Vicki Notes

• It is the leading cause of morbidity and death in people over 65 years old.
• Age is the most important determinant of cancer risk
• Myths and biases, related to treating older adults with cancer could interfere with early detection, treatment and management of cancer.
• Ageism - refers to negative attitudes or beliefs people have about aging and the older adult.
• Ageism in oncology (study of cancer) can lead to discrimination such as poor screening practices, treatment decisions and health care practices.

• Defense mechanisms change with aging.
• Changes in the functions of the immune system occur with aging and there is decreased immune surveillance (supervision). There is debate as to whether low immune responses of the older adult contribute to vulnerability to cancer.
• There is longer duration of carcinogenic exposure because aging allows for the cellular alterations responsible for the development of neoplasm. Longer exposures refer to the fact that they have lived longer and thus been exposed to carcinogens for a longer period of time. That is why aging or living longer is associated with cancer.
• It is believed that there is increased susceptibility of cells to carcinogens. Some results show that susceptibility or sensitivity of cells is related to the amount of exposure. The person is exposed to large amounts of carcinogens or small amounts of carcinogens. So you might consider that the person exposed to large amounts of carcinogens will have the more susceptible cell and develop cancer.
• There is decreased DNA repair. This DNA damage may also stop the action of cancer suppressor genes.
• Conclusion: It is apparent that some combination of the preceding factors and addition of others will be noted to account for development of neoplasia in the older adult.

• Screening is a type of secondary prevention.
• Issues that face older adults with a potential risk for a diagnosis of cancer include age, gender, extent of disease, and presence of comorbidities. These affect decisions concerning cancer control, adequate and appropriate treatment, and rehabilitation.
• Alterations in body systems, changes in psychologic and social support, diminished resources, and altered mobility all affect the capacity of the older adult to cope with a diagnosis of cancer.
• A framework or guide for analyzing the factors that may influence decisions for the older adult at risk for the development of cancer is the Comprehensive Gerontologic Model.

• The American Cancer Society has provided guidelines for cancer screening since 1980.
• It is generally accepted that the ACS guidelines have had a positive impact on the early detection and diagnosis of cancer.
• Recommendations for screening usually begin after age 50. It must be recognized that screening for cancer is not an exact science and decisions concerning whether or not to screen are based on the individual.
• Factors to be considered when deciding whether or not to screen in all people include the cost of the test, the specificity & sensitivity of the test, the ability to treat the cancer if diagnosis is made, and the discomfort & potential risk to the person from the test.
• Additional considerations of the older adult include the presence or absence of other diseases, ability to perform ADLs and life expectancy.
• The decision to treat is separate from deciding how aggressive that treatment should be.
• There are recommendations for screening of many cancers & they only serve as a starting place for practitioners. Differences in decisions in certain situations must be based on specific individual patient information, not on categorical decisions made on the basis of age.
• Other factor that influence decisions regarding screening for cancer include:
• The older adult may not participate in routine cancer screening possibly due to fears, myths or biases about cancer or cancer diagnosis. And the inability to pay for screening services.
• Healthcare providers lack of information concerning eligibility for screening.
• Older adults tend to visit the doctor for episodic and not preventive services.
• Doctor's and the pubic need education on the value of early detection.

• After deciding to screen the decision as to which screening tests should be used for the purpose of diagnosis. The decision should consider the social, psychologic, and biologic factors seen in the comprehensive gerontologic model. Also consider the following when deciding to pursue diagnosing cancer:
• The effectiveness of the screening test, its cost & potential for causing morbidity.
• How extensive the workup should be or how many test to include.
• The availability of the appropriate health care provider and treatment once a diagnosis is made, as well as what the older adult prefers.

• Research suggests significant age bias exists in relation to treatment decisions for the older adult.
• Bias is reflected in decision's doctors make concerning whether or not to treat the older adult with cancer, the type of therapy offered, and how aggressive it is.
• Doctors tend to offer older women more conservative therapy and refer them to specialists less frequently.
• Chronologic age should not be the sole factor used in deciding on cancer treatment in the older adult. Other factors include expected outcomes from each therapy, impact of the chosen therapy on the patient's quality of life, and economic factors.
• Just a little FYI: Tamoxifen is often prescribed for postmenopausal women with diagnosis of breast cancer.
• The preferences of the older adult must be included in the decision-making process.

• Treatments for cancer include surgery, radiation therapy, chemotherapy, hormonal therapy and biologic therapy.
• The choice of which therapy to use depends on the type of cancer, the extent of the disease at diagnosis (whether or not it has spread), tumor aggressivity & prognosis.

• Is one of the mainstays of cancer therapy and has been around since ancient times.
• Surgery is used to establish a diagnosis of cancer, to determine the extent or stage of the disease, to treat the primary cancer with intent to cure, and to provide palliative treatment in more advanced stages of cancer.
• Surgery is a local therapy & frequently followed by additional therapies.
• Two major factors that may influence the choice of surgery include the risks and possibility of death that comes with all surgery patients and the fact that older adults may choose surgery over other therapies. The attitude of some older adults seems to be to use the quicker treatment, such as surgery, and move on with their lives as opposed to the more conservative or time-consuming treatments.

• Radiation is local and can be used with intent to cure, with other therapies such as surgery or chemotherapy or as palliative treatment.
• Especially with the older adult, radiation as the first form of treatment helps to decrease tumor size and need for extensive surgery.
• As with prostate and breast cancers, radiation and surgery have been shown to provide equal outcomes of overall survival.
• Side effects that accompany radiation must be considered when suggest it as a therapy. The effects of radiation on normal tissue are said to be more pronounced in the older adult.
• Side effects from radiation therapy are generally limited to the site at which the therapy is delivered. However, when radiation therapy is delivered to organs that are experiencing the normal decline that occurs with aging, such as salivary glands, mucous membranes & skin, the effects potentially will be increased.
• Fatigue is a side effect experienced by most people receiving radiation therapy. In older adults that can result in a change in quality of life & the ability to perform ADLs.

• The effects of chemotherapy are both therapeutic and potentially toxic.
• The aim is to have the maximum therapeutic effect; however there is an expectation that there will be side effects.
• In the older adult the dosing is complicated by:
• The effects of normal aging on body systems
• The presence of comorbid conditions
• And polypharmacy
• Changes associated with normal aging may affect absorption, distribution, metabolism and excretion. Changes may include decreases in body tissue mass, decreases in renal & hepatic functioning, changes in gastric absorption & motility, and alteration in bone marrow reserve.
• Underdosing as a means to prevent side effects may cause patient more harm because they are receiving medication designed to kill cancer cells in a dose that is less therapeutic.

• Improved treatments for diseases will result in more people surviving & subsequently being at risk for cancer. The increase in older adults who will require cancer care clearly makes research on aging a national priority.
• Current research on aging focuses on biologic aspects of oncogenesis, prevention & control, clinical management, social & psychologic factors, ethical issues concerning allocation of resources & treatment decisions, and access to and costs of care.
• The most important aspect of health promotion among older people is to maintain health & functional independence. Determining why cancer incidence & death rates differ with advancing age is the only high-priority research need that specifically focuses on older people.
• The Oncology Nursing Society published a fact sheet as a resource for nurse & other health care providers interested in care of the older adult with cancer. It summarizes major issues in providing care for this population. They also published a position paper with ten statements to guide the nurse caring for the person over 65 years old with cancer.
• Lobbying by groups such as the American Association of Retired Persons (AARP) has lead to changes in approaches to care & dispelling myths & biases.
• Primary care & political advocacy are but two areas in which nurses are well positioned to effect change.

Read over Box 19-3, 19-4 and Box on page 541 and table 19-2

• Obtain a detailed personal & family medical history.
• Determine what the person's level of understanding is about cancer, and if they know their potential risk, physical ability to perform routine screening (i.e. breast self-exam) & desire to participate in screening.
• Compliance with screening guidelines can be increased if these examinations are incorporated into routine health care.
• Reminder systems such as chart reminder flow sheets, personal contact by phone or mail, clinic posters, mass media & community agencies help to increase frequency of screening in older adults.
• Nurses are well-positioned to recommend appropriate screening tests that are consistent with ACS guidelines, to schedule necessary screening tests, and follow up to ensure that tests have been obtained.

• Assessment of cancer risk is appropriate for first visit to a clinic, admission to acute care or long-term residency.
• Cancer checkups should be completed every years for people over 40 years of age.
• Checkup should include:
• Demographics (age, gender, martial status, height, weight, alcohol and/or smoking history)
• Exposure to environmental risk factors (Smoking, severe sunburns, carcinogens).
• Record of personal & family history of cancer.
• Physical assessment (For cancers of breast, ovary, prostate, lymph nodes, oral cavity, skin, testicles and thyroid.
• Any changes in body function (Weight loss, blood in stools & changes in appetite).
• Assessment of general cancer knowledge, myths, biases, cultural factors, previous screening, and changes in cognition & ability to perform self-examination.

• High risk for the development of breast cancer
• Risk for the development of ovarian cancer
• Risk for the development of cervical cancer
• Risk for the development of colorectal cancer
• Risk for the development of prostate cancer
• Risk for the development of oral cancer
• Risk for the development of lung cancer
• Risk for the development of melanoma and nonmelanoma skin cancers

• Compliance with cancer screening guidelines is the primary desired outcome or goal.
• Increased knowledge on the part of the patient about cancer, its causes, and its risks is another desired outcome, which contributes to compliance with screening guidelines.

• Educate the older adult about cancer, cancer screening tests and self-exam.
• Provide educational materials such as ACS guidelines.
• Provide resource telephone numbers (Local ACS and 1-800-4-CANCER).
• Provide information on availability of financial assistance.
• There are methods developed that assist in teaching older adults:
• Elderly Education Method -Allows an older adult to role model & teach other adults about colorectal cancer.
• Adaptation for Aging Changes Method - Teaching takes into account the special needs of learning for the older adult such as more time to process information, etc.
• Combination Method - Uses both of the methods above and is found to be the most effective & have a higher level of participation.

• Return demonstration is an effective why to determine a person's ability to perform self-examination.
• Patients are never too old to be screened for cancer.

American Cancer Society recommendations

• Age, family history of breast cancer or genetic predisposition, young age at menarche, first full-term pregnancy after 30 years of age, late menopause, nulliparity, history of ovarian or colorectal cancer & alcohol use.

• Age, history of breast cancer, family history of ovarian cancer & low parity.

• Multiple sexual partners, intercourse before age 20, HPV (human papilloma virus) and smoking.

• Personal or family history (first-degree relatives) of polyps, history of polyposis syndromes, high-fat diet and personal history of inflammatory bowel disease.

• Age and being a black North American man.

• Poor dental hygiene, tobacco use and alcohol use.

• Age, smoking, asbestos and other environmental or occupational exposures.

• Age, dysplastic nevi, family history, being white & fair-skinned, severe sunburns (particularly before the age 18).

• Decreased immune surveillance
• Longer duration of carcinogenic exposure
• Increased susceptibility of cells to carcinogens
• Decreased DNA repair
• Oncogene activation or amplification and tumor suppressor gene loss

• Cancer is contagious (It is not - Some are transmitted genetically or associated with some viruses i.e. AIDS)
• Cancer is incurable and means death & pain (Diagnosed early it's very curable, pain is a late symptom & controlled in many patients).
• Cancer is caused by personal vulnerabilities such as stress & unhealthy behavior (Stress alone does not cause cancer but it can affect the immune system & it is not caused by physical injuries. Smoking, high-fat diets & lack of exercise are few factors related to cancer).

• Treatment is painful & should be avoided (Pain & discomfort are usually short in duration & treatment shouldn't be avoided due to fear of pain).
• Older adults have less pain & tolerate it better (There is no evidence that pain decreases with age or tolerance increases).
• Pain medication causes addiction (Pain medications do not cause addiction in the patient being treated for cancer; May develop tolerance & need increased dose. Allows people with cancer to perform ADLs).
• Surgery can cause metastasis (Spreading is very rare).
• Radiation therapy is dangerous, painful & a last resort treatment (Side effects have been well managed & radiation effectively controls symptoms in more advanced disease).
• Chemotherapy is very dangerous (Chemotherapy can be safely given when consideration is given to the physiologic status & presence of other existing disorders/diseases).

• Ageism is associated with inadequate treatment (Older adults are screened less often & receive less aggressive therapy than younger adults).
• Belief that rehabilitation is not necessary in older adults (Activity, involvement in therapy & choice have resulted in decreased morbidity & depression).
• Cultural biases have been associated with increased incidence, morbidity & mortality (Examples include Latinos who relate cancer to sugar substitutes, bruises, microwave ovens, eating spicy foods, breastfeeding and antibiotics. Some Hispanics view breast self-exam as contrary to moral beliefs.

• Existence of comorbid conditions
• Extensive surgery
• Psychologic distress or fear of surgery
• Potential risk for anesthesia
• Potential for infection

• Skin: potential dryness, desquamation and infection
• Mucous membranes: sloughing, alterations in taste and decreased saliva
• Alterations in nutrition and weight loss
• Target organ injury such as cardiac or pulmonary
• Weakness and/or fatigue

• Nausea & vomiting resulting in malnutrition
• Depletion in marrow reserve resulting in infection
• Alopecia (hair loss) resulting in alterations in body image
• Pain as a result of therapy
• Constipation as a result of altered bowel elimination
• Mucositis

• Avoid overexposure to the sun
• Eliminate smoking
• Cut down on excessive alcohol use
• Eat a diet high in fruits, vegetables & fibers
• Exercise daily
• Participate in regular screenings & self-examinations to detect cancers at an early stage. Early detection can lead to a better prognosis.

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