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When is aggressive cancer treatment too aggressive?

Alarm bells are constantly clanging about the rise of horrific diseases and our inability to cope with them because of hospital bed gridlock and overburdened caregivers.

Last week, it was the coming surge in cancer cases: According to Canadian Cancer Statistics 2015, compiled by the Canadian Cancer Society and other sources, the projected number of new diagnoses is expected to rise 40 per cent over the next 15 years.

That's in addition to the estimated 50-per-cent increase in dementia, especially Alzheimer's disease, over the same time period. Some unlucky people will develop both, along with heart disease, arthritis and any number of other chronic ailments.

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The culprit behind these gloomy statistics, of course, is something for which there is no cure: aging. Not only are we getting older, but we are living longer because of medical advances. Blame the baby boom, the swaggering generation born between 1946 and 1965. Boomers turn 69 this year and will be approaching 85 in 2030, the year pegged as ground zero by the Cancer Society.

Here's the question: Should we be treating older cancer patients as aggressively as we do younger ones?

It depends on what we mean by old, says Dr. Shabbir Alibhai, a geriatrician and geriatric oncologist at University Health Network in Toronto. Back in the previous century, 65 was the Rubicon between work and retirement and the onset of old age. That no longer holds. You can't just assess patients chronologically and arbitrarily label them as old, he says.

Old has been reclassified into three subgroups. The "young old," roughly between 65 and 74, who are vigorous and robust, are usually offered the same aggressive cancer treatment as middle-aged adults. For them, 70 truly is the new 50.

The second group, the "frail old," are usually between 70 and 75. Often they are beginning to show signs of comorbidities and impairments, illnesses that may carry greater and more immediate dangers than a cancer diagnosis. Assessing the risk involved in treatment is key for this group.

Finally, there are the "vulnerable old," often 85 or older. Most of them have comorbidities, dementia and are extremely frail. Their cancers are often treated less aggressively.

Here's the problem: Setting aside rigid age parameters, how do you know which group the cancer patient belongs in – fit, frail or vulnerable – so you can determine which ones to treat aggressively?

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"That's the crux," Dr. Alibhai says: At the moment, some fit older cancer patients are under-treated, while frail ones are over-treated, a situation that is complicated by the fact that older people are underrepresented in clinical research studies.

As well, there are relatively few geriatricians in this country – Dr. Alibhai puts the number at about 200. That means they are often not part of the assessment team in making treatment decisions for older cancer patients. He thinks that should change with the development of geriatric assessment tools and the inclusion of health care practitioners trained in palliative care (not necessarily doctors) who can talk with patients about their hopes and fears regarding proposed treatment plans, and about the significance to them of quality versus quantity of life.

Research bears him out. A 2013 review of treatment decisions for older cancer patients, published in the journal Acta Oncologica, concluded that information about "comorbid conditions and the patient's psychosocial context" were often missing at multidisciplinary patient conferences. But, in situations where geriatric evaluations were conducted and included in the discussion, "the initial oncologic treatment plan was modified in a median of 32 per cent of patients, and non-oncological interventions were recommended in a median of 83 per cent."

In other words, if asked and evaluated, older cancer patients have a "significant impact" on treatment decisions.

Dr. Alibhai, who is launching a demonstration project on geriatric assessment tools in the next month at Princess Margaret Hospital in Toronto, says he knows of several other clinical trials that are in the works. They should be reporting in the next five or six years, or starting in 2020 when the earliest boomers will be in their mid-70s.

Will the population age too fast for the research? That's the rub and that's why making your wishes known and appointing a substitute decision-maker is so important.

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Meanwhile, keep eating those veggies and walking the dog.

Follow me on Twitter: @semartin71.

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About the Author
Feature writer

Sandra Martin is a Globe columnist and the author of the award-winning book, A Good Death: Making the Most of Our Final Choices. A long-time obituary writer for The Globe, she has written the obituaries of hundreds of significant Canadians, including Pierre Berton, Jackie Burroughs, Ed Mirvish, June Callwood, Arthur Erickson, and Ken Thomson. More

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