School of Medicine, University of Queensland, Ipswich, Queensland
Most people who become ill with cancer are over 60 years old, and the incidence rate will increase as the population ages. The role of general practice and primary care will become greater with time, as limits of the abilities of specialist cancer and palliative care services to provide care for all will be tested. There are challenges in determining how to integrate specialist and generalist services. Caring for older persons with cancer requires consideration of the whole person – a perspective that is routine for general practice and primary care. This contextual knowledge could be very valuable in planning cancer treatment. In particular, the patient’s aims for treatment, physical and cognitive state, and social circumstances have to be taken into account. The care for carers, who will often have their own medical problems in addition to the burden of care, could be a first step in engaging general practice/primary care routinely into cancer care.
The developed world is growing older. In 2006, 13% of Australia’s population was over 65. This is projected to be over 26% by 2051.1 While the population is living longer than ever before, it is also inevitable that people will become ill and die. In the next 50 years, the proportion of people of retirement age will grow to levels where existing social and health infrastructure will simply not be able to manage the demand for services. As a society, we need to become far smarter at delivering health care that is primed to meet the challenge. Effective health care coordination will be crucial.2 At the core of these changes has to be a vibrant primary care sector.
Ninety per cent of Australia’s population visits a general practitioner (GP) every year.3 While Australia’s health system already promotes general practice as the lynchpin for chronic disease management,4 the size of the problem means that the primary care system has to continue to evolve in order to readily meet the challenge. Cancer in older people poses particular challenges.
As people grow older, the burden of illness increases. In 2012, most cancers were diagnosed in people over the age of 60 – 75% for men and 65% for women.5 The commonest non-cutaneous cancers are – prostate, bowel, melanoma and lung in men and breast, bowel, melanoma and lung in women.5
In addition to cancer, older people are very likely to suffer from multiple conditions, and to be taking multiple treatments. Furthermore, the proportion of people who become more frail with time increases, and frailty itself causes the greatest proportion of death in those over 70.6 Frailty is a condition of reduced physiologic reserve and dysregulation of multiple physiologic systems, which produces a high risk of vulnerability for adverse health outcomes.7 Cognitive decline is a reality for many, and dementia for a substantial number of older people. The proportion of people with cognitive impairment increases exponentially with age.8 This brings with it risks of poor self-care, including inadequate nutrition, difficulties with compliance with medicine and a reduced awareness of what may be happening to the body. The consequences are considerable – medication misadventures, slower healing and an inability to exercise properly, to name a few.
Cancer in older people involves the same biological processes as in the young, but the consequences of the ageing process mean that the physiological and social context in which cancer occurs plays a dominant part in determining how best to manage it. Patient choice is paramount, and close communication between primary care providers and the patient and close relatives is essential. There are many evidence-based tools to assist people to communicate their needs and desires.9
Most older people prefer symptom control over curative intent in cancer treatment.10 The ageing process will determine how the body can withstand what are often challenging treatment processes. The physiological reserves of the body decline with age, so the ability to withstand treatment similarly declines, and even without comorbid disease, may preclude some therapies. Further, comorbid diseases add insult to bodies with slowly but steadily declining reserves.
In addition to the biomedical considerations of age, the rigours of treatment – multiple trips to hospital for chemotherapy and radiation therapy, may be an insurmountable burden for some. It may be that treatments that can be administered on a daily basis at home are preferable, even if the chance of cure is less likely. Available social support structures also need to be considered.
Prevention can be considered in terms of preventing cancer, and in maintaining optimal health as age progresses. Healthy patients have more cancer treatment options available to them. It is essential to encourage preventive measures as early as possible, and promote healthy habits in exercise, nutrition and social interaction to minimise the risk of declining general health. Habits of a lifetime are hard to break, and if people are not used to an active lifestyle, or have indulged in harmful habits over many years, it is very difficult to introduce healthy behaviours in the latter years of life. Cancer prevention activities should be started early and continue through life. These include stopping smoking, appropriate diet, safe levels of alcohol consumption and sun protection.11
It is possible to detect common cancers early. This applies in particular to breast and cervical cancer in women and bowel cancer in both sexes. Screening for breast cancer should start at 50, and regular mammography be conducted biennially until the age of 69. Similarly, pap smears should continue for women who have been sexually active until the age of 69.11 Faecal occult blood testing to detect bowel cancer should be conducted every two years from age 50-75 if all tests are negative, and lifelong in those with any positive test.11,12 Australia has a national bowel cancer screening program which offers free five yearly faecal occult blood testing from ages 50 to 65.13
In most cases, GPs will not have a major role in the active primary treatment of cancers, but there is potential to have significant roles in cancer treatment care.14 They can facilitate referral to the appropriate service in a timely way.15 GPs can facilitate the oncology team’s decision-making process easily by ensuring that all relevant pathology and radiology is ordered and completed well before the treating team is consulted. Further, they should play a role in determining treatment, because of their knowledge of the patient’s health and social circumstances. Their input should be considered in the multidisciplinary team’s decision-making process. Treatment decisions made by disease-based multidisciplinary teams are considered best practice, with positive impacts on treatment outcomes.16 However, these specialist multidisciplinary teams have struggled to work out where GPs actually fit in.
Many GPs have contextual knowledge of their patients, their health status and their family that has taken years to build. Their contribution has the potential to make a substantial impact on cancer treatment decisions. This is particularly the case in older patients where the whole context is critical in deciding whether to treat, and if treatment is contemplated, to what extent.
Further, they could be given the responsibility for the care of the primary caregiver. Carers’ issues are frequently acknowledged, but because of resource constraints, cancer centres find it is very difficult to identify and manage their issues and concerns arising from the patient’s cancer. Indeed, the act of caring can be exhausting and can directly impact on the ability of carers to continue the care of very ill people. Formalising this role for GPs could be a major advance for the management of the whole situation.17
This rationale for engaging GPs in multidisciplinary teams is not questioned, but how to action this is challenging. GP participation in multidisciplinary case conferences are supported by Medicare, and do influence patient outcomes and service utilisation in the palliative care setting.18,19 Different models of actioning participation of GPs have been tried, notably using videoconferencing and teleconferences. Evidence of similar impact in the cancer setting has not yet been generated.
Discharge from treatment can be a fraught process for patients.20 Many patients feel a keen loss of a very supportive structure when they are discharged. The processes to return to a ‘pre-cancer’ life have not been considered till recently, when the issues surrounding ‘survivorship’ have received serious consideration. Central in this is the importance of resuming the need to pay attention to normal health issues. In older people, this includes the need to maintain the care of comorbid conditions. Periodic cancer checks need preparation, and this can be a role facilitated by the GP. Particularly in regional and rural areas, much post treatment surveillance can be done locally, so long as there is good communication between the treatment team and the GP.15 Much unnecessary travel, time and expense can be prevented by forethought and communication.
Advance care planning is a process where patients, close relatives and their medical advisors anticipate health needs that may arise in the future.21 These are recorded in Advance Health Directives, which are legally binding documents that allow the patient’s wishes to be respected. In addition, they record the appointment of a health advocate, who can make decisions on behalf of the patient. Each state in Australia has similar but not identical processes. All legislation allows for patient wishes to be overridden in the cases where preferred treatment options are futile. Such decisions would be made in conjunction with the patient’s health advocate.
One of the most challenging aspects of medical care is breaking the news that cancer has progressed and cure is not possible. In order to assist the patient to make this choice, a ‘benefit-burden’ assessment should be undertaken by the patient and his/her medical advisors (box 1).22 The benefits of successful treatment are obvious. However, the burdens for older people can be formidable. The GP can be a key person in guiding the person through this assessment. Once decisions are made, from time to time the GP will be called upon to convey treatment decisions back to the specialist team. Thus the advocacy role of the GP is both one of advising other team members, and of interpreting the advice of specialist colleagues back to the patient.
About three quarters of GPs express willingness to be involved in palliative care with their patients.23,24 This is a given part of the role of general practice in rural and regional areas. Increasingly though, patients in urban areas are referred to specialist palliative care services directly from oncology services, and GPs may find themselves marginalised.15 This may concentrate end of life cancer care on already overstretched services. Again, processes like case conferences may allow shared care to take place. The best results will occur when tasks of care are negotiated and allocated. Again, this means negotiation and time. However, the long-term benefit of this is likely to be more efficient care.25
Needs based palliative care has been advocated in recent years. Needs based care is the care that patients are provided by the service most suited to the intensity of their needs.26 For many, their needs can be perfectly managed in primary care. There may be times when care requires consultation by palliative care services and the care can still be provided at the community level. Perhaps a period of inpatient care to stabilise a problem may be needed. However, a small proportion of patients will require far more intense care, or complex symptom problems need high levels of multidisciplinary and specialist input. Importantly, people can move in and out of different levels of need (figure1).27 An instrument which allows an objective assessment of the level of need has been devised and tested.26 It can be used at regular intervals by any health professional, and takes a couple of minutes to complete and does improve patient outcomes.
When cancer is diagnosed in older people, appropriate treatment is required. The problem here is determining what ‘appropriate’ means in the context of older people. Here GPs have to make judgments about the health of the person, and make it clear to the treatment team what the patient’s normal health state is. What are the morbidities the person already has? What will be the person’s capacity to withstand what are often challenging treatment regimes? What treatments is the patient already taking? What social supports are in place? What is the health of the spouse and their ability to provide care if advanced illness is in place?
It may be that the person is fully capable of undertaking curative treatment for their disease. However, it is also possible that the burden of comorbid diseases and the patient’s goals of care should lead to modifications in cancer treatment. The aims of treatment need to be conveyed to the patient. Ultimately, decisions about how treatment will be undertaken will be made by the patient and his or her support network. This must be an informed choice.
Cancer and its symptomatic sequelae frequently require powerful therapies. It is not in the scope of this article to consider these in detail. However, it is relevant to consider how the ageing process can alter the way therapies are used.
Treatment regimes can be complex. In the presence of cognitive decline, safeguards have to be instituted that minimise the risk of confusion. Use treatments that require once or at most twice daily administration for preference. Additionally, impaired vision may make reading labels impossible. Interventions that include blister packaging and cognitive support, and those that provide education about medicine use can be effective.28 Make use of dispensing strategies that minimise the risk of confusion. Consider supervision of treatment by a responsible carer, or where there is none, domiciliary nursing services.
Chronic kidney disease can develop insidiously, and early stages of chronic kidney disease are common in older people.29 Since many drugs used in cancer and palliative care are excreted renally, there is a major risk of toxicity in the presence of unrecognised renal impairment. Irreversible causes of impaired renal function include vascular disease, hypertension and diabetic nephrophy. Renal function is reversibly affected by a number of problems in older age. In particular, drugs such as non-steroidal anti-inflammatory drugs, diuretics and other anti-hypertensives (especially angiotensin converting enzyme inhibitors and angiotensin receptor blockers), the so-called ‘triple whammy’,29 together with dehydration, can seriously reduce renal function. Attention paid to these risk factors will reduce the risk of adverse events.
Approximately one in three older people in the community taking five or more medicines will suffer an adverse drug reaction within 12 months, and many of these will be hospitalised.30 Many of these episodes are preventable. Cancer and palliative care therapies add far more medicines, and the risk rises accordingly. The benefit versus the risk of each therapy needs to be carefully considered. Critical review of medicines is essential. Consider the overall aims of treatment for the patient. For cancer, that goal may be cure. In the palliative care setting, the aim is comfort and potentiating function. What is the potential for benefit of each medicine, including the time until that benefit is manifested? Balance this against the potential for short-term and long-term harm.31 Can one medicine have an impact on more than one condition? Long-term preventive agents like cholesterol lowering agents and even low dose antiplatelet agents should be considered for withdrawal.
Cancer care in older people has to be influenced by the patient’s physical and mental state, their psychosocial supports and their life goals. General practice can play a pivotal role in the successful management of older people with cancer. GPs have multiple roles in this setting. Finding ways to bring GPs into the formal care of cancer patients should offer improved outcomes, adding their contextual knowledge to the disease based knowledge of specialist colleagues. Further, GPs are in an excellent position to be the designated care provider for the carer of older persons with cancer. Overcoming the technical barriers to involvement of GPs in multidisciplinary decision-making is a priority.