspects of the disease.

Conclusion

The lengthening of life expectancy has contributed to changes in health/disease binomial approaches. Advanced age is a wide and varied stage in which early detection and lifestyle change may improve the life of patients. Promoting public education and trainings to professionals is necessary so that they consider the developmental idiosyncrasy of elderly patients with cancer. This approach should also be applied to children having cancer. Our data reveal that the elderly are often unaware of being in a population at risk of cancer. This case and the taboos about the disease make the elderly develop attitudes of resignation and denial. Thus, we must devise tools that can generate change and achieve self-efficacy in this stage. As mentioned, old people deal with complex situations. Therefore, our study is developing two lines to further our research. First, we are currently determining how the attitudes of the elderly toward cancer can be improved using different tools. Second, we are exploring the reproduction of a comparative study in other countries to verify if the aspects that we have found are related to age or cultural differences. Similar studies have been conducted in Andorra and Florida and are open to the participation of other countries.

Financial support and sponsorship

This work was supported by FEFOC Fundació and Fundació La Caixa.

Conflicts of interest

There are no conflicts of interest.