1130-0108/2008/100/11/706-715
SPANISH JOURNAL OF GASTROENTEROLOGY
Copyright 2008 ARN EDICIONES, S. L.
POINT OF VIEW
Prevalence and treatment of oncologic disease in the elderly
an impending challenge
A. Gmez Portilla, C. Martnez de Lecea, I. Cendoya, I. Olabarra, E. Martn1, L. Magrach1, E. Romero1,
J. Corts1, J. Muriel1, A. Mrquez1 and M. Kvadatze1
Peritoneal Carcinomatosis Program. Hospital San Jos. Vitoria. lava, Spain. 1General and Digestive Surgery
Department. Hospital Santiago Apstol. Vitoria. lava, Spain
ABSTRACT
Life expectancy in Spain has more than duplicated during the
last 20th Century, and is currently 75 years for men and 83 years
for women. Predictions on the evolution of the National and glob-
al population anticipate a demographic shock in Spain when indi-
viduals older than 65 years eventually make up more than 33.5%
of the Spanish population by year 2050.
It is known that cancer is directly related with age, and that it
is a disease of older people at least 60% of all cancers are diag-
nosed in patients older than 65 years. The older people group is
the most important group of patients in oncologic practice to-
day. Predictions on the aging of the Spanish population show
that cancer in the aging patient and its treatment must be con-
sidered a first-line health problem. The diagnosis of cancer is
not associated with death in the majority of patients. Sixty per-
cent of cancers are globally cured or chronified. This advanced
prognosis has its toll not only in the expectancy of treatment but
also in subsequent follow-up and post-treatment adverse effects
that can be generated.
A greater and better knowledge and understanding of the ag-
ing process will allow to identify and select those old patients
that can benefit from prevention and treatment options, and
more importantly will identify those other patients that are not
candidates to treatments with curative intention because of their
frail status.
Progress in surgery, mainly in minimally invasive surgery, and
its application to the field of oncologic surgery allows to forecast
that a greater number of aging patients will benefit from treatment
with curative intent. Age will not be a barrier for adequate treat-
ment in healthy elderly patients, especially in those with long life
expectancy and functional reserves. Fighting this healthcare dis-
crimination is one of the main priorities in the strategy of im-
proved health in the elderly
We present in this study and analyze the foreseen changes in the
worlds population, particularly in Spain; the association between
Received: 02-01-08.
Accepted: 06-05-08.
Correspondence: A. Gmez Portilla. Programa de Carcinomatosis Peritoneal. Hospital San Jos. C/ Beato Toms de Zumrraga, 10. 01008 Vitoria. lava,
Spain. e-mail: agomezpor@teleline.es
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Vol. 100. N. 11, pp. 706-715, 2008
RESUMEN
La esperanza media de vida en Espaa se ha ms que duplica-
do a lo largo del siglo XX, llegando en la actualidad a 75 aos en
el varn y 83 aos en la mujer. Las predicciones de la evolucin y
crecimiento poblacional a nivel mundial y nacional auguran un
shock demogrfico cuando en Espaa el nmero de mayores de
65 aos alcance el 33,5% de la poblacin en el 2050.
Es conocido que el cncer est intrnseca y directamente rela-
cionado con la edad, siendo una patologa de personas mayores,
ya que al menos el 60% de ellos aparecen en mayores de 65
aos. Los ancianos constituyen el grupo ms importante de la
prctica oncolgica mdica. Las predicciones de envejecimiento
de la poblacin espaola, permiten intuir que el cncer en el an-
ciano y su tratamiento deba ser considerado un problema sanita-
rio de primer orden.
El cncer ya no es sinnimo de muerte para la mayora de los
pacientes. Globalmente el 60% se curan o cronifican. Esta mejora
pronstico tiene un precio tanto en las expectativas de tratamien-
to como de posterior seguimiento y mantenimiento de las secue-
las que pueden generarse.
El mayor y mejor conocimiento y comprensin del proceso de
envejecimiento, permitir identificar y seleccionar aquellos pacien-
tes mayores que pueden beneficiarse de medidas de prevencin y
tratamiento, y lo ms importante permitir identificar aquellos pa-
cientes que no son candidatos de tratamientos con intencin cura-
tiva por tratarse de poblacin frgil.
Los adelantos en el campo de la ciruga, especialmente en la
ciruga mnimamente invasiva y su aplicacin al campo de la ciru-
ga oncolgica, permiten prever que un mayor nmero de pacien-
tes ancianos podrn beneficiarse de un tratamiento con intencin
curativa. La edad no prevendr de tratamientos apropiados en in-
dividuos ancianos con cncer, especialmente aquellos en los que
tengan una adecuada expectativa de vida y reserva funcional.
Combatir esta discriminacin sanitaria constituye una de las prin-
cipales prioridades en la estrategia para el mantenimiento de la
salud del anciano.
Vol. 100. N. 11, 2008 PREVALENCE AND TREATMENT OF ONCOLOGIC DISEASE IN THE ELDERLY
AN IMPENDING CHALLENGE
cancer and age with its peculiar specificities; the general criteria for
frailty in older patients, the limitations that aging generate for adju-
vant treatments, and the new alternatives of treatment to be used in
elderly oncologic patients for the most frequent tumors.
Key words: Surgery. Cancer. Elderly.
Gmez Portilla A, Martnez de Lecea C, Cendoya I, Olabarra I, Martn E, Magrach L, Romero E, Corts J, Muriel J, Mrquez A, Kva-
datzem. Prevalence and treatment of oncologic disease in the elderly an impending challenge. Rev Esp Enferm Dig 2008; 100:
706-715.
POPULATION CHANGES
The predictions by Thomas Malthus in 1798 on the ex-
ponential growth of the population, limited only by the
linear growth of resources, external events, and birth con-
trol, have been complied with over the last two centuries.
Up to year 1800 the world population had increased to
only a thousand million inhabitants (global transitional
phase); population growth until the present 6,000 million
inhabitants has been concentrated in two hundred years,
more specifically in the last 12 years.
It is estimated that zero population growth, the stabi-
lization of the ratio between births and deaths, will be
reached around year 2100, with an increase in population
of 70-90% over the present one. This means we can ex-
pect that the number of people over 65 will rise from 580
million in 1998 to 1,970 million in 2050, i.e., 22% of the
world population (1). In a later phase there will be a pro-
portionally greater increase in the population group of the
very elderly (> 80 years).
The fastest growing segment of the population in the
USA at present is that of patients over 65 (2). In 1980,
25.5 million people in the USA were over 65; at the end
of 2020 this figure will have doubled to 52 million, i.e.,
17% of the population. Today 1 out of every 9 inhabitants
in the USA is over 65 years, but in the next 50 years this
figure will double and projections indicate that in 2030 1
out of every 5 people in the USA will be over 65 (3).
In Europe this group already comprises a quarter of the
population, with a larger growth in those over 85 years
(3).
The division generally made among the elderly into
young old (65 to 75 years), old (76 to 85 years) and the
oldest (more than 85) people is of some use as it is asso-
ciated with a greater prevalence of comorbidity and a
greater functional dependency that increases progressive-
ly with age, but nevertheless is not useful for the treat-
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707
Presentamos y analizamos en este trabajo los cambios pobla-
cionales que se avecinan de forma particular en Espaa, la vincu-
lacin del cncer con la edad con sus particularidades especficas,
los criterios generales de fragilidad del anciano, las limitaciones
que la edad suponen para la aplicacin de distintos tratamientos
adyuvantes complementarios, y las nuevas alternativas quirrgicas
aplicables en pacientes oncolgicos ancianos en los cnceres ms
frecuentes de la prctica clnica.
Palabras clave: Ciruga. Cncer. Anciano.
ment of the individual patient, as decisions cannot be
based purely and simply on chronological age.
The life expectancy of 65-year-old patients is over 15
additional years; furthermore, in most cases patients will
remain functionally independent. The life expectancy of
patients of 75 is over 10 years, and of those with 85 more
than 5 years; likewise both groups in most cases will also
continue to be functionally independent for most of this
time (2), as shown in table I.
Table I. Total life and active, disability-free life expectancy,
in years, for different ages (4-8)
Age Total life Active disability-free life
expectancy expectancy
65 17 15
75 11 7.5
85 7 3
95 3 1
100 2.5 0.9
The Spanish demographic crisis is apparent in the
number of over 65s, which will reach 33.5% of the Span-
ish population in 2050 compared to the present 16.9%
(9).
Life expectancy in Spain has more than doubled in the
20th century, passing from 35 years at birth in 1900, to 75
in men and 83 in women in the year 2000 (10). These fig-
ures will improve in the future as can be seen in table II.
Maximum life expectancy is calculated by finding the
average age of individuals belonging to the last percentile
in the survival curve of the successive cohorts examined,
this being between 100 and 130 years; this constitutes the
708 A. GMEZ PORTILLA ET AL.
Table II. Life expectancy in Spain (3)
Year of Life expectancy in Percentage of population by sex
birth years by sex > 65 years old > 85 years old
M F M F M F
1900 33.8 35.7
1990 73.4 80.4 9 9.2 2.45 2.47
2020 76 83.7 15.5 19.1 4.97 5.71
upper limit of the range of life expectancy. However, the
proven maximum age is the value reached by an individ-
ual, and this corresponds to the French woman Jeanne
Calment, who died in 1997 at the age of 122.5 years
(11,12).
The challenge presented by the increase in the elderly
population is underestimated and requires well-defined
action plans for the future.
GENERAL ASPECTS OF CANCER IN THE
ELDERLY
Epidemiology of cancer and age. Is age a risk factor
for cancer and its treatment?
It is well known that cancer is intrinsically and directly
related to age, and a condition of the elderly. In the Unit-
ed States a notable increase in cancer incidence with age
has been shown, starting at 30 years and reaching its
maximum incidence in patients over 80 (13,14). The el-
derly are rapidly becoming the largest group in medical
oncology practice. Early diagnosis and treatment are a
pressing need for this age group (15).
Epidemiologically, the incidence of the majority of
cancers and mortality from cancer increase with age.
More than 60% of cancers and 80% of deaths from can-
cer occur in the 12% of the population over 65 years
(16,17), and it is estimated that some 10-12% of the pop-
ulation over 70 years have a previous history of cancer
(18). The rise in cancer development as age advances af-
fects both sexes and every type of cancer studied, but par-
ticularly breast cancer in women and prostate cancer in
men. Cancer is the first cause of death in women between
40 and 79 years of age, and in men between 60 and 79
years (19,20). While cancer is the second cause of death
in the general population after heart disease, in the popu-
lation over 85 years it constitutes the first cause of death
in both men and women (20). The predictions on the ag-
ing of the Spanish population indicate that cancer in the
elderly and its treatment should be considered a health-
care problem of the first order. These data reflect the
magnitude of the problem facing our society, a problem
that can only intensify as the population grows older (10).
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This may only reflect the better condition of our elderly
patients with cancer, as in general they have less comor-
bidity and a better functional status when compared to the
general population. These factors may allow them to live
to an older age and develop cancer because of a longer ex-
posure to carcinogenic factors, as well as a greater expo-
sure to new carcinogens (21). Paradoxical data such as
these have been demonstrated in breast cancer, where it
has been shown that it affects more healthy women more
than others, those with the best bone density readings and
the ones who have benefited from the longest estrogenic
effect (22). In a series of autopsies of 350 patients over 95
years and 99 patients over 100 years, Stanta et al. (23)
demonstrated that both clinical cancers and occult cancers
were more common in those elderly patients with optimal
nutritional status and lowest comorbidity.
Fortunately cancer is no longer synonymous with
death for most patients. Globally 60% are cured or be-
come chronic. Breast, prostate, and colorectal cancers are
most frequent in the elderly (10), and all of these have
nowadays high cure rates; this means a survival at five
years from around 84% in breast cancer to 58% in col-
orectal cancer (24). This improved prognosis is expen-
sive regarding the cost both of treatment and of later fol-
low-up and maintenance: early detection of second
tumors, disorders, or after-effects resulting from treat-
ment received, such as radiotherapy, mutilating surgery,
organic changes caused by cytostatic drugs (cardiac, neu-
rological, thyroidal) or the inability to return to previ-
ous daily activity.
The aging of the population will no doubt give rise to
an increase in cancer cases in the elderly population. This
fact, added to the higher survival rates of cancer patients,
means that we have to draw up new proposals to guaran-
tee a decent quality of life or survival.
Nowadays it is not enough to plan how to treat cancer
patients while causing as little damage as possible, but
also how to prevent long-term sequels (25). Recent ef-
forts have focused on a reduction or prevention of sec-
ondary cancers on the one hand, and on the other hand
the comorbidities secondary to anticancer treatment re-
ceived (26,27).
Hewitt et al. (28) have demonstrated that those el-
derly persons who have survived a cancer have more
chronic illnesses and functional limitations than the el-
derly population in general, a phenomenon that other
more recent studies have confirmed (29,30). However,
it is not exactly known whether this bears a direct rela-
tionship with the tumor, with existing comorbidities or
simply with subsequent aging. Cancer survivors are
more prone to suffer from associated metabolic dis-
eases (diabetes, cardiovascular disorders, dyslipemia),
osteoporosis, depression, and loss of function, all of
which require improvements in lifestyle habits and
pharmacologic support.
Smoking cessation, a balanced diet, and regular exer-
cise have proved beneficial in preventing disease and
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AN IMPENDING CHALLENGE
dysfunction, and may delay the development of senile
fragility by up to 7 years (31), but there are studies that
have shown that older patients are not likely on their own
to change their habits and maintain changes, so this is an
important function of their carers (32).
Age-related differences in cancer behavior
Some neoplasias may behave more aggressively or
more sluggishly according to the age of each individual pa-
tient (33,34).
The physiological changes that take place in the body
are particularly relevant as long as the biology of cancer
and its treatment are concerned. They may be involved in
factors such as tumor growth, the patients capacity to re-
spond to radical treatment, the pharmacokinetics of the cy-
totoxic agents used, and the toxicity of drugs given.
Senescence, that is to say, the loss of the capacity for
cell replication that occurs with age, paradoxically may on
occasion favor carcinogenesis and cell growth. This mech-
anism may explain why low-proliferation neoplasias, such
as follicular lymphomas or myelodysplasia, are more com-
mon in elderly patients (35).
In a recent French study, age was a negative factor in the
prognosis that was limited to the first year after diagnosis
(24). Overall survival is generally lower in the elderly,
though this is due to the greater probability of dying as age
advances rather than to causes related to cancer (21).
Age-related differences in treatment tolerability.
Is the elderly patient able to tolerate cancer
treatment with curative intent?
The fact that there is disparity in treatment according
to age is undeniable, (36) given that a greater mortality in
patients over 65 has been observed for all cancers stud-
ied. This disparity in results becomes even more pro-
nounced when studying the difference in mortality ac-
cording to the number of cases treated annually in
different hospitals. The difference in mortality in
esophageal and pancreatic cancer in patients over 65 was
10% higher in small hospitals with a limited case load,
compared to the results obtained in high-volume hospital
centers (37).
The main challenge in the treatment of cancer in the
elderly lies in the treatment of the disease with the inten-
tion of achieving a cure without putting the patients life
at risk (10) or worsening his or her general status. Age
will not preclude appropriate treatment in elderly persons
with cancer, especially in those with a reasonable life ex-
pectancy and functional reserve (35).
A greater and better knowledge of the aging process
enables the identification and selection of those older
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709
patients who may benefit from prevention and treat-
ment measures, and most importantly enables the iden-
tification of those patients who are not candidates for
treatment with curative intent because of their belong-
ing to the frail group in the population. Fragility is
synonymous with instability. It is important to recog-
nize that fragility is not synonymous with age, and that
a majority of elderly persons are not fragile.
Various prognostic scales have been developed for
the assessment of the geriatric status of patients, and
these allow us to ascertain the degree of functional de-
pendency and the reserve capacity of patients to face
aggression. The criteria for fragility have been based,
according to Balducci and Extermann (38), on the
presence of one of the following: age over 85, depen-
dency in one or more of the activities of daily living; 1
or more comorbidities, and 1 or more geriatric syn-
dromes.
Activities of daily living (ADLs) are basic activities
that mean having total autonomy to be able to perform,
and include: going for a walk, personal hygiene, going
to the toilet (urinating and defecating), getting dressed,
and eating. Dependency in 2 or more of these daily ac-
tivities implies a 2-year mortality of 30% of patients,
and requires either full-time attendance in the home by
a specialized carer or admission to a geriatric center
(39).
Instrumental activities of daily living (IADLs) are
basic activities requiring total autonomy to carry them
out and include: use of transport, ability to take med-
ication, self sufficiency to acquire food, ability to use
the telephone and manage money. Dependency in 1 or
more of these daily activities is associated with death
within 2 years for 15% of patients, and also implies a
need for part-time help in the home by a specialized
carer (40).
As well as functional dependency and its prognostic
implications, there is evidence for an increase in co-
morbidity with age and its association with reduced
life expectancy and tolerance to treatments. There are
various scales of comorbidity: the Cumulative Illness
Rating Scale-Geriatric CIRS-G (41), or the Charlson
Comorbidity Scale. (42). Among comorbidities, two
have special significance for prognosis in elderly pa-
tients depression and anemia. Both conditions may
be reversible but may compromise tolerance to treat-
ment, and the functioning of the individual.
Anemia implies levels below 12 mg/dl, in that be-
low this functional dependency is generated, with fa-
tigue and increased toxicity with chemotherapy.
Finally, geriatric syndromes include conditions that
are typical of, though not exclusive to, advanced age
and are associated with reduced survival. They include
delirium, dementia, depression, osteoporosis, inconti-
nence, falls, negligent driving, etc.
Based on these prognostic scales for the assessment of
the geriatric status of patients according to their depen-
710 A. GMEZ PORTILLA ET AL.
dency, comorbidity or associated geriatric syndromes, we
will find at one extreme patients who are totally indepen-
dent with no comorbidity, and who are candidates to any
type of treatment, and on the other extreme patients with
multiple comorbidities and functional dependencies who
are not candidates to any type of treatment regardless of
chronological age. The prevalence of the three entities to-
gether increases with age, and is greater in the most el-
derly group. However, the association of one or two of
them with age is not so consistent and related, the per-
centage of patients with breast cancer with dysfunction
and geriatric syndromes being relatively small (0.7 to
1.7%) up to the age of 85 years, at which moment it in-
creases to 10.2% (43).
Functional loss initially affects the most dependent
tasks of the cognitive and affective domains, such as the
activities related to social life (advanced activities of dai-
ly living- ADLs), later the activities that enable mainte-
nance of independence in the community (instrumental
activities of daily livingIADLs), and finally compro-
mise the basic tasks of self-care (basic activities of daily
living BDLAs). When disability is very severe, mortali-
ty within five years is nearly 80%.
In the treatment of elderly patients, a function that is
also considered is wellbeing during life: the expectation
of active life. There is no value or sense in carrying out
diagnostic and therapeutic actions whose expected bene-
fit will result within a time period that is greater than the
life expectancy of the individual.
More recently a new cardiovascular health scale (44)
enables the identification of three clinical risk types of
patients: those with no limitation, patients with pre-
fragility who are those with 1 or 2 limitations out of the 5
parameters studied in the scale, and fragile patients with
3 or more parameters. The variables of the study are
shown in table III.
Table III. Cardiovascular health scale parameters (44)
Involuntary loss of weight = or > 10% in the last year or less
Loss of strength of grasp
Early exhaustion
Slow walk
Difficulty in initiating movements
TREATING CANCER IN THE ELDERLY
Cancer is a disease linked to age, and its prevalence in-
creases as the elderly population increases. Improve-
ments in screening results in earlier diagnosis; this,
linked to the availability of better therapeutic choices,
contributes to a greater number of cancer survivors.
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Of long-term cancer survivors, 65% are over 65 years,
and of these 22% had breast cancer, 17% prostate cancer,
11% colorectal cancer, and 10% gynecological cancer
(26).
In the elderly population there is unfortunately a
lesser diagnosis of cancer-related diseases, and a
greater number of late or imprecise diagnoses; both of
these result in inadequate treatment of cancer in the
older population. One of the origins of this difference
and the difficulty in diagnosis lies in a reduced self-
perception of illness by elderly patients, and conse-
quently in delayed communication. This is added to a
false belief among the general population that the pos-
sibility of developing cancer is lower in elderly pa-
tients, and finally there is the factor of the erroneous at-
tribution by medical practitioners of the clinical
changes suffered by older patient as products of aging
and not a manifestation of disease.
The diagnosis of cancers in an advanced stage is of-
ten associated with inadequate health care, and in gen-
eral is an indicator of fatal prognosis in almost all types
of cancer (45). Ineffective health care for a target group
of the population results inevitably in a marginalization
of such a population group; this is usually disguised in
old age as a so-called social problem. Fighting
against this healthcare discrimination constitutes one of
the main priorities in the strategy for maintaining
health for elderly people. The application of population
screenings for patients over 70 would yield very good
results because of its effectiveness for breast cancer
and cervical and endometrial cancer in women, for
prostate cancer in men, and for colorectal cancer in
both sexes (14).
The different results in patients treated for cancer in
old age may be due both to the standard treatments ap-
plied that exceed the biological reserves of the patients,
and to palliative treatments administered to patients mis-
takenly labeled as unable to stand conventional treatment
(43,45).
It is widely accepted that the treatment of cancer
may be life-saving for patients who are totally func-
tional; however, it may aggravate geriatric syndromes
and even compromise the lives of patients with limited
functional reserve, hence the importance of awareness
and diagnosis of fragility when decisions are made on
the treatment of cancer patients (38). It is essential to
choose the best alternative in particular patients and at
particular moments.
In the elderly decisions about treatment rely on factors
that depend on the patient: discapacity, life expectancy,
and tolerance of treatment, and on factors that depend on
the tumor: aggressiveness, imminent risk of urgent clini-
cal manifestations, or death.
The options for antitumoral treatment include surgery,
radiotherapy, chemotherapy, hormone therapy, and bio-
logical therapies with target agents, and on many occa-
sions the association of several of these.
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Surgery
The success rate of geriatric surgery has increased
spectacularly thanks to better preoperative preparation
of patients, advances in anesthesia-resuscitation, im-
provements and greater experience in the various op-
tions and surgical techniques. To these factors should
be added a better control of postoperative complica-
tions, advances in artificial nutrition, and a greater
knowledge of homeostasis and fluid balance therapy.
Improvements in anesthesia and alternative therapeutic
technology imply new surgical choices for elderly can-
cer patients.
Until a short while ago it was unimaginable that mini-
mally invasive surgery would permit a surgical excision
of solid organs (liver, pancreas, spleen, suprarenal
glands) and of malignant processes in the digestive tract.
The development of safer, less aggressive forms of treat-
ment (advanced laparoscopic surgery, interventionist en-
doscopy, and radiology, radiofrequency, etc.) will enable
these to be used more frequently in those with a limited
functional reserve.
Although it is known that morbidity and mortality
as a result of postoperative complications increase
with age (46), risks are mainly raised in emergency
surgery (31,47), partly due to elderly patients having
less clinical manifestations (48), or that diagnosis is
delayed until more advanced stages of disease (49). In
general, it is acknowledged that, except for prostate
cancer, surgery is the principal treatment tool for solid
cancers (21).
Currently, surgery for breast cancer does not imply any
increased risk in older patients (26), though prostatecto-
my in the older patient is associated with a greater degree
of impotence and urinary incontinence as compared to
younger patients.
In abdominal surgery there are no significant differ-
ences in mortality and morbidity in pancreas cancer, al-
though it has been found that people over 70 years suffer
more hemorrhagic complications and require more repeat
laparotomies.
Neither have differences according to age at surgical
treatment of liver metastases from colorectal cancer
with respect to the rate of complications, mortality, or
survival average (50) even in the over 90 age group
(51).
Improvements in treatment are allowing a reconsid-
eration of age limits when planning population screen-
ings; while these appear not to be defined, screening
may not be appropriate in persons over 85 or in those
among the elderly with a very limited total or active
life expectancy. Colorectal and breast cancer are the
only conditions in which screening with early diagnosis
tests for those over 75 may be advisable, given that ear-
ly diagnosis of these two pathologies may be of benefit
if the individuals concerned have a life expectancy of 5
years or more.
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711
Radiotherapy
External radiation is very well tolerated by patients
over 80 years, with at least 90% of patients being able to
complete treatment plans (52).
The application of new technologies with fractionated
radiotherapy or local brachytherapy seems to contribute
new advantages in the treatment of the elderly with cer-
tain types of cancer (53). Radiotherapy fulfils a crucial
role in the treatment of malignant tumors in the geriatric
patient, both as radical treatment and in palliative care
(54).
However, at the moment only 18% of patients aged be-
tween 75 and 84 years with breast cancer receive comple-
mentary radiotherapy, and it is prescribed for scarcely 8%
of patients over 85. It is most serious that the reasons for
depriving many of these women of the best treatment for
their illness are socioeconomic rather than scientific (54).
Radiotherapy is offered more and more to elderly pa-
tients with prostate cancer. Active treatments, even when
given as palliation, represent an important gain in health
for patients, including those over 80 (55).
Chemotherapy
The physiological changes that occur in the body are
particularly relevant in the treatment of cancer. They may
interfere with the pharmacokinetics of cytostatic agents
given as treatment, and the toxicity of the drugs used.
The most significant pharmacokinetic change is the re-
duction of renal excretion of cytostatics (56).
Agents derived from platinum such as cisplatin, carbo-
platin and oxaliplatin, may cause nephrotoxicity and pe-
ripheral neuropathy, and more markedly so in elderly pa-
tients.
Similarly, cardiotoxicity linked with antracyclins and
monoclonal antibodies may be more pronounced in older
patients, who may already, because of this, have their car-
diac functioning compromised.
It has been shown that hematological toxicity repre-
sents a greater risk of neutropenia and anemia in older
patients, and these are more difficult to correct when they
appear.
More elderly patients are receiving chemotherapy, and
in general the benefits of chemotherapy treatment in this
group of the population are more readily accepted. Clear-
ly, older people benefit as much as younger individuals
from chemotherapy (57), as long as precautions are taken
to make a correct selection and to prevent the commonest
complications of treatment (21). Treatment schedules and
drug doses should not be modified taking age into con-
sideration as the only factor.
In cancers of gastrointestinal origin the main problem
of treatment with chemotherapy in the elderly is the toxi-
city of the drugs used; however, various drugs have cur-
712 A. GMEZ PORTILLA ET AL.
rently been developed that, as well as having less side-ef-
fects, avoid the need for parenteral administration, with
capecitabin and UFT being the ones that have acquired
greater clinical relevance (58).
Hormone therapy
Though the physiologic changes produced in the or-
ganism secondary to hormone treatment are known and
fully established, both in the treatment of breast cancer
and in prostate cancer, we do not at the moment have
enough data to affirm that these treatments have a
greater or lesser deleterious effect according to patient
age (26).
RESULTS OF SPECIFIC TREATMENT FOR THE
COMMONEST CANCERS
Cancer of the colon and rectum
Cancer of the colon and rectum is the third most com-
monly diagnosed cancer in the USA and constitutes the
second cause of death from cancer. Americans have a
5.6% (1 in 18) risk of suffering from cancer of the colon
and rectum during their lifetime. It is estimated that
106,680 patients were diagnosed with colon cancer and
41,930 patients with rectal cancer in 2006 in the USA,
and statistics show that 55,170 patients died from cancer
of the colon and rectum in 2006 (36).
Colon cancer is the second most frequent tumor in
the elderly, and causes 13,000 deaths annually in Spain
(59).
Colorectal cancer is age-specific with an incidence and
mortality that increases with age. The incidence is 18%
under 45 years of age, and reaches 30% in patients be-
tween 45 and 49 years. Its incidence increases after 65
years of age; 50% of cases occur in persons over 70.
Survival has increased in the last 35 years, rising from
49% at 5 years in 1970-73 to 66.1% at 5 years in 1996-
2002; this has been attributed to improvements in diagno-
sis with earlier diagnoses and better treatments.
Colorectal carcinogenesis is a long-lasting process that
takes between 15 and 20 years. Most tumors grow from
an adenomatous polyp (60).
Cancer of the colon and rectum can be prevented with
colonoscopies and extirpation of pre-malignant polyps.
Complete colonoscopy every 10 years seems to be the
most effective measure (35).
There is evidence of differences in the treatment of pa-
tients with cancer of the colon and rectum because of
their age.
The treatment of choice for local cancer is surgical re-
section (61). In the decade of the 90s, various random-
REV ESP ENFERM DIG (Madrid)
ized studies demonstrated the benefits of adjuvant
chemotherapy for stage-III colon cancer, the indications
for adjuvant chemotherapy increasing from then on even
in the elderly population.
The safety of elective resection of a colorectal carci-
noma in the older patient has been demonstrated in var-
ious studies. However, when the surgical intervention
takes place as an emergency, operative mortality in
such patients is significantly higher than in younger pa-
tients. Placement of a self-expanding stent in patients
with an occluding neoplasm of the left colon for pallia-
tive purposes or as a first step before conventional elec-
tive colectomy has clinical advantages such as colosto-
my sparing.
The advantages of laparoscopic colectomy may be
more beneficial in the elderly (62), as has been demon-
strated by recent studies comparing open colon resection
with resection through laparoscopy in patients over 75
and of 80 years of age (63); it has been found that there is
a reduction in the use of narcotics, an earlier recovery of
bowel movement and a shorter hospital stay in those pa-
tients where a laparoscopy technique was used, with the
same morbi-mortality rate in both groups (64).
Breast cancer
Breast cancer is the most frequent tumor found in
women in the USA and worldwide.
As it is a hormonal disease, its incidence and mortality
are variable for a multitude of factors, age among them.
One of every 15 women over 75 years will develop breast
cancer. It affects mainly healthy women, with the best
bone densities and those who have had the benefit of the
longest estrogenic effect (22).
At present, breast cancer has a high cure rate, this
meaning a survival at 5 years of around 84% (24).
Cancer of the cervix
Cervical cancer varies with age, a higher incidence
having been found in fertile women compared to older
women. Elderly women are disproportionately represent-
ed among cervical cancers, particularly those over 65.
They represent approximately 25% of cervical cancer
cases, and are responsible for 40% of deaths from cervi-
cal cancer.
The usefulness of screening using the Pap test in
women over 65 is controversial (65). The treatment of
pre-malignant diseases at this age may be a risk rather
than a benefit. Most clinical guides nowadays recom-
mend stopping screening over 65-70 years with repeated-
ly negative exudate smears or with a short life expectan-
cy.
REV ESP ENFERM DIG 2008; 100 (11): 706-715
Vol. 100. N. 11, 2008 PREVALENCE AND TREATMENT OF ONCOLOGIC DISEASE IN THE ELDERLY
AN IMPENDING CHALLENGE
In general there are age disparities in treatment, with
older patients being offered more conservative treatment
as compared to younger patients, and for this reason they
have shorter survival rates.
Patients who present with advanced disease, includ-
ing aortic or pelvic node metastases have a reduced
survival rate and are generally offered palliative treat-
ment. Women with limited early disease are generally
treated with radical surgery, while those with large or
invasive tumors receive radiotherapy or combined
treatments (66).
Globally survival at 5 years is 70%. It should be re-
membered that treatments should be applied individu-
ally.
Stomach cancer
The benefits of gastrectomy aided by laparoscopy in
comparison with the conventional form include less post-
operative pain, a rapid recovery of bowel function, and
shorter postoperative hospital admission (67, 68).
Overall survival at 5 years was 22% in men and 30%
in women in the study carried out in France (22). Howev-
er, survival at 5 years in octogenarian patients were not
achieved by the group of Gupta et al. (57), in spite of car-
rying out complete surgical resection in 77% of their pa-
tients, with an operative mortality of only 3%.
Prostate cancer
With the aging of the population, prostate cancer has
become the most frequent tumor in men. It is the only one
capable of remaining asymptomatic for decades in most
patients, and also the only one that can be restricted for a
long time to just one zone of the body.
Thanks to screening studies with determination of spe-
cific PSA, the incidence of diagnoses of prostate cancer
continues to rise with the characteristic that nowadays
91% of prostate cancers are diagnosed at a local or lo-
coregional stage in which survival at 5 years is 100%
(20).
One of every 7 men over 75 will develop a prostate
cancer.
Overall survival at 5 years was 77% in the French
study (24). At the moment there is no agreement as to
which is the most effective therapeutic option (surgery,
radiotherapy, green laser, hormone therapy, or even cas-
tration).
CONCLUSIONS
The elderly already constitute the largest group of pa-
tients in oncological medical practice. The predictions re-
REV ESP ENFERM DIG 2008; 100 (11): 706-715
713
garding aging in the Spanish population enable us to fore-
see that cancer in the elderly and its treatment should be
considered a healthcare problem of the first order.
Cancer is no longer synonymous with death for most
patients. Globally 60% are cured or become chronic dis-
eases. This improved prognosis has a price both in expec-
tations of treatment and in the later follow-up and mainte-
nance of sequels that may arise.
A greater and better knowledge and understanding of
the aging process will enable the identification and selec-
tion of those older patients who can benefit from preven-
tive and treatment measures and, most important, will per-
mit an identification of patients who are not candidates to
treatments with curative intent because of their inclusion
among the fragile population.
Advances in the field of surgery, especially in minimal-
ly invasive surgery, and their application in oncology allow
it to be foreseen that a greater number of elderly patients
will be able to benefit from treatment with curative intent.
Age will not prevent appropriate treatments in elderly indi-
viduals with cancer, especially those who have a reason-
able life expectancy and functional reserve. It is the re-
sponsibility of all healthcare professionals to adopt the
necessary measures to satisfy adequately the needs of this
age group in which sooner or later we all hope to find our-
selves included.
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