Overcome Inequalities in Cancer Treatment Options Across the Ages
Larry is an 83-year-old rancher who was diagnosed with pancreatic adenocarcinoma and treated with gemcitabine and nab-paclitaxel. A three-month follow-up scan reveals recurrent disease. Larry’s son tells you he wants to explore clinical trials but is frustrated that several promising trials do not accept patients older than 70 years. He asks you why a person’s chronologic age is a major exclusion factor and their performance status is only considered after they meet the age criteria. He also asks you whether his father’s age influenced the choice between first-line therapy with FOLFIRINOX (https://www.cancer.gov/about-cancer/treatment/drugs/folfirinox) or gemcitabine and nab-paclitaxel.
What Would You Do?
Advanced age is a universal risk factor for cancer. In the United States, the most frequent diagnoses of any kind of cancer are in people aged 65–74 (https://doi.org/10.1200/jco.21.00207). Yet when stratified by age, clinical trial participation doesn’t represent the real-world patient population. Clinical trials participants’ average age is 64 years and only 10% of participants (https://www.scientificamerican.com/article/we-must-end-ageism-in-cancer-clinical-trials/) in NCI-sponsored studies are aged 70 or older (and 4% are aged 80 or older)—but nearly 60% of pediatric patients (https://www.scientificamerican.com/article/we-must-end-ageism-in-cancer-clinical-trials/) participate in a research study. Because new medication approvals and oncology standards and guidelines are based primarily on statistically significant results from clinical trials, study populations must be more representative.
A first step in changing the current system (https://www.who.int/news-room/questions-and-answers/item/ageing-ageism) is becoming aware of how ageism (how we think, feel, and act toward others and ourselves based on age) can affect oncology care and then identifying strategies to better address the older adult with cancer. The Institute for Healthcare Improvement envisioned an age-friendly health system (https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx) in its 4Ms framework, which helps providers shift their perception and incorporate evidence-based essentials of quality health care. The framework addresses peoples’ wellness and strengths, transcending the influence of culture, race, ethnicity, religion—and of course, age. Oncology nurses can help overcome inequalities in older adult care by using the 4Ms.
You acknowledge with Larry’s son that a person’s chronologic age can influence their treatment options, recalling cases when adolescent and young adult age patients have been excluded from pediatric clinical trials. You address the 4Ms with Larry and his son. Larry’s son is surprised to learn that his father does not want to travel for a clinical trial because he does not want to leave his animals, who give him a sense of purpose. He is also concerned about neuropathy and the chemo brain he experienced when on treatment. You facilitate a frank conversation between Larry and his son to help Larry share his goals and desires.