The role of self-perceived age in older adults considering adjuvant chemotherapy

Abstract

Introduction:

Aging-related concerns can increase the risk of treatment toxicities among older adults considering adjuvant chemotherapy. We previously demonstrated that older adults with cancer who reported feeling older than their chronological age (i.e., self-perceived age) were more likely to have aging-related concerns identified during a geriatric assessment. We explored how decisions about adjuvant chemotherapy vary with or are related to older adults’ self-perceived age.

Materials and Methods:

We conducted a secondary analysis of a multi-phased feasibility pilot using semi-structured interviews that were conducted to explore the patient decision-making process for adjuvant chemotherapy. Interviews incorporated questions about chronological and perceived age as factors for decision-making. Patient eligibility for the study included (1) age ≥70 years and older, (2) a diagnosis of breast, colon, or lung cancer and considering adjuvant chemotherapy, and (3) able to read size 18 font in English. Interview data were analyzed using constant comparative method.

Results:

Twenty-one patients were enrolled. The mean chronological age was 78 years (range 71–91). The average perceived age of patients was 57 years (range 21–80). Eleven patients chose to receive treatment while ten patients did not. Aging-related themes illustrated that self-perceived age plays an important role when patients make decisions about adjuvant chemotherapy. More specifically, patients who reported their self-perceived age as younger than their chronological age also reported better perceived health status and chose to receive adjuvant chemotherapy.

Discussion:

Patients’ experiences of aging and self-perceived age may have different implications for decision-making.

Funding:

Wilmot Cancer Institute Program Pilot Award; NIA K76 AG064394 (Magnuson); NCI K12CA001727 (Sedrak); NIA K24 AG056589 and R33 AG059206 (Mohile); NCI-funded postdoctoral T32 Fellowship Program in Cancer Control T32CA102618 (Yilmaz).

Introduction

Self-perceived age is defined as the subjective evaluation of one’s own aging and has wide-reaching implications for health.(1) More precisely, older perceived age is associated with poor health and higher healthcare utilization among older adults.(2) Previous studies have demonstrated that self-perceived age is a robust biomarker of aging, predictive of survival among patients 70 years of age and older and correlated with important functional and aging-related processes.(3) Many older patients who receive adjuvant chemotherapy are at high risk for chemotherapy toxicity and other adverse health outcomes due to comorbid and aging-related concerns.(4, 5) In fact, a number of studies have shown that older adults with cancer who receive treatment report impairments in several aging-related processes.(6–8)

The growing literature suggests that self-perceived age is associated with both physical and cognitive functioning.(3) Furthermore, studies suggest that older patients who report feeling younger than their actual chronological age also report better health and survival.(2, 9) While those with more positive self-perceptions of aging live longer, those with negative self-perceptions of aging are more likely to disengage and to reject life-prolonging medical treatment.(1, 9–11) Older patients who report feeling the same or older than their chronological age are more likely to have impairments in several geriatric assessment (GA) domains including physical performance, functional status, psychological health, nutritional status, and polypharmacy.(2)

Understanding how older adults with cancer perceive their own aging processes can have implications for treatment decision-making.(2) Several studies (12–14) show that older age is a strong predictor of patient preferences about shared decision-making, with older patients less likely to want active participation, and they may opt for limited involvement in treatment decisions, preferring to leave the decision-making to the treating physician.(15) Despite the growing body of literature describing how aging influences the decision-making process, there is limited understanding as to how older adults with cancer incorporate their perceptions about their own age and the aging process into cancer management decisions. To our knowledge, only a few studies have investigated how self-perceived age affects cancer treatment decision-making. In this study, we explored how older adults make decisions about adjuvant chemotherapy based on their self-perceived age.

Methods

Study Design and Setting

This is a secondary analysis of a multi-phased feasibility pilot that was conducted using convenience sampling with medical professionals, patients, and caregivers. We focused on the patient data for this paper. The initial patient sample size was estimated to be 15 to 30 and data collection was stopped at 21, as determined by data saturation. Interviews were conducted to gain a better understanding of how older adults make decisions about adjuvant chemotherapy. Patients were recruited from the University of Rochester Wilmot Cancer Institute in Rochester, NY, USA and affiliated satellite locations (i.e., Highland Hospital, Interlakes, and Pluta Cancer Center) between January 1, 2017 and end of December 2018. Patients consented to participate in semi-structured interviews with open-ended questions exploring how they approached their decisions about adjuvant chemotherapy, as well as quantitative surveys including their perceived age. Interviews were administered by a member of the research team in a private location, (i.e., clinic room, office space) or over the phone, and lasted approximately one hour.

Participants

Patient eligibility for the study included (1) age ≥70 years and older, (2) a diagnosis of breast, colon, or lung cancer and considering adjuvant chemotherapy, and (3) able to read size 18 font in English. Patients were excluded from the study if they were (1) unable to speak, read, and/or write in English or (2) unable to provide informed consent due to lack of decision-making capacity, as determined by their primary medical oncologist or medical chart.

Patients were identified by the research team, with the permission of their treating provider and were approached in-person or contacted by phone to discuss the study. Patients were paid $40 in the form of a gift card for their participation in the study. The study was approved by the Institutional Review Board at the University of Rochester Medical Center.

Measures

Patients were asked to complete a survey consisting of demographic information (e.g., chronological age, race, ethnicity), cancer type, and treatment type (adjuvant chemotherapy versus no chemotherapy), and a measure of their perceived age (“How old do you feel you are?”) (16) which was entered as a continuous variable.

In addition, semi-structured interviews were conducted to explore how patients perceived their age and its relation to their decision to receive adjuvant chemotherapy or not. The interview consisted of open-ended questions focusing on cancer treatment, patient preferences, and values that may have an impacted their decision on whether to receive adjuvant chemotherapy. The semi-structured interview included two prompts referencing age: “While making your decision about treatment, was your age discussed?” and “Did you think about other medical problems or age-related issues with regard to making a choice about treatment?” The qualitative interviews were audio-recorded and transcribed for qualitative data analysis.

Data Analysis

Quantitative.

We used descriptive statistics to summarize patient demographics and perceived age (Table 1).

Table 1.

Patient Characteristics (n = 21)

Variable Name	Mean (SD), %
Chronological Age	77.5 (6.3)
Self-perceived Age	56.6 (17.2)
Sex	52% Male
Race	100% White
Ethnicity	100 % non-Hispanic
Education	62% Some College or Higher
Marital Status	52% Married 38% Widowed 5% Divorced
Income	38% Less than 50k 48% 50k or More 14% Declined to Answer
Cancer Type	81% Gastrointestinal 14% Breast 5% Lung
Treatment Type	52% Chemotherapy 5% Hormone Therapy 43% No Treatment

Qualitative.

The audio-recorded interviews were transcribed and analyzed by three coders (SY, FK, AM) using the constant comparative method(17) which is used to simultaneously code and analyze the data by comparing specific themes in order to develop concepts and explore relationships. Codes related to patients’ perception of age were extracted and consolidated based on relationships among themes.

After developing the themes, we compiled and integrated all of the analyzed data (both quantitative and qualitative; see Table 2) to look for connections between themes and the decision to receive or not receive adjuvant therapy.

Table 2.

Themes, Representative Patient Quotes, and Adjuvant Treatment Choice (n=21)

Themes	Chronological Age	Self-perceived	Patient Quotes	Adjuvant Chemotherapy
Theme # 1: Do not want to go through the potential side effects associated with chemotherapy at their age	72	62	“…but he said that at this point with the four or five percent differential between having some kind of chemo treatment and not, he said he probably would lean to saying that it probably would benefit me not to. Now I will say I personally felt if I had to have it I would. But I also know many times there’s a lot of side effects. I am 72 and I just didn’t want to deal with [them]. ”	No Treatment
	74	60	“I am not looking to live to be 100…” “I don’t want to go through this stuff when I’m 75 and older.”	No Treatment
	91	75	“.just didn’t want to go through it at this particular time. I’m 91 years old and I don’t know if I could handle the chemo, from all of the things I’ve heard…”	No Treatment
Theme # 2: Comfortable with current health/quality of life and concerned about disrupting that with the treatment	85	21	“.Now I’m going to be 86 in January, I’m in basic good health.” “I have no death wish because I have a wonderful life, but I’m not involved with heroics that are going to continue my life for 3 months and a life that is not quality. I’m more interested in quality than quantity.”	No Treatment
	87	77	“.I mean, it would take a while to develop and at 87, I think can make it.” “.at my age, why put the burden of treatment on me. ” “I’m comfortable, I feel good and I don’t want to disturb it.”	No Treatment
Theme # 3: Age and health at their age are not a factor in decision making for treatment	75	60	“I’m 75 and hopefully I have quite a few years left. But no, age wasn’t really talked about in any specific manner.”	No Treatment
	76	21	“I don’t have any medical issues – they weren’t really discussed. I’m very healthy until February of this year. ”	No Treatment
	71	60	“.I never think of myself as being very old so” “I’m otherwise basically healthy, so there is nothing else to really worry about.”	Hormone Therapy
	73	37	“I don’t think it [age] made any difference if I put down 37 or 73; it’s a hell of a choice to make. I opted for what I think is the best choice, the most successful, the best documented. ”	Chemotherapy
	78	55	“I’m 78 years old too, so…”, “they never said that was a problem that my age would be a problem. ”	Chemotherapy
Theme # 4: Otherwise feels healthy and has a goal for longevity	72	50	“I’ve had a good run; I’ve stayed healthy all these years. I’ve been busy all these years. ” “But I’m already there at 72 or 73. So I want a good ten more years of this life.”	Chemotherapy
	72	65	“As far as I know, I don’t have any other medical issues.”, “If I have ten greatyears.look like this.can do what I do now…I’d sign on now. ”, “And I kind of think if we can clean this up, it would take something else at least 10 years to get started. ”	Chemotherapy
	74	40	“I’ve got to try and out-brat my father; my father lived to be 90 – I want to get to 99 at least.”, “I don’t have any other medical issues.”	Chemotherapy
Theme # 5: Believe that feeling healthy and/or appearing younger is more important than actual age when discussing treatment	71	55	“He said, “I operate on you. There wasn’t anybody in the operating room that believed you were 70 – 50 maybe, but 70 no. ” Your age is not an excuse for you. ”	Chemotherapy
	83	50	“I’ve had good health up to this point… No health issues, mental issues, anything of that nature. ”, “In some respects, I guess I’m a young 83. ”	Chemotherapy
	84	60	“One of the nurses said “I was wondering who I was going to see in here when they read off all this stuff” – she was surprised, fortunately. ”, “.Your body starts to break down and all things start happening as you get older. Luckily, we have all these good doctors to fix us up. ”, “.people are living to be over 100.”	Chemotherapy
Theme # 6: Some ambiguity; appear resigned to treatment despite concerns about their age/health	71	80	“I’m taking care of my 91 years old mother and she’s in better shape than I am, literally. ”, “Your body’s weaker when you get my age. If I were 50, the treatment would probably be a lot more effective. ”	Chemotherapy
	83	73	“Life is very difficult when you go through this. It makes a difference when you’re an older person and widowed and on your own. ”	Chemotherapy
	81	75	“.as far as my age is concerned, yeah, that’s a factor – I’m 81 years old and I don’t know how that’s going to affect me, but we’re going to find out.”	Chemotherapy
No discussion around the topics included in the themes	78	60	n/a	No Treatment
	81	55	n/a	No Treatment

Results

Patient Characteristics

Patient characteristics are shown in Table 1. Twenty-one patients were recruited for this study. The mean age was 78 years old (range 71–91) and 52% were male. All patients were non-Hispanic White. Most patients had some college or higher education, were married, and reported $50k or greater income. Patients considering adjuvant chemotherapy for gastrointestinal, breast, and lung cancer were included. Of the 21 patients enrolled in this study, eleven chose to receive chemotherapy, one patient chose hormone therapy, and nine declined chemotherapy.

Self-Perceived Age and Decision-making

The mean “self-perceived age” was 56.6 years old (range 21–80). The mean difference between chronological and self-perceived age was 20.9 (standard deviation [SD] = 17.4).

Qualitative Themes and Decision-making

All but two patients made comments during the interview related to their self-perceived age, health status, and treatment decision. Six themes related to treatment decision-making emerged (Table 2).

Theme #1: Do not want to go through the potential side effects associated with chemotherapy at their age. Three patients made comments that were categorized as theme #1, indicating that they would rather not undergo the potential side effects of chemotherapy at their age, due to the burden it might cause them. In other words, at their age, the risks and potential side effects of chemotherapy outweighed the potential benefits. A patient who decided not to receive treatment said, “…but he said that at this point with the four or five percent differential between having some kind of chemo treatment and not, he said he probably would lean to saying that it probably would benefit me not to. Now I will say I personally felt if I had to have it I would. But I also know many times there’s a lot of side effects. I am 72 and I just didn’t want to deal with [them].”

Theme #2: Comfortable with current health/quality of life and concerned about disrupting that with treatment. Patients were content with their overall health and did not want to disturb it. For this theme, two patients were more concerned with their quality of life than their quantity of life. They felt that good quality of life was more important than living longer and dealing with the effects of treatment. A patient who received no treatment stated, “… I mean, it would take a while to develop and at 87, I think I can make it”. “... at my age, why put the burden of treatments on me”” … I’m comfortable, I feel good and I don’t want to disturb it.”

Theme #3: Age and health at their age are not a factor in decision-making for treatment. Five patients made comments that fell into theme #3, highlighting the idea that their age and health had no influence on their decision for receiving treatment. A patient who received chemotherapy said, “I don’t think it [age] made any difference if I put down 37 or 73; it’s a hell of choice to make. I opted for what I think is the best choice, the most successful, the best documented.”

Theme #4: Otherwise feels healthy and has a goal for longevity. Patients wanted to proceed with chemotherapy because of their goal to live longer, and they perceived no significant issues with their health. Three patients expressed feeling healthy and chose to receive treatment because they had a desire to live longer. A patient said, “I’ve had a good run. I’ve stayed healthy all these years. I’ve been busy all these years” … “But I’m already there at 72 or 73. So I want a good ten more years like that.”

Theme #5: Believe that feeling healthy and/or appearing younger is more important than actual age when discussing treatment. Patients felt that in the context of discussing treatment options, the perception of good health and appearing younger was important. This theme was expressed by three patients and reveals that chronological age does not play an important role for some patients when considering treatment options, and perceived age is more influential in their decision-making. A patient who chose to receive chemotherapy said, “I’ve had good health up to this point… No health issues, mental issues, anything of that nature” … “On some respects, I guess I’m a young 83.”

Theme #6: Some ambiguity; appear resigned to treatment despite concerns about their age/health. In other words, the necessity of receiving treatment outweighed how some patients felt about their age and health. This theme was expressed by three patients; these patients seemed resigned to having to take treatment even though they had concerns about their age and health. A patient who chose to receive treatment expressed “I’m taking care of my 91-year-old mother and she’s in better shape than I am, literally.” … “Your body’s weaker when you get my age. If I were 50, the treatment would probably be a lot more effective.”

Overall, based on the themes that emerged, most patients’ self-perceived age appeared to have a role in the decision-making process regarding cancer treatment. Each theme highlighted a different aspect of self-perceived age and health, and illustrated its impact on the decision-making process for patients. We observed that patients who declined adjuvant chemotherapy also mentioned side effects of treatment in the context of their self-perceived age and the potential impact of these side effects on their quality of life. In contrast, patients who opted for adjuvant chemotherapy appeared to report feeling healthier, and more importantly, younger than their chronological age and as a result prioritized living longer. There were also a few patients who reported that their age was not a factor in their decision-making about whether or not to receive adjuvant chemotherapy, and instead decided based on what they thought as the best option for them at the time.

Discussion

In this study, we observed that most patients’ self-perceived age was younger than their chronological age. We also observed that older patients’ self-perceived age was one of the six factors considered when making decisions about adjuvant chemotherapy. Overall, patients who declined adjuvant chemotherapy tended to mention side effects of treatment and the potential impact of these side effects on their quality of life or were comfortable with current health status and quality of life and did not want treatment to disrupt these areas. In contrast, patients who chose to receive adjuvant treatment expressed a desire to live longer and valued their health and sense of youthfulness or appeared resigned about treatment despite concerns about their age and health. There were also patients who, regardless of opting for chemo or no treatment, reported that age and health did not have a significant influence on their decisions about treatment.

Our finding that most patients perceived their age as younger than their chronological age is consistent with past work. For example, in a study evaluating how perceived age may reflect on the health-related quality of life (HRQoL) of older adults with cancer, less than 14% of patients reported feeling older than their chronological age.(18) This study also observed better HRQoL in patients who felt younger than their chronological age, compared to those who felt older. In our study, themes focused on the burden of treatment and the importance of quality of life were more commonly observed in patients choosing to forego adjuvant chemotherapy, potentially because of not wanting to risk disrupting their HRQoL. This is also confirmed in a study by Soto-Perez-de-Celis and colleagues, where they observed that older patients may prioritize maintaining quality of life (QOL), independence, or cognitive ability over longevity when making decisions about treatment that come with competing health outcomes. (19)

While other qualitative studies have explored cancer treatment decision-making for older adults, they did not focus specifically on self-perceived age. However, other studies have found similar themes related to aging and goals of treatment. For example, in a study by Sattar and colleagues of twenty older adults with any type/stage of cancer considering chemotherapy or radiation therapy, one qualitative theme identified patients who expressed a goal to “prolong life.”(20) This theme was similar to a theme observed in our study of patients who otherwise felt healthy and had a goal of longevity. Patients in the current study had a more “youthful” perspective of their age and felt that receiving treatment would help maintain this and provide longevity. It is important to note that the study by Sattar and colleagues included patients with cancer of all stages, and only ten of the twenty patients made a decision about chemotherapy. Our study adds to these previous findings by providing information about how patients connected their perceived age to their overall health and, in turn, what factors they considered when deciding to receive or defer adjuvant chemotherapy.

Themes related to aging have emerged in previous qualitative studies exploring the experiences of patients in relation to their treatment decision-making processes. For example, in a study conducted by Harder and colleagues exploring older adults’ experiences and preferences for receiving information from health care professionals and making decisions for treatment (21), a theme that emerged was “side effect of treatment/impact on quality of life.” Our study had similar findings, but we identified two distinct aspects to this: theme 1, “do not want to go through the potential side effects associated with chemotherapy at their age” and theme 2, “comfortable with current health/quality of life and are concerned about disrupting that with treatment”, suggesting that some view treatment as a way to maintain their good QOL while others perceive it as a potential threat to QOL. Furthermore, in the study by Harder and colleagues, all patients had breast cancer, while our study included multiple tumor types and thus may be more representative of the general older adult population.

Our study suggests that self-perceived age is different than chronological age and that self-perceived age is an important factor to consider when making decisions about treatment. Oncologists, however, typically focus on chronological age and do not routinely inquire about self-perceived age or assess for physiologic age through a more comprehensive evaluation such as the GA.(22) The GA is used to assess health and well-being in domains such as function, nutrition, other medical conditions, mental health, social support, and several others.(23) Using the GA in oncology clinics can provide a better understanding of the overall health status of an older adult and may lead physicians and oncologists to discuss perceived age, overall health status, and QoL goals more regularly in the context of oncology decisions.(24) Furthermore, the incorporation of the GA could facilitate discussions about treatment planning that are more individualized to the patient, helping patients, families, and clinicians make better treatment decisions when considering adjuvant chemotherapy.

Study Limitations

There are a few limitations of our current study. Our study population was solely non-Hispanic White, which may not reflect how self-perceived age is viewed and considered across a diverse population of patients. In other studies of decision making, subtle variations in aspects related to decisional control and treatment preference were seen among different racial/ethnic groups.(25) Recognizing the importance of diversity, equity, and inclusion for representation and participation of different groups in research studies, it is our goal to explore the concepts of this study in a larger sample including more diverse and underserved populations of older adults. Our study also included a majority of patients with gastrointestinal cancer, as well as patients who perceived their age as being younger than their chronological age. However, most prior studies evaluating decision-making and age in older adults have focused on breast cancer, and thus the current study provides additional context by including other tumor types.

Conclusions

In this study, we explored how self-perceived age and the aging processes are considered in adjuvant chemotherapy decision-making by older adults with cancer. Further research is warranted for analyzing the direct implications of self-perceived age, as opposed to chronological age, on treatment decision-making in older adults.