Old, older, too old. A categorizing of “age” or of “medical thinking” regarding age? At different times and from different vantages, such as those of sincere caring, lesser technologies, and relative ignorance, patients of “that certain age” have been assumed noncandidates for certain treatments (i.e., that treatment risks are too much and that benefits are too little—at that age). Sometimes, we have been right in this, of course. However, increasingly, when depending on arbitrary thinking, we are not. Furthermore, and as Wright et al.'s article in this issue of Cancer opens the door to considering,1 the consequences of well intended but misplaced assumptions could compromise the health of the very patients we wish to serve/protect. For reasons ranging from evidence-based to philosophic, historically based pessimistic medical thinking deserves reassessment.2 Although this applies continuously across medicine, the focus herein will be oncology; along with perceptions of treatment tolerance in the elderly, their spin-off implications, and other influences affecting cancer treatment decisions in older age groups. If the premises underlying current perceptions are reevaluated earnestly, then it is likely the conclusion will be that, contrary to traditionally held negative presumptions, the only thing certain is that we no longer should be so certain.3, 4 Pragmatically, however, as it is with most truisms (e.g., elderly patients do not do as well with cancer or cancer treatments), just considering alternative possibilities is hard enough; but translating them into clinical behavior, well…that is an age-old, high hurdle made all the higher when the definitions, resources, and engulfing politics constantly are moving.
First, in 2004, what defines “old”? I will leave it to Wright et al. to defend their definition of “elderly” as age ≥ 70 years.1 Suffice it to say that there is ample room for social disagreement, and the point at which the line finally is drawn will affect the conclusions of any analysis significantly. Another cogent yet amorphous, moving target is the definition of “quality of life.”5 With inferences to both, we receive sardonic, crape-hanging, milestone birthday cards that proclaim—age…it's only a number. Still, and as those of us of “that certain number” soon come to know, in this linear world, numbers count and carry far-reaching impact, right and wrong.6 The stigma of the early-bird special and corresponding service, or lack thereof, appears instructive here.
True in all spheres of life, including medicine, the possibility of subtle influence on (medical) decisions caused by mere chronologic numbers is not something to be dismissed casually. Although they are not sinister in origin, the ramifications of such influence can bring sub-par results. Aware that ageism is ever lurking, how could it still happen in health care?3, 4 The reasons, obviously complex, may start quite simply in physicians being human and, thus, not immune to the shallowness of culture and pop images that celebrate revered life as having 20-year-old airbrushed skin and thick, non-gray, Hollywood hair (i.e., definitions of “old” and “quality of life” compliments of several popular magazines, a vanity that some in medicine also profit from as purveyors of expanding arsenals of youth-stimulating drugs and cosmetic surgery).
However, it would be unfair to point accusatory fingers at dazzling media and reactionary consumerism as the prime explanations for medical distortions regarding age as a treatment criterion.7 Many elements, some occult, doubtlessly contribute; and we in medicine are complicit in most, if only through passivity. Let us study examples of negative influence taken from various categories, beginning with a seemingly facetious example close to home: the way clinicians formally communicate to one another about patients (but only to the extent HIPPA permits useful communication, needless to say). Everyday, virtually every case presentation begins: Mr. X/Ms. X is a (insert number here) year-old male/female presenting with…. There it is, right up front, the number, blazing with all the drama afforded by juxtapositional primacy. How far behind is bias?
To avoid being completely absurd, yes: In a general sense, “age” is an important, long-recognized component in differentiating suitability for various medical and surgical managements. Obviously, not all patients of any age are candidates for all treatments.8 Aging brings well documented changes in multiple functional capacities,9 many with meaningful implications for treatment tolerance, quality of living, and life expectancy.10 However, age is also nonspecific. Whatever the “shared number,” it is clear that chronologically identical individuals do not constitute a biologically homogeneous group.5, 6 Some individuals at “that age” are younger physiologically, whereas others of us are older.11 Biologic context is critical in determining physiologic endurance, longevity, and other matters for the individual patient.3 So too are the medical capabilities of the era and the institution in question.12
Even at this, there is much more that effects the therapeutic choices made in the care of elderly cancer patients. Physicians and hospitals are not alone in that responsibility. Negative stereotypes regarding “age and treatments” are deep and far-flung. Paradoxically, some of the strongest pessimism that comes into play is held by the elderly themselves and their families.13 Whatever their origin, whether it is common sense, past realities, myths, stories from friends, depression, or ordinary misinformation, each can narrow the vision of current potential patients.14 Much of the hope for fairly rebalancing the scorecard relies on physicians educating patients, families, society, and ourselves about the pros and cons of state-of-the-art treatments along with their alternatives, including the option of “no treatment”—and its consequences.7 Maximal palliation always is a given.
Okay then: What is new in cancer care for the elderly? Fortunately, a lot. For instance, once insurmountable physiologic risk factors often accompanying age now can be screened for proactively with comprehensive geriatric assessment-like tools15, 16 and can be diagnosed and accurately monitored before, during, and after treatment.6, 8 If encountered, such risks have relevance for treatment, treatment modification, and outcomes, including survival. At the extreme, if the “frailty syndrome” is proven, then it may preclude most semblances of standard cancer management.17, 18 Fortunately, contrary to pessimistic stereotypic notions, absolute contraindications to treatment are very rare. Furthermore, the lesser risks that are present more commonly, although once limiting, today are resolvable or are managed increasingly better, thus affording effective cancer interventions to go forward. Beyond the “purely medical,” we now recognize that all constituencies have unique psychosocial needs that also must be addressed to maximize outcomes. The elderly, as a group, are no exception, and their optimal oncologic care, which is the balance of so much (and much so unique), depends on our learning about all areas and working to help in all areas. Contributing to the remarkable overall success are new insights, more specific and effective treatments with less toxicity, an array of side-effect antidotes,19 and the prospective multidisciplinary team approach to oncology care. Stunning evolution in knowledge and technology constantly will alter the risk:benefit ratio, as it does today, opening unprecedented horizons for all ages.
Thus far, so good, at least technically; but having new medical abilities and deciding to employ them are two different things. The latter is less predictable, in that it is nuanced by human behavior and by what motivates and demoralizes it. In this vast world of forces, it is easy to understand why individual clinicians feel tiny and incapable of inspiring broad, meaningful change. Although some power venues do require larger organizational advocacy, the cry, “let the American Cancer Society or the American Society for Clinical Oncology handle it,” is dangerously near a cop-out. Rather, as the poets suggest, slowly, each small thing adds up. Herein lies the call for personal involvement despite few guarantees of conspicuous achievement. Because our own physician behavior is the one thing we can control predictably, introspection informing personal vigilance is a good and pragmatic place to begin.
Germane to the implications of the article by Wright et al.1 (in which similar cancer patients in different age groups often received different cancer treatments) in our reflective self-scrutiny, we should wonder seriously about what we do if it differs from today's medical potentials.9 Every discrepancy between actions and possibilities should be seen as a “red flag” marking the need to dig deeper for evidence of merit. However, as much as personal exploration may find, is not likely to be earth shaking.7 Indeed, compared with the shiny commotion of super medical technologies or the drama of “the smoking gun” that exposes devious agendas, the relevant influences on individual behavior, at first blush, may appear small, insignificant, or rather silly. However, as fortune cookies aptly warn, left to their own devices, the mundane can mysteriously morph into insidious. The example of syntax in medical case presentations, again, may pertain. In that ubiquitous medical construct, is age, per se, worthy of its headliner prominence, as life's foremost characteristic and/or determinant of treatment? Furthermore, does having “age,” sequenced so eminently, innocently create a quiet bias that now is part of the medical day-to-day routine? “No,” we would quickly voice…at least to the bias aspect; but is this being naïve?20 Either way, quasiageism finds ways into health care from other quarters.
Joining the distortions of pervasive pop culture, subtle medical convention, and those held about themselves by the elderly are other diverse influences. In the best of worlds, having additional thoughtful perspectives is invaluable in shaping health care.12 Under less than ideal circumstances, the milieu of: health care, money, votes, and power forms a perfect morass for demigods and catastrophe. Although different in origin and impetus, together, the dispirit influences can dampen the likelihood of older patients receiving complex and state-of-the art cancer treatments. Although, at times heart-felt and valid, at other times, the opposition dubiously propagandizes today's best cancer modalities as “not clearly superior” or “too aggressive,” sprouting anxiety and reluctance concerning that treatment: For who among us would self-inflict those risky fates?12, 21 An example of this deceptive posturing is seen in cost-first priorities veiled as otherwise appropriate patient-centered concerns.21 Whatever the full motivation behind these espousals often made by nonclinical groups (e.g., third parties, health care administrators, politicians), an intention to retard medical expense is usually part.20 Quite different, however, is their holistic public persona. Nevertheless, their bellicose thesis on economic cost and its consequences is a rightful concern to a society with limited resources.
Just beneath the specter of warm platitudes, their fiscal reasoning concerning health care goes something like this: Because there is an inevitable and costly correlation between aging, illness, health needs, and dying; and because major fiscal expenditures for medical treatment are not likely to be recouped from an elderly, nontaxpaying constituency; expensive (i.e., aggressive) interventions are invested best in a more youthful, longer living stratum.21 Logical enough, the young-eyed, one-dimensional, quick-fix mathematician will conclude,22 a factual deduction only made clearer from the abstract of never having sat at the bedside. However, if it is applied literally, beyond being short-sighted and hurtful, such a policy would be wrong on virtually all important counts.20
This is not an argument against “hospice.” Depending on many factors, the fullness of supportive care only near the end of life can be a wise choice for anyone.23 Still, in the example presented by Wright et al.,1 it is curious that the hospice-like, “no-treatment option,” was selected nine times more frequently by the older group. Empiric explanations relating to age, more advanced stage at diagnosis, and otherwise more limited expectations, appear most plausible.24 Standing in opposition to the “no-treatment” selection are the effective therapies and long-term palliations now available, even for patients with advanced stage disease.20, 25 Although it once was considered an anathema of medical care and ethics, today, patients who formerly were categorized with “end-stage” cervical carcinoma who present primarily with urethral obstruction readily are unblocked with minimum morbidity using interventional radiology. The restored renal function then facilitates platinum chemotherapy alone or, more often, as a radiation sensitizer. Compared with the dire outcomes of the past, let alone the consequences of “no treatment,” relatively superb results now follow current-day “aggressive” interventions.9
Concerns about costs are important, nevertheless. They are not the proprietary interest of the nonmedical community with their magnanimous, balanced vision.26 To the contrary, all agree about the responsibility to engage finite economic and medical resources thoughtfully.27 However, in the spectrum of real health care needs, where are these assets accorded more justly than to the sick (who, by laws of nature and probability, often are aged, not to mention that they are long-term taxpayers who similarly supported those preceding them)? With regard to notions of “return on investment,” the cold question has many validating retorts, none more fundamental than the humanistic inquiry in return: What is the value of living (to patients, family, and society) for 6 months, let alone for 6 years? Imperfect by many criteria, today's cancer management, even when not literally “curative,” can allow individuals of all ages to live in relative, if not excellent, quality, and, thus, to have time to address all-too-forgotten priorities. Sadly, this is more than most of us who die suddenly will ever get around to doing. What a wonderful difference this makes in the lives of real individuals, as can be seen readily in those left behind.
Standing for precious opportunities such as this is central to physicianship and the type of caring society we should want to live in: a society that is proud to invest its resources in human needs at the age and time they actually occur. However, when it comes to investing in elderly cancer patients, optimal therapies may not rise to activation.28 This is cause for ongoing concern and introspection regarding validity, priorities, complicity, and change.22 Although there is no absolution amid the harsh mix of diverse negative influences and old data, understandably, physician perceptions concerning what treatments to suggest at certain ages may be misaligned with the best of today. This stark possibility is an indirect “red flag” for us in the report by Wright et al.1
Purportedly just another article cataloging treatments for cervical carcinoma treatments and their tolerance in different cohorts—a worthy endeavor in itself—the study's more far reaching value is in stimulating contemplation regarding the findings. Specifically, what accounts for the lower rates of surgery, lower doses of radiation, less use of adjuvant therapy, higher rates of posttreatment persistent disease, and the previously mentioned more frequent opting of “no treatment,” all by the study's similarly staged elderly subgroup? Like other authors, the data reported by Wright et al. show that many older patients can successfully endure comparable oncologic interventions.9, 29, 30 Despite their proven treatment tolerance, the older patients frequently underwent different, typically lesser, cancer treatments. Among the multifactorial reasons behind the variation, some may be attributable to the study's duration (1986–2003). After all, the value and superiority of using sensitizing chemotherapy with radiation in patients with advanced cervical carcinoma was not established finally until 1999, 13 years into Wright et al.'s data base. Another reason for their study's lopsided treatment distribution is ascribed to enrollment onto prospective protocols that dictated therapy. There undoubtedly are many “medically sound” reasons behind the treatment choices made here or anywhere in general. More important yet is the patient's preeminent right to choose any way they wish and that, as physicians, we accept that, true to human nature, subjective reasoning often will trump objective reasoning.31 With all of this, the nagging question still lingers: why, in the majority of patients with early-stage cervical carcinoma no less, did the elderly patients make so many seemingly negative treatment decisions when more effective, well tolerated alternatives existed?
Hysterectomy, including radical hysterectomy and pelvic lymphadenectomy, has been proven tolerable in all age groups.32, 33 In the clinical setting of early cervical carcinoma, when its cure rates are at least equivalent to radiation, surgery offers important advantages, including shorter treatment time, accurate surgical-pathologic staging furthering treatment to the specific patient, less long-term morbidity, and better sexual function34 (and yes, shocking as it is to Generation X, us old people do have, and enjoy, sex, too17). Nevertheless, in the study by Wright et al.,1 the early-stage, older patients were three times more likely to forego surgery and its benefits. Again, reasons from physiologic to psychosocial are likely.31 However, could some portion reflect a pessimistic, passé experience when the surgical option was indeed less tenable in that age range; or, worse, could it be a narrow, one-sided reaction to a mere chronologic (age) number?30
Despite its advantages, surgery is not always the best recommendation for patients with early cervical carcinoma, of course.35 Future studies may someday show radiation with sensitizing chemotherapy is generally superior to surgery, even in this setting.36 In the fast world of exploding science, all clinicians are obligated to stay tuned for breaking insights, and this surely applies to subspecialty oncologists at centers in which relatively “esoteric” malignancies are seen more frequently; thus, such centers appropriately are sought out for their academic and clinical expertise.12 However the dynamic medical facts lay over time, two broad concepts likely will remain constant. To the extent possible, the best treatment of that moment is what should be employed for all patients.30 In addition, to meet this challenge, difficult as it is, health care must continue shaking ingrained, out-dated perceptions, such as “radical pelvic surgery is too much for elderly patients to endure”—a standard teaching in gynecologic oncology and radiation oncology fellowship programs not long ago. Fortunately, realizations about this and similar matters are changing, so that the optimal use of surgery, radiation, chemotherapy, adjuvant treatments, etc., can occur into the tenth decade.2, 10, 37, 38
Maybe so, the skeptics respond, but the question of treatment tolerance is moot,19 because the elderly intrinsically fare worse with cancer. Although, admittedly, with certain cancers and at certain ages, there is biologic reality to this dark truism.39 Even assuming that the incomprehensible maze of confounding variables somehow could be controlled for perfectly, there still likely would be oncologic instances in which older patients just fare fundamentally worse.31, 40 In fact, the data reported by Wright et al.1 support this perception, although, in reflection, the authors appear to question the conclusion. Then again, considering the physiology of aging, is not this observation both logically inevitable and, yet, a false comparison?2 The more relevant contrast would be between like-matched older patients who were treated differently.9 When up against younger, healthier counterparts, the older group inevitably may have an inferior outcome; but there also should be relative outcome differences within the elderly cohort itself according to their treatment.11 That benefit, mathematically smaller though it may be, is just as important humanistically as any other, especially to the patient and family involved.
When available, biologic factors affecting oncologic-prognosis surely become key ingredients in the decision making.5, 38 At the same time, although integrating different sources of information into the equation, we must not fall prey to undue pessimism spinning from disorienting circular arguments.27 In the realm of potential reasons for the inferior oncologic outcomes in the older population, it is the self-fulfilling prophecy that looms most ominous. Could a subtle circular fatalism be “positively” reinforcing an otherwise iffy proposition? To paraphrase an established therapeutic principle—half treatments, well intended as they are, rarely yield even “half results.” What, then, do we expect to occur with “half” oncologic treatments, the types more typically received by older groups?9, 37 The virtues of extreme dose intensity notwithstanding, treatments administered to established therapeutic thresholds continue to carry the best chance for a good outcome regardless of age.9 This is quality cancer care, the kind to be encouraged for its direct value to individuals, and its ripple effects that, not unlike the National Aeronautics and Space Administration, drive learning and progress for a wholly better future.
While collectively championing the right of all patients to receive the best treatment,26 what can we also do, personally, to improve the everyday? Many ideas, and hearts, will apply here. One is working to diminish any skewed age-oriented “medical thinking.” Remembering the age-old principle, “first things first” is one practical, easy step taken. In vitalizing the simple phrase into the formulation of real-life patient-centered recommendations, our best first question would seem: what is the optimal treatment for this (oncologic, cardiac, gastrointestinal, etc.) problem? With that universal answer in mind, secondary questions, such as those relating to a specific patient's physiologic risk factors, take their place in sequence to create the appropriate, patient-specific context for the final conclusion. Could a minor change in the order of deductive questions, or in the juxtaposition of age within medical case presentations, actually reduce bias-related blind spots to therapeutic choices? Well, okay: The syntax thing may be pushing it a bit or even may be silly. Then again, are we so sure…and, either way, what is the downside risk of trying? What actually is most important is our simply thinking about these matters and realizing that, without fanfare, the seemingly “little things” within our control add up and make a big difference. Just as it depends on new technologies and new understandings—often about old ideas—genuinely better health care depends on us for this vital, incremental change. The defrocked arbitrary mantra—too old for the best treatments after “that certain age”—is an example of just such “old thinking” that now, thankfully, is at rest for lack of a priori foundation.