Cancer and geriatrics: towards a holistic approach to the disease

Cancer is mainly a disease of very old people. Almost half of cancer patients are older people, and it is the second leading cause of death after cardiovascular diseases. From the point of view of gender, it is more frequent in men than in women. It is estimated that 30% of men and 25% of women over the age of 70 will develop cancer in their lifetime.

Demographic changes in all Western societies, with the progressive ageing of the population, especially in the older age group (the so-called "ageing of ageing"), brings with it an increase in these pathologies, as well as the possible appearance of different tumours in the same individual.

What is the reason for this increase in the number of cases with age and what is its origin? On the one hand, there are genetic alterations that can alter the mechanisms that regulate the cell cycle, facilitating the disproportionate growth of certain cells. In addition to this, there are inflammatory changes caused by the ageing process itself and prolonged exposure to different environmental or toxic substances.

The great dilemma lies in knowing the type of tumour. Knowing whether it is localised or widespread will help in the prognosis, as well as in making the right balance between the benefit of the different interventions (surgery, chemotherapy, radiotherapy) and the risks for the person themselves (both if they undergo an intervention and the risks if they do not).

The age is not the key

As we already know, the elderly population is very heterogeneous, so chronological age is not the most important factor. An adequate approach requires knowledge and incorporation of aspects such as life expectancy, comorbidities, medications, decision-making competence, degree of functional dependence, previous falls, social network, as well as the person's wishes and values.

It is not just a matter of adding years to life, but of being able to generate an active survival in which the functional capacity, autonomy and quality of life of the person is the main axis of action (global wellbeing).

For this reason, the creation of "tumour committees" is of great relevance in order to, from a multidisciplinary point of view, assess the type of intervention to be followed (coordinating the necessary diagnostic and therapeutic tests, providing guidance so that the elderly person does not get lost in the health system itself...).  

The comprehensive geriatric assessment can help to establish the proportionality of the different interventions and set more realistic objectives. It is a matter of considering different alternatives, from curative to palliative, integrating the help of different scales that can estimate the risk of surgery or the toxicity of chemotherapy, knowing the fragility of each person.

Along these lines, after an estimation of life expectancy, the geriatric professional's gaze is focused on inferring the time required for the disease to cause damage, and the time needed to obtain a certain benefit from the interventions. The degree of risk of possible tolerable side effects depends on this, as well as not creating therapeutic inertia, establishing clinical protocols that can often be useless and with a high physical, nutritional and emotional cost that greatly detracts from the person's quality of life.

For all these reasons, the motto of primum non nocere (the ethical principle of not causing harm) takes on special relevance, after due reflection, so as not to fall into problems of age discrimination or "ageism" that hinder a fair and appropriate approach to the disease.

Cancer is already a challenge for the individual. Let us not let chronological age make it insurmountable.