Linda L. Steele, PhD, APRN, ANP-BC and James R. Steele, MSN, APRN, NP-C On completion of this chapter, the reader will be able to: 1. Describe the physiologic and environmental factors that contribute to the increased risk of cancer in older adults. 2. Identify the malignancies most commonly found in older adults. 3. Discuss the nurse’s role in cancer prevention and early detection. 4. Design therapeutic nursing plans of care by applying principles of cancer treatment to older adults. 5. Develop strategies to manage symptoms experienced by older adults receiving cancer treatment. 6. Discuss unique dimensions of psychosocial problems encountered by older adults with cancer. 7. Analyze ethical concerns related to the care of older adults with cancer. 8. Identify appropriate resources for older adults with cancer. The National Cancer Institute (2009d) estimates that approximately 11.1 million Americans alive today have a history of cancer. This has increased from 7.4 million Americans in 2003. Of the survivors, some may be completely cured, whereas others have some evidence of disease. Cancer accounts for 22.9% of all deaths. Between 1950 and 2001 death rates from cancer have remained stable. The 5-year relative survival rate for all cancers diagnosed between 1996 and 2004 is 66%, which is up from 50% in 1975 to 1977. The improvement in survival reflects progress in diagnosing certain cancers at an earlier stage and improvements in treatment. Nonetheless, in 2010, Americans are expected to die of cancer at the rate of more than 1500 people a day. In the United States, cancer accounts for nearly one of every four deaths (American Cancer Society, 2008). Based on 2001 through 2003 data, the likelihood of developing cancer during one’s lifetime is approximately one in two for men and one in three for women. The 5-year relative survival rate for all cancers diagnosed between 1996 and 2004 is 66%, up from 50% in 1975 to 1977 (American Cancer Society Cancer, 2008). The 5-year relative survival rate for all types combined ranges from 16% for patients with lung cancer to 99% for patients with prostate cancer. Cancer survival varies by stage of disease and race; survival rates are lower in blacks compared with whites (National Cancer Institute, 2009c). Like the rest of the population in the United States, the aging population is becoming more diverse. In addition to whites of European descent, four other main racial and ethnic groups are present in the American population: African Americans, Hispanic Americans, Asian/Pacific Islanders, and Native Americans. Cancer affects Americans of all racial and ethnic groups; however, the incidence of cancer does demonstrate patterns according to racial and ethnic origins. African Americans have higher overall incidence rates than whites, whereas Hispanic Americans and Native Americans have lower incidence rates overall (Tables 19–1 and 19–2). TABLE 19–1 CANCER INCIDENCE RATES (NUMBER OF NEW CASES EACH YEAR)∗ ∗Statistics are for 2000 to 2006, age adjusted to the 2000 U.S. standard population, and represent the number of new cases of invasive cancer per year per 100,000 of both sexes, males and females, respectively. From National Cancer Institute. (2009). Surveillance epidemiology and end results (SEER). Retrieved June 2009, from seer.cancer.gov/faststats/selections.php#Output. TABLE 19–2 CANCER DEATH RATES (NUMBER OF DEATHS EACH YEAR)∗ ∗Statistics are for 2000 to 2006, age adjusted to the 2000 U.S. standard population, and represent the number of new cases of invasive cancer per year per 100,000 of both sexes, males, and females, respectively. From National Cancer Institute. (2009). Surveillance epidemiology and end results (SEER). Retrieved June 2009, from seer.cancer.gov/faststats/selections.php#Output. Because the incidence of cancer has demonstrated patterns by race and ethnicity, both these factors are important in determining which groups are at risk. When incidence is examined by race, several cautions are in order. First, race and ethnicity are both prone to misclassification. The U.S. Census Bureau has defined race and ethnicity (Box 19–1), but there is no accepted scientific definition for race. Persons with mixed-race parents lack a single classification. Second, as demonstrated by Freeman (1989) in his landmark investigation of genetics and cancer, there is no known genetic basis to explain the major racial differences in cancer incidence. Third, race and ethnicity may be viewed as a rough indicator for certain lifestyle and environmental factors. Race and ethnicity are highly correlated with socioeconomic status. Persons living in poverty tend to lack education, employment, adequate housing, good nutrition, preventive health practices, and access to health care. Within any one race or cultural group, economic status is the major determinant for cancer risk and outcome. Economic status as a risk factor for cancer is demonstrated globally. For most cancers, there are notable geographic variations in incidence rates that reflect socioeconomic differences, particularly differences between developing and developed countries (Hansen, 1998). Freeman (1989) concluded that correcting poverty among groups of people, regardless of their race or ethnic origin, would lead to decreased cancer incidence and increased survival rates. The leading cancers among white men are prostate, lung, colorectal, urinary bladder, melanoma, and non–Hodgkin’s lymphoma. White men have higher urinary bladder cancer incidence rates than men of any other racial or ethnic group: the rates are almost two times higher than those of Hispanic men, who have the second highest rates along with African American men. Breast cancer rates among white women are higher than those for women of any other racial or ethnic group. African American men have a higher overall cancer incidence rate than any other racial or ethnic group in America (666.4 vs. 558.3 for white men per 100,000). In contrast, white women have the highest cancer incidence rate among all ethnic groups (424.6 per 100,000) (Tables 19–3 and 19–4). In the United States the incidence rate for all cancers combined was 16% higher among African American men than white men (a decrease of 4% in the last 5 years), whereas the incidence rate for all cancers combined was 7% higher for white women than African American women (an increase of 2% over the last 5 years) (American Cancer Society Cancer Facts and Figures for African Americans, 2007 to 2008). TABLE 19–3 CANCER INCIDENCE RATES OF AFRICAN AMERICAN AND WHITE MALES TABLE 19–4 CANCER INCIDENCE RATES OF AFRICAN AMERICAN AND WHITE FEMALES • Aging increases the duration of exposure to substances that may act as promoting agents. Because the effects of promoters are dose dependent, older adults can accumulate a significant dose over decades. Also, cellular transformations and progression of cancer cells occur over time. Cancer cells grow at various rates, and in some cases significant time is needed for the small cluster of cancer cells to grow large enough to cause signs and symptoms. • Aging cells demonstrate a tendency toward abnormal growth. Aged cells are more vulnerable to damage; thus aging likely increases the susceptibility of cells to substances that cause genetic mutations. • Once an aged cell is damaged by an initiating substance, it is more difficult to repair. • Oncogene activation might be increased in older persons, resulting in increased loss of regulation of cell growth and the development of cancer cells. • Decreased immune surveillance, or immunosenescence, may contribute to increased development of cancers and their progression, although the evidence on the role of the immune system in the development of cancer is inconclusive (Crawford & Cohen, 1987; Pfeifer, 1997a). Although all women are at risk for developing breast cancer, the older a women is, the greater her chances of developing breast cancer. Breast cancer is more common in white women than in other racial or ethnic groups, but according to the most recent data, death rates are continuing to decline in white women. According to the SEER program of the National Cancer Institute (2009a), white Hawaiian and African American women have the highest incidence of invasive breast cancer in the United States. Korean, American Indian, and Vietnamese have the lowest incidence of invasive breast cancer in the United States. African American women have the highest death rate from breast cancer and are more likely to be diagnosed with a later stage of breast cancer in the age group 55 to 69. However, in the age group that is 70 years or older the death rate is higher for white women than for African American women (American Cancer Society, 2004a) (see Cultural Awareness Box). menopause (after age 55), lengthy exposure to postmenopausal estrogen, recent use of oral contraceptives, and never having given birth or having first given live birth at a late age (after age 35) (Reigle, 2000). The highest incidence of breast cancer is in women ages 50 to 59. A first peak of incidence occurs between ages 45 and 49, when women are either premenopausal or menopausal. The high incidence in this age group is thought to be related to ovarian estrogen. A second peak of incidence occurs in women between ages 65 and 69, most of whom are postmenopausal. The second peak appears to be related to an imbalance of adrenal estrogen. Given these findings, breast cancer appears to be two separate diseases differentiated by menopausal status. Although hormones are not inherently mutagenic, they may act as initiators or promoters by altering cell reproduction and growth (Pfeifer, 1997a). A major advance in understanding breast cancer is that the disease has a genetic basis. Approximately 5% to 10% of breast cancers are hereditary. The genes involved in most inherited breast cancers are BRCA1 and BRCA2. These are tumor-suppressor genes that also serve to protect and preserve DNA. Mutation of these genes has been linked to hereditary breast and ovarian cancer. A woman’s risk of developing breast and/or ovarian cancer is greatly increased if she inherits a deleterious BRCA1 or BRCA2 mutation. Men with these mutations also have an increased risk of breast cancer. Up to 40% of inherited breast cancers are due to mutations in BRCA1, and mutations in BRCA2 are responsible for up to 30% of inherited cancer (Cummings & Olopade, 1998; American Cancer Society, 2008). High-fat diets and obesity have been suggested as risk factors, although the evidence is inconclusive. In animal studies the proliferation of breast tissue may be altered by changes in estrogen levels and pituitary and thyroid function, which are all sensitive to dietary intake (London & Willett, 1989). The risk associated with obesity may differ according to menopausal status and is thought to be associated with the metabolism of estrogen. Additional risk factors associated with breast cancer include pesticide and other chemical exposure, alcohol consumption, and physical inactivity (Knobf, 1996). Radiotherapy is indicated postlumpectomy. Postoperative breast irradiation is well tolerated by older women; therefore age is not a contraindication to breast preservation treatment (Wyckoff et al, 1994). In general, older women treated for breast cancer do not experience greater complications or treatment toxicities when compared with younger women (Masetti et al, 1996). Although mastectomy is not the treatment of choice, if mastectomy is done, breast reconstruction is an option, depending on personal preference and the extent of the disease. As with all women, older women should be given information and support to help make treatment decisions. Breast cancer should be treated promptly but is not an emergency. Nurses should provide a supportive atmosphere and encourage family members to participate in treatment decisions. It is unclear what the exact prostate cancer risk is for men who have a first-generation relative with prostate cancer. Some studies have shown a twofold to elevenfold increase in men with a positive family history (American Cancer Society, 2004a). In the United States men have a 15% lifetime risk of a diagnosis of prostate cancer, but only a 3% lifetime risk of dying from it (American Cancer Society, 2004a). Annual digital rectal examination (DRE) and prostate-specific antigen (PSA) testing are the two primary screening tests for prostate cancer in the United States. However, only a portion of the prostate can be palpated using the digital technique. Studies suggest that DRE alone detects less than 60% of prostate cancers. Adding PSA testing detects 26% more cancers than DRE testing alone. The American Cancer Society (2004a) recommends that every man older than age 40 have a DRE as part of a regular annual physical examination. Ultrasound of the prostate is expensive and to date has not been demonstrated to be more predictive of prostate cancer than DRE. PSA is an immunologically distinct antigen made exclusively by prostate tissue. The American Cancer Society (2004a) recommends that men ages 50 or older have an annual PSA blood test. If either test result—DRE or PSA—is questionable, a complete evaluation is necessary. While the highest rate of prostate cancer is among African Americans, Collins (1997) found that, when surveyed, only 21% of African American men correctly identified the screening recommendations and early symptoms of prostate cancer. Like surgery, radiotherapy, in the form of either external beam radiation or internal implantation of seeds, can be a primary treatment for prostate cancer. External beam radiation is administered daily in small doses for approximately 40 treatments. Often the radiation treatments are coupled with hormonal therapy with agents such as luteinizing hormone–releasing hormone agonists. The benefits of the use of accompanying hormone therapy are a decrease in the serum testosterone level and shrinkage of the tumor in preparation for radiation (Millikan & Logothelis, 1997). Both surgery and radiotherapy are effective. Convincing proof of the superiority of either approach is not available. The choice of treatment often depends on the presence of comorbidity, availability of treatment facilities, requisite medical expertise, and individual preference. Erectile dysfunction can be a consequence of any of these procedures. Dr. Anthony D’Amico (2008) states, “In order to get the highest cure rate for men with high-risk prostate cancer, it appears that five weeks of external beam radiation and at least four months of hormonal therapy should be added to brachytherapy,” (D’Amico et al, 2008).
Cancer
Incidence
Racial and Ethnic Patterns
GROUP
BOTH SEXES
MALES
FEMALES
African American
467.30
582.95
388.10
White
458.13
524.68
412.53
Asian/Pacific Islander
297.80
228.35
280.07
Hispanic/Latino
331.00
379.86
300.14
American Indian/Alaskan Native
307.37
303.31
312.78
GROUP
BOTH SEXES
MALES
FEMALES
African American
218.79
287.74
176.91
White
180.09
218.74
153.43
Asian/Pacific Islander
107.77
128.23
93.31
Hispanic/Latino
119.49
145.57
101.49
American Indian/Alaskan Native
150.40
171.27
136.40
TYPE
AFRICAN AMERICAN
WHITE
ABSOLUTE DIFFERENCE
RATE RATIO
All Types
666.4
558.3
108.1
1.2
Prostate
258.3
163.4
94.9
1.6
Lung/Bronchus
112.2
81.7
30.5
1.4
Urinary/Bladder
19.8
30.2
-20.4
0.5
Skin Melanoma
1.1
-26.5
-25.5
<0.1
TYPE
AFRICAN AMERICAN
WHITE
ABSOLUTE DIFFERENCE
RATE RATIO
All Types
395.5
424.6
–29.1
0.9
Colon/Rectum
56.1
44.7
11.4
1.3
Breast
118.0
134.0
–16.0
0.9
Lung/Bronchus
53.1
54.7
–1.4
1.0
Aging and Its Relationship to Cancer
Common Malignancies in Older Adults
Breast Cancer
Risk Factors
Treatment
Prostate Cancer
Risk Factors
Early Detection
Treatment
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