Reshaping cancer control for ageing societies

According to the United Nations, currently 9.1% of the global population is over the age of 65 and estimates suggest that this is expected to rise to 15.9% (1 in 6 people) by 2050, with nearly half a billion over the age of 80. Low- and middle-income countries are ageing faster, with the Middle East, Africa and China experiencing the highest increase. 

This is particularly concerning for cancer control, as 50% of new cancer cases worldwide in 2018 were among people aged over 65, with 13.3% or 2.3 million cases in people over 80. An increase of over 200% (an estimated 6.9 million new cancer cases among those aged over 80) is expected at the global level by 2030. 

These numbers, however, again hide a great discrepancy among regions. According to Sophie Pilleron, Epidemiologist affiliated with the Big Data Institute at the University of Oxford and a panellist at the Virtual Dialogue there will be a 144% increase in cancer burden between 2012 and 2035 in LMICs, compared to 54% in higher-income regions (HICs) such as Europe. The most significant increases in cancer cases among people over 80 are expected in China (+327%), followed by Latin America and the Caribbean (+253%), and Africa (+228%).

“The population is ageing at an unprecedented rate thanks to the improvement of healthcare systems worldwide. There are, however, important implications in terms of strained healthcare systems, major economic and social burden, as well as increased burden for caregivers who may be old as well.”
– Sophie Pilleron, Epidemiologist affiliated with the Big Data Institute at the University of Oxford

Integrated, person-centred care

Panellist Yuka Sumi, Medical Officer for Ageing and Health at the Department of Maternal, Newborn, Child & Adolescent Health and Ageing (MCA), World Health Organization (WHO) raised how essential it is to define a person’s age as a factor of health (“health age”) not merely their chronological age. There is no typical older person. 

WHO has defined healthy ageing as “creating the environments and opportunities that enable people to be and do what they value throughout their lives”. The organisation issued in 2015 the World report on ageing and health, which outlines a framework for action to foster healthy ageing based on the concepts of “intrinsic capacity” (the combination of all the physical and mental capacities of an individual and “functional ability” (the combination and interaction of intrinsic capacity with the environment a person inhabits).

WHO’s Integrated Care for Older Persons (ICOPE) is a coordinated model of care that addresses the differences in health, socioeconomic environments and other factors between older patients, and is organised around their particular needs and expectations. It maximises the intrinsic capacity and functional ability of older people and emphasises community-level and home-based interventions, as well as multidisciplinary care teams and support for caregivers and self-management by the patient. 

Singapore, for instance, has developed a new township that will have a polyclinic next to a nursing home, allowing older adults to age in place and remain socially connected to their community, according to panellist Ravindran Kanesvaran, Consultant in the Department of Medical Oncology of the National Cancer Centre Singapore and President of the International Society of Geriatric Oncology (SIOG). 

Yuki Sumi cited the example of a Japanese prefecture with community centres offering salons for older people to meet for social activities and physical exercise. She also highlighted the vital role that patient navigators or care managers play in person-centred care to assess the health and social needs of patients and facilitate finding appropriate care and financial support.

The major challenge with implementing integrated, person-centred care is the lack of qualified practitioners, as oncologists are often in short supply in many countries. General practitioners, nurses and other primary caregivers must therefore be equipped with the skills and training in cancer care and the core principles of geriatric oncology. 

“It is really important to have capacity-building for primary care physicians so that they understand how to take care of older people in their setting, and then only if needed refer them to a specialist.”
– Yuka Sumi, Medical Officer for Ageing and Health at the Department of Maternal, Newborn, Child & Adolescent Health and Ageing (MCA), World Health Organization

Telemedicine is a tool that can be used to access specialised cancer services and train community health workers, particularly for rural populations. It is important, however, to take into account the availability of resources and the technological know-how of patients and caregivers to ensure that telemedicine creates opportunities and not further barriers to care.

Addressing ageism and the cultural barriers to effective geriatric care

Individualised integrated care can also assist in overcoming cultural barriers that can lead to discrimination or ageism. Such barriers exist among the patients themselves, as illustrated by Ravindran Kanesvaran who pointed to one of his patients over 80, relatively fit and with few co-morbidities, educated and cognitively aware, to whom he had offered active treatment for her cancer; but the patient felt that as an “older adult” a family member should make that decision for her – and the family had a different perspective, believing that the treatment would be too harsh. “Older patients themselves sometimes feel that they are not entitled to the same care as younger patients,” he said.

In many families, particularly in cultures with tight-knit family groups such as in Asia, members may conceal a serious diagnosis from an older relative, undermining that person’s right to make their own decisions regarding treatment.

In Sub-Saharan Africa, where there are few specialists and limited infrastructure, attitudes can be tied to the lack of resources according to Sophie Pilleron, with families unwilling to pay for older patients, who are considered less productive and with limited life expectancy. 

Doctors themselves may suffer from ageism. Yuka Sumi told of her experience as a young doctor when she would consider certain ailments as part of “natural ageing” (such as a painful knee), when the patient was looking for explanations and treatment. For Sophie Pilleron, cancer caregivers should not base treatment decisions on a patient’s chronological age and how they might manage treatment, but rather on a geriatric assessment that looks a patient’s quality of life (what it is now, what it might be later) and objectives (live longer, in greater comfort?), which can provide answers on the type of care to provide.

“Ageism can be seen from screening to treatment to palliative care. Not only society as a whole but individuals are ‘ageist’. If we want to fight ageism, we need to see what tools are being used to empower victims of racism or sexism… We will all be old one day – we need to change society’s views on age and healthy living.”
– Sophie Pilleron, Epidemiologist affiliated with the Big Data Institute at the University of Oxford

Palliative care

The topic of palliative care is not always easily discussed within families, and even among medical practitioners, it is sometimes regarded as a failure to cure. As Yuka Sumi pointed out in the virtual dialogue, palliative care is not equal to end-of-life care, palliative care is part of holistic, integrated health care. 

“Education on what palliative care means as symptom management and pain management is key, not only at the patient level but also with policymakers and government authorities.”
– Ravindran Kanesvaran, Consultant in the Department of Medical Oncology of the National Cancer Centre Singapore and President of the International Society of Geriatric Oncology (SIOG)

Furthermore, providing effective palliative care in many countries faces major institutional and cultural barriers that need to be overcome, with significant discrepancies between LMICs and HICs. There are, for instance, misconceptions about opioids for pain management. Many governments in Asia, according to Ravindran Kanesvaran, view them as a health risk to the population and patients themselves may refuse to take them for fear of becoming addicted. 

Quality and value of care, quality of life vs life prolongation

Panellist Ravindran Kanesvaran pointed to a number of new drugs in oncology that can provide additional survival benefit of up to three to six months. He asked the question, however, that while this is statistically significant, is it clinically meaningful? Does it have a noticeable effect on the patient's daily life?

It is therefore important for countries to invest in robust health technology assessments to better ascertain the value and cost-effectiveness of cancer drugs. Government health budgets as well as individuals and families facing large out-of-pocket expenditures for cancer treatment would benefit.

Finally, it emerged during the virtual dialogue that studies on whether geriatric assessments can prolong life represent a misunderstanding of the goals of many older adults. Indeed, more important than prolonging life, which they may not necessarily do, these assessments improved their quality of life with good control of symptoms, which patients have declared preferring to living longer with the side effects of cancer.

“The goals of living change with age. When you are in your 30s or 40s, you are thinking of starting a family, of your professional career. When you are in your 70s and 80s, the goal is no longer about prolonging life but about quality of life.”   
– Ravindran Kanesvaran, Consultant in the Department of Medical Oncology of the National Cancer Centre Singapore and President of the International Society of Geriatric Oncology (SIOG)

For more information on Cancer and Ageing, see UICC’s dedicated webpage and read about “Growing old with cancer”

View UICC’s first Virtual Dialogue on “Caring for older cancer patients during COVID-19” and this second Virtual Dialogue, "Reshaping cancer control for ageing societies".