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Ageing and cancer: psychosocial burdens
Cancer Council Australia Essay
Competition
Priya Maheshwari
UNSW IV
Word count: 2399 (excluding references)
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Table of Contents
Introduction ................................................................................................................................ 3
The older patient with cancer seen through a psychosocial lens ............................................... 4
Psychosocial support needs........................................................................................................ 6
Caring for the older patient with cancer .................................................................................... 8
Preparing the future medical workforce .................................................................................. 11
Conclusion ............................................................................................................................... 12
References ................................................................................................................................ 13
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Introduction
The ageing of the Australian population means that the issues related to cancer care in the
older patient will become more prominent, especially with the potential for increasing
numbers of cancer diagnoses and elderly cancer survivors. People diagnosed with cancer and
their loved ones can take some comfort from the knowledge that remarkable advances in
cancer treatment have dramatically increased the rates of survival from cancer. However,
these advances in biomedical care have not always been matched with progress in the
development of high-quality care to address the social and psychological consequences of a
cancer diagnosis, which can especially burden older patient groups.
This essay will examine the psychosocial effects of cancer and its treatment on older adults,
and the supportive care needs of the older patient. The ways in which practitioners can meet
those needs will be explored, as well as the importance of the medical school curriculum in
producing practitioners who are well-equipped with the skill set to do so.
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The older patient with cancer seen through a psychosocial lens
‘It is much more important to know what sort of a patient has a disease than what sort of a
disease a patient has.”
- Sir William Osler, Canadian physician.
In 2011-2012, approximately 1.5% of the Australian population had cancer, with the
prevalence of cancer increasing with age [1]. The highest rate of cancer was found to be for
the 75 years and over age group, and one in approximately 14 people in that age group had
cancer [1]. Prostate and breast cancer remain the most common cancers diagnosed in men
and women respectively [2].
The impact of cancer and its treatment is influenced by the patient’s age. However, the
elderly are not a homogenous population with respect to health, ability to cope with the
psychosocial and physical impacts of cancer and views about management [3]. The clinician
therefore must avoid making presumptions about the patient’s needs and attitudes stemming
from age-based stereotypes. The need to be mindful of this is illustrated by the fact that
health care providers have been found to generally underestimate the quality of life of older
patients with chronic disease [4].
Cancer can bring significant emotional upheaval, and people with cancer may experience a
range of social and emotional difficulties, including potent feelings of distress, fear and
anger. An individual’s level of psychological distress may vary depending on the extent to
which a person which cancer feels supported by family and friends [5]. Financial stress from
the cost of health care and reduced income and employment may also contribute to the stress
experienced by people living with cancer. Although the resolution of such financial and
social problems is beyond the capability of medical practitioners, an understanding of how
these problems can affect the psychosocial state of the patient with cancer is a vital part of
good-quality health care as it facilitates the addressing of these issues within the constraints
of clinical practice [6].
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Older people often have medical conditions in addition to cancer that are likely to affect
function, and the number of comorbid conditions increases with age. Cancer-induced
physical stressors include fatigue, pain and various disabilities which may create limitations
in the ability of patients with cancer to perform activities of daily living [6]. Older patients
with cancer are more likely to require functional assistance than those without cancer [7]. The
physical sequelae of cancer and cancer treatment can exacerbate emotional and mental health
problems.
Older people with cancer frequently have a slightly different set of concerns than other adults
with cancer, which can affect how they cope with their diagnosis and treatment. One of the
key concerns for many older adults with cancer is whether they will be able to maintain
independence and remain in control of their health and health-related decision-making [8].
For example, cancer treatment may limit the ability of people to perform independently
activities of daily living such as cooking, washing and accessing transportation [8].
Furthermore, older cancer patients are less likely to have social support systems in place,
especially as they may not live close to family or may have experienced the loss of family
members and friends [9]. Isolation increases the risk of depression and anxiety, the
development of which increases the difficulty of older adults to cope with cancer treatment
[10].
Older people have typically retired from paid employment and they may have reduced
opportunities to be involved in their local community. Older people may have a reduction in
the scope of their social lives especially if they are gradually spending more time at home
alone, which slowly narrows of their life-space [11]. For elderly patients with cancer, the
death of the primary wage earner, retirement and existing financial issues can be important
factors contributing to limitations on financial resources, especially to pay for costs
associated with cancer treatment [11]. Such concerns can contribute to feelings of anxiety and
depression in patients. Thus, a multitude of factors unique to the older patient demographic
result in cancer typically having psychosocial impacts significantly disparate to the impacts
of cancer on younger people.
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Psychosocial support needs
‘Mental pain is less dramatic than physical pain, but it is more common and also more hard
to bear. The frequent attempt to conceal mental pain increases the burden: it is easier to say
“My tooth is aching” than to say “My heart is broken”.’
- C.S. Lewis, English novelist and scholar.
There has been an increasing interest in formal needs assessments in Australia and abroad.
The first known study to explicitly examine the supportive care needs of people with cancer
was conducted over 30 years ago by the American Cancer Society [12]. Needs not addressed
and where additional support is required were classified as “unmet needs”. Growing evidence
points to the detrimental effects on patient wellbeing from unmet needs [6]. These unmet
needs include the domains of psychological and other forms of patient support, access to
health information and the ability to undertake activities of daily living.
A systematic review demonstrated that the level of unmet needs in older adults newly
diagnosed with cancer and undergoing active cancer treatment is high, with a wide-ranging
prevalence of between 40 and 90% because of the vast range of tools and definitions used to
assess unmet needs in various studies [13]. This systematic review found that the most
common unmet needs include psychological needs (typically fear of the spread or return of
cancer), information needs (most frequently regarding the likelihood of cure and the adverse
effects associated with treatment) and physical needs (most commonly with complaints of
tiredness and lack of energy) [13]. Older patient groups are more likely to be vulnerable to
unmet needs and treatment toxicities due to their comorbidities and decreased physiological
reserve capacity [13].
Failures to address psychosocial problems can result in suffering for both the patient and their
family, and potentially affect the course of the disease. Stress, social isolation and untreated
mental health problems can contribute to emotional distress and interfere with the ability to
perform social roles and adhere to treatment regimens [14]. These problems may cause
changes in the functioning of the endocrine, immune and other organ systems in the body,
which could then have implications for the course of the disease [14].
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One out of two cancer patients report psychiatric disorders, especially depression, and elderly
patients with cancer are at a particularly increased risk of depression [15]. Depression can be
difficult to identify in elderly patients because they may not manifest prominent anhedonia or
sad mood which are the main symptoms of unipolar mood disorders [16]. Unrecognised and
untreated mood disorders in aging people with cancer is a key cause of disability and
suffering for patients and their caregivers [17].
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Caring for the older patient with cancer
‘The physician should not treat the disease but the patient who is suffering from it.’
- Maimonides, 12th century scholar and physician.
Cancer and its treatment can lead to psychological distress, physical disabilities and increased
healthcare needs [13]. Supportive care is defined as care that helps people with cancer and
their families to cope with cancer and its treatment, beginning at diagnosis and continuing
throughout treatment to cure, continuing illness, or death and bereavement [18].
It is particularly important for medical practitioners to address practical issues of coping and
the limitations on home activities created by cancer diagnosis and treatment in older patient
groups [19]. This may not always be a straightforward process, as the psychosocial needs of
older patients can be hidden beneath a façade of stoicism and a wish to be compliant. Thus
clinicians may need to question older patients sensitively in order to fully understand their
patients’ psychosocial needs [19]. Specific concerns which may need to be explored include
body image concerns, interpersonal problems, existential concerns, anxiety and depression
[19].
Supportive care needs can be diverse. They may relate to coping with the physical impacts of
cancer and its treatment, or with its psychosocial and psychological effects in the form of
depression, anxiety and feeling isolated [20]. Practical measures such as assistance with
transportation and daily activities and the provision of prostheses and wigs are considered
important elements of supportive care and they can reduce the psychological distress
experienced by people with cancer [20]. Access to evidence-based information throughout
the cancer journey is also viewed as an essential aspect of supportive care [20]. It is important
to note that the goals of treatment for the older patient with cancer often differs from those
for younger patients. This is because the focus of treatment can shift from prolonging
survival to quality of life endpoints, and especially aiming to prolong the period during which
the person is independent (‘active life expectancy’) [21].
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The ageing of the Australian population has particularly driven the need for geriatric
oncology in order to identify and manage psychosocial and other health needs of older
patients with cancer. Over the last 10-15 years, oncologists and geriatricians have begun to
have a greater collaboration in order to integrate geriatric principles into oncology care [22].
Use of a comprehensive geriatric assessment (CGA) for assessment of older patients with
cancer is an example of such efforts in Australia. A CGA involves an evaluation of an older
person’s functional status, cognition, nutritional status, comorbidities, psychological state,
social support and a review of their medications [23]. The International Society of Geriatric
Oncology has arrived at recommendations regarding the use of CGA in older cancer patients
[23]. There is growing evidence that the variables examined in a CGA can predict mortality
and morbidity in older patients with cancer and expose problems relevant to cancer care that
would otherwise go unrecognised [22].
Although the CGA is a useful tool, it can be unsuitable for daily clinical practice because it is
time-consuming, as it can take between 45 minutes and 2 hours to complete a CGA for a
single patient [24]. There are a wide variety of other instruments that can be used to assess
the needs of cancer patients and their families in place of the CGA, of which two were
developed in Australia, namely the Cancer Patient Need Questionnaire and the Supportive
Care Needs Survey [25] [26].
Regardless of the specific tools used to do so, it is essential that a plan be developed by the
treating health care team to assist the person with cancer to manage their illness and maintain
the highest possible level of wellbeing and functioning [6]. The ‘Care Coordination for Older
Australians with Cancer’ project which is an initiative of Cancer Australia and funded by the
Australian government is an example of the type of initiatives which can assist Australian
medical practitioners to coordinate supportive care for older cancer patients [27].
It remains vital for medical practitioners to re-assess older people with cancer frequently in
order to ensure that their psychosocial needs are being addressed. This is especially important
given that there are a number of supportive care interventions available. Such interventions
include peer support programs, counselling and psychotherapy, family and caregiver
education and provision of comprehensive illness self-management and self-care programs
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[6]. As such, medical practitioners are well-placed to significantly assist elderly patients with
cancer to cope with their disease.
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Preparing the future medical workforce
‘There are two objects of medical education: to heal the sick and to advance the science.’
- Charles Mayo, American medical practitioner and co-founder of the Mayo Clinic.
The Cancer Council Australia’s Oncology Education Committee has stated the “psychosocial
and cultural significance of cancer” as a learning objective in its Ideal Oncology Curriculum
for Medical Schools [28]. Medical students who meet this objective are able to demonstrate
an ability to assess the psychosocial state of patients, the cultural and psychosocial factors
mediating the effect of cancer on the patient and can demonstrate an understanding of sources
of reliable patient support information [28]. The importance of this learning objective
becomes clear when we consider that the number of cases of cancer diagnosed in Australia
each year is projected to rise over the next decade for both men and women and it is
anticipated to reach about 150,000 cases in 2020 [2]. The medical practitioners of the future
therefore need to be equipped with the skills to manage the growing number of patients, and
particularly those from older age groups, who will present with the psychosocial issues
associated with cancer.
Health professionals may avoid discussion of emotional concerns with patients due to a fear
of causing unnecessary worry or distress, feeling out of their depth or assuming that the
spiritual elements of the cancer trajectory are not the domain of the medical practitioner [19].
A concerted effort by medical schools and those involved in developing medical curricula to
foster an improved understanding in medical students of the psychosocial needs of people
with cancer and particularly those of older patients will go some way towards removing these
barriers to high-quality psychosocial support for people with cancer.
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Conclusion
The older cancer patient has a set of psychosocial needs that can differ greatly from that of
the younger patient. A recognition of this fact is vital for the provision of individualised,
patient-centred care to elderly patients in order to assist those patients to maximise their
quality of life. The provision of adequate training to medical students in managing both the
biomedical and psychosocial aspects of care for elderly cancer patients is important
especially in the context of the ageing Australian population.
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