Cancer care for older adults during COVID-19

The recent Special Focus Dialogue on “Caring for older cancer patients during COVID-19”, hosted by UICC and supported by Sanofi, was the first of two Virtual Dialogues dedicated to Ageing and Cancer that aim to highlight the challenges to health services resulting from the rapid ageing of populations worldwide.

The webinar gathered 42 organisations from across the globe, including cancer societies, hospitals, civil society and private companies. It sought to address the dilemmas faced in clinical decision-making processes and in public health policies during the pandemic. Discussions focused on how to respond to the age-related inequities and bias that can exist in health systems, and looked at lessons learned to enhance the responsiveness of health systems to the needs of older adults and close the equity gap going forward.

Assessing the specific needs of older cancer patients

Older adults tend to have other health issues that must be addressed when considering appropriate cancer care. In addition to multimorbidity, older adults often face specific financial, psychological, social functional challenges, as well as difficulties in accessing adequate health care and information, particularly in an increasingly digital world.

The burden of cancer and COVID-19

Currently, about 1 in 11 people in the world are over 65. That proportion is expected to grow to 1 in 6 by 2050. In the least developed countries, the increase is even more dramatic, from 37 million people over 65 currently to some 120 million in 2050. 

When it comes to cancer, age is a risk factor as cells are more likely to turn cancerous as the body ages. Cancer kills nearly 10 million people a year and some 70% of those are aged 65 or older, with about half of all new cancer cases occurring among that population. 

The coronavirus pandemic also confronts older adults with additional risks. In his presentation, Dr Nicolò Matteo Luca Battisti, Senior Clinical Research Fellow in medical oncology at the Breast Unit of The Royal Marsden NHS Foundation Trust, explained how older adults were more frequently symptomatic and experienced higher hospitalisation rates and increased mortality than younger adults.

For this reason, cancer patients – and older cancer patients even more so – are caught between the proverbial rock and a hard place, forced to weigh the risks from exposure to COVID-19 infection and those related to discontinuity of treatment and under-treatment of pre-existing conditions. Through a live poll during the UICC Virtual Dialogue, 44% of participants stated that at least several services had been reduced to protect higher risk individuals, with an additional 44% stating that a majority of cancer services had been disrupted due to low demand or to avoid risks.

This is anticipated to have devastating consequences on mortality rates and the severity of outcomes for cancer. A recent study in the UK expects up to 35,000 additional cancer deaths within a year due to delays in treatment and other services (which may also have been interrupted due to a diversion of resources to fight the COVID-19 pandemic). 

A lack of geriatric expertise

Webinar panellist Antonella Cardone, Director of the European Cancer Patient Coalition  (ECPC), highlighted a lack of research on how best to treat cancer patients above the age of 65 and an underrepresentation of older populations in clinical trials (a 2019 US study found that one-third of 600 clinical trials funded by the National Institutes of Health (NIH) had upper age limits – an exclusion since addressed by NIH).

“Even in developed regions, such as the US, Europe and Japan, health systems are not identifying the specific needs of older people living with cancer and defining individual care pathways. Yet this is essential to ensure that they receive a level of care equal to that of other populations.”
— Antonella Cardone, Director of the European Cancer Patient Coalition  (ECPC)

In low- and middle-income countries the demographic shifts have been even more rapid and are occurring at a time that is already witnessing great inequity in healthcare. Dr Alexandre Kalache, gerontologist and President of the International Longevity Centre Brazil and co-Director of the Age Friendly Foundation, said that in Brazil life expectancy had increased from 45 years of age to 75 years since 1945. “The problem is, people are getting older without resources, in poverty, with tremendous inequalities. And not just in Brazil or other developing nations – immigrant and other vulnerable populations in high-come countries are also often unable to access the care they need," he said. 

Older adults tend to have other health issues that must be addressed when considering appropriate cancer care. In addition to multimorbidity, older adults often face specific financial, psychological, social functional challenges, as well as difficulties in accessing adequate health care and information, particularly in an increasingly digital world.

Older populations should not be considered as a uniform group. Older adults with cancer are very heterogeneous not only in terms of their disease status but also in their functional and cognitive abilities, their social support, their overall health and activity level. Therefore, their preferences and needs should be individually assessed.

“A geriatric assessment of older cancer patients should be standard practice, even amidst the coronavirus pandemic, as issues of isolation or depression and other psychosocial factors could be overlooked in regular clinical assessments. Geriatric assessments provide valuable input for anti-cancer treatments adapted to an individual’s overall physical and mental health and life situation.”
— Dr Battisti, Senior Clinical Research Fellow in medical oncology at the Breast Unit of The Royal Marsden NHS Foundation Trust

Antonella Cardone cited insufficient geriatric expertise within oncology departments, stating that caregivers from across the different disciplines require more training on this topic in order to offer better service provision. The aim is to establish individualised, multidimensional and multidisciplinary treatment pathways. Examples of multidisciplinary approaches exist, but while multidisciplinary cancer care has been recommended for 25 years, its implementation remains challenging.

The pandemic has revealed the urgency of increasing geriatric expertise and for geriatric assessments, as older adults are more susceptible to the collateral effects of the policies issued to contain the spread of the virus. Lockdown measures have threatened not only the health and mental well-being of older adults but also their social networks and access to adequate care.

Furthermore, responses to social distancing, such as telemedicine and virtual consultations, are not easy to implement across the board, as familiarity with and access to digital technologies within older adult populations vary greatly. In some regions, these difficulties compound pre-existing health literacy issues. “One-third of older adults in Brazil are illiterate, another one-third are functionally illiterate, so they cannot cope with all the guidelines, they cannot follow treatment properly – let alone telemedicine,” said Dr Kalache.

Risks of age bias and inequity in health care

“We are facing a situation of increasing scarcity of resources, information and evidence – on a global scale. And we are losing patients because of this lack of resources.”
— Dr Enrique Soto Perez De Celis, geriatric oncologist and researcher in the Department of Geriatrics at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City, UICC panellist.

Indeed, the pandemic has strained health systems, further limiting resources and sometimes forcing “medical rationing” and the need to decide who receives care – and who does not. Antonella Cardone reported on situations in countries hardest hit by COVID-19, such as Spain, where specific guidelines were issued on who to treat based on life expectancy and chances of survival. The pandemic has also accelerated discussions with patients in susceptible populations and their families on restricting aggressive interventions. 

The cumulative risks related to ageing, cancer and COVID-19 that have led to these difficult clinical and ethical decisions could reinforce already existing ageism and magnify health inequity between generations. Dr Soto added that “because of the scarcity of information and evidence, we are seeing in some cases a move away from evidence-based treatment to opinion-based decision-making.” 

This situation highlights, above all, the need to strengthen health systems, expand health resources, end the barriers faced by older populations in accessing health care and guarantee greater equity in service, to promote ‘Health for All’ – the goal of Universal Health Coverage (UHC).

However, barriers accessing healthcare must also be addressed from the perspective of older adults. It is not sufficient merely to remove age limits on clinical trials; it is also essential to address the misperceptions that older adults may have about clinical trials, as well as the inherent biases in research programmes. Furthermore, research on chronic diseases and ageing must be expanded such that the conditions and needs associated with growing older are better understood.

Neither is it sufficient to equip health facilities with digital tools to adapt to the current environment and shift away from in-person consultations towards telemedicine. Older adults must be assessed and assisted individually so that adequate support systems can be set up to enable them to use digital technologies effectively. Otherwise, inequities in health care may only grow larger.

“The coronavirus pandemic has accelerated changes already taking place in how we dispense care. We must be careful in the process that we do not further reduce access to care for those – in particular older adults – who are already often discriminated against in their access to care. Let’s not make health systems even less age-friendly than they already are but seize this moment as an opportunity to move towards greater equity and universal health coverage.”
— Dr Enrique Soto Perez De Celis, geriatric oncologist and researcher in the Department of Geriatrics at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City, UICC panellist.

Assessing the specific needs of older cancer patients

Older adults tend to have other health issues that must be addressed when considering appropriate cancer care. In addition to multimorbidity, older adults often face specific financial, psychological, social functional challenges, as well as difficulties in accessing adequate health care and information, particularly in an increasingly digital world.