Question 1: What are the most common types of cancer diagnosed in people over age 65?
Dr. Muss: Cancer is a disease of aging and those cancers that are most common in younger patients are for the most part the most common in older patients. These include lung cancer, colorectal cancer, breast cancer, prostate cancer, lymphoma, and leukemia. It is not well appreciated but the average age of a person diagnosed with cancer in the United States is about 67 years old. Also, most people who die of cancer in the United States are older than 65.
Question 2: How long does a person need to continue cancer screening for colon and breast cancers?
Dr. Muss: There is no hard and fast rule as to when an older person should stop cancer screening. It is generally suggested that an older person in good health who has an estimated survival of longer than five years should continue in an active screening program. This includes screening for cervical cancer, colorectal cancer, prostate cancer, and breast cancer. There are differences of opinion among experts as to what constitutes appropriate screening. Details on screening from the American Cancer Society, one of the major groups involved in screening recommendations, can be obtained from their website.
Question 3: Do older people metabolize cancer drugs differently than younger people? I'm wondering if I need to talk to my father's doctor about adjusting the dose of his drugs for colon cancer.
Dr. Muss: As we get older, almost all our bodily organs decline in function. Even with this decline, however, older patients metabolize cancer drugs similar to younger patients, and with few exceptions dosage modifications are not necessary. Since kidney function decreases with age, drugs that are excreted by the kidneys may need lower dosing. The liver, which is the main route of metabolism of most drugs, has great reserve and rarely are dose changes needed when liver function is normal. Since older patients are more likely to be taking medications for other illnesses, one must always be on the lookout for adverse drug interactions. Much research is underway today to further explore if dose modifications are necessary for some of the newer cancer drugs.
Question 4: My 71-year-old father is being considered for radiation therapy for unresectable non-small cell lung cancer. Is this safe? What questions should we ask his doctor?
Dr. Muss: Radiation therapy is generally as well tolerated in older patients as in younger patients. Older patients, like younger patients, should ask their radiation oncologist to explain to them the side effects of radiation and what precautions should be taken to minimize these effects. In older patients given radiation concurrently with chemotherapy (for example, in cancer of the esophagus) side effects may be more common and patients should report any new symptoms to their health care team
Question 5: My aunt is 62 and may have early leukemia (we are still waiting for final lab results). I'm worried because she also had a lung infection (and is on steroids), shoulder pain, and currently takes beta blockers for her heart. Would any of these conditions interfere with possible treatment?
Dr. Muss: Your aunt at age 62 is still rather a young woman. What is important is the fact that she has other co-existing illnesses that might interfere with her treatment and which also might compromise her survival – even if she didn't have leukemia. These other diseases increase the chance of toxicity from her leukemia treatment and need to be factored in to your aunt's treatment program. However, since any acute leukemia can be a life threatening problem within a period of weeks to months if untreated, consideration of treatment should be given even with your aunt's other medical problems.
Question 6: My mother, 83, is in a nursing home about 200 miles away and was just diagnosed with breast cancer. The nursing home's staff doctor said he's able to manage her treatment, but I feel uneasy. Shouldn't she be seeing a specialist? And is it ok to ask for a second opinion?
Dr. Muss: I would recommend that your 83-year-old mother see a cancer specialist, provided she is not critically ill with another disease. I would assume that she has already been seen by a surgeon, but she should also be seen by a medical oncologist and a radiation oncologist. These cancer specialists can work with her nursing home staff doctor to give your mother the best available treatment options. It is always perfectly reasonable to ask for a second opinion. Most physicians shouldn't be threatened by such a request and in most instances almost all physicians are happy to arrange for such a consultation.
Question 7: I will soon be starting chemotherapy and expect to lose my hair. I am most concerned about how my grandchildren (ages 5 and 7) will react to that. Is there anything we can do to prepare them?
Dr. Muss: Communicating and caring for children and grandchildren while dealing with cancer treatment is always a challenge. Nevertheless, studies show that being honest with your grandchildren and discussing your treatment and its anticipated and possible side effects is almost always the best policy. There are books, videos and other communication tools that can help teach families how to communicate with children concerning a cancer diagnosis. See the Cancer.Net, American Cancer Society, and National Cancer Institute websites for helpful information. Moreover, many supportive care personnel, including social workers and psychologists, are trained to help work with families in addressing cancer-related issues. It is surprising how well children usually understand the concepts related to cancer and its treatment and how supportive children can be of parents and grandparents.
Question 8: How much authority does a living will have? My wife and I have different opinions about end-of-life care, and I'd like my wishes for me carried through.
Dr. Muss: All individuals irrespective of age should complete a series of documents that provide for their medical care should they become ill. A living will can be very helpful, but almost never can address all the issues that might occur during one’s battle with cancer. A mentally competent patient has the legal right to make his or her decisions concerning how he or she would wish to be treated. Sometimes spouses, children, close friends and relatives may have opinions different from your own concerning how they would wish to be treated were they in your place – but they are usually not in your place and your wishes are the ones your physicians and other healthcare providers are legally bound to follow. It is best to discuss your wishes in detail with your family and your physicians. Other health care personnel including psychologists and social workers might also be helpful is resolving such differences.
In addition to your living will, all persons should have a durable health care power of attorney. This health care power of attorney gives someone that the you choose the legal right to make decisions concerning end-of-life care should you not be in the position to do so. Although a spouse is frequently the one that is delegated for this task, other close family members, close friends, and even one's attorney may be asked to perform this task. It is important that whoever is assigned to carry out your health care wishes be someone who is clearly and fully informed concerning your views and someone you trust to carry out your wishes should you not be able to make your own decisions.
Question 9: I heard a story on the news about whether more aggressive cancer treatment really helps after a certain age – what is the current thinking on this?
Dr. Muss: For many but not all cancers, older patients derive similar benefits from treatment as younger patients. However, cancer treatment for certain malignancies, such as acute leukemia and ovarian cancer, may not be as effective in older patients as in younger patients. A key issue is whether the older person with cancer is in otherwise good general health. Frequently older patients may have other serious diseases in addition to their cancer. When this is the case, these diseases may increase the risk of side effects and may also minimize the effects of treatment, as these other diseases may even be more life threatening than the patient's cancer. A careful discussion of treatment risks and benefits, especially in an older person who has other serious illnesses, should always factor in co-existing illness and the patient's estimated life expectancy.
Question 10: There are so many decisions to make about my treatment and financial concerns, I often feel overwhelmed. I live alone and my children live far away, and I don't want to call them every day. Where can I find some help?
Dr. Muss: Many patients faced with a diagnosis of cancer feel overwhelmed. This can be a bigger problem in older patients who live alone and have limited resources to help them get to medical appointments, and who need some help with day-to-day care to maintain the normal activities of daily living. Older patients faced with such problems should talk with their physician and request a consultation with a social worker or other support personnel. Social support personnel including social workers and nurses are usually aware of multiple resources in the community that can help patients with limited resources. Resources can also be found on the following websites: Cancer.Net, American Cancer Society, National Cancer Institute, and the National Institute on Aging.
Question 11: I am a 58-year old, non-smoking female and was diagnosed with stage 4 non-small cell lung cancer. I underwent six cycles of taxotere/carboplatin in combination with Tarceva and am presently still taking Tarceva. I had few side effects during my chemotherapy treatment but have recently developed polymyalgia rheumatica. Could this be a result of any of my chemotherapy treatments?
Dr. Muss: I doubt it. I searched to see if there was any association of chemotherapy and polymyalgia but could find none. Polymyalgia rheumatica is a common problem as is lung cancer so having both these problems is most likely coincidental.
Question 12: My 77 year-old husband had lymphoma and colon cancer surgeries within the last few years and his recent blood tests show increasing signs of cancer while his PET/CT scans do not show any signs of cancer. In addition, he has put on a good deal of weight and has lost some of his energy even though he exercises regularly. My husband's primary physician and oncologist cannot figure out what is causing these recent changes. Do you have any ideas?
Dr. Muss: Sometimes blood tests can suggest a relapse of cancer before any other signs, symptoms, or scan show evidence of recurrence. I am uncertain as to what tests are elevated in your husband but careful follow-up and repetition of the blood tests and scans is indicated. Sometimes blood tests may be elevated for reasons other than cancer, so repeating them is important.
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