Regardless of when patients receive their diagnosis, their age impacts the next step
For Younger Patients
Younger patients often have to contend with unique challenges, such as coping skills, social concerns, behavioral issues, employment matters and treatment-related infertility. Doctors should discuss these issues, particularly fertility preservation options with all fertile patients—male or female—and, in the case of children, with their parents or guardians.
A single cancer treatment can decrease fertility, so it is essential that a patient’s doctor develop a fertility preservation plan before treatment begins, which may mean delaying treatment to accommodate fertility preservation methods, such as banking sperm or freezing fertilized eggs.
Prostate and testicular cancer therapies can affect sperm production, resulting in low sperm count or infertility. For men wanting to preserve fertility, banking sperm has been a successful technique for decades. If sperm count is low, a process called intracytoplasmic sperm injection requires only one sperm to fertilize an egg. Another technique, called testicular sperm aspiration—where sperm is taken directly from the testicle or from resected testicular tissue—is being tested in men with low sperm count.
For women, certain chemotherapy drugs and hormone treatments, as well as radiation to the pelvic area, can damage the ovaries and other reproductive organs and cause early menopause. Because women are born with a limited number of eggs, or oocytes, damaging them during cancer treatment can leave a woman infertile.
If treatment calls for radiation to the pelvis, the ovaries can be surgically moved away from the field of radiation, called oophoropexy, which reduces the risk of damage by 50 percent. Treatments that temporarily shut down ovarian function during chemotherapy are also being investigated as a means to prevent damage to eggs.
With in vitro fertilization (IVF), an egg is fertilized and frozen, or cryopreserved; it is later thawed and inserted into the uterus. IVF must be done before treatment and may require several weeks to retrieve viable eggs. Hormone injections may be given to promote egg development, but natural methods are also available.
While freezing unfertilized eggs is possible, the success rate is lower than freezing embryos. Once thawed, the egg is fertilized by intracytoplasmic sperm injection and inserted into the uterus. Although freezing unfertilized eggs is still considered experimental, better freezing and fertilization techniques are improving success rates. Researchers are also exploring ways to freeze testicular and ovarian tissue to be transplanted back into the patient after therapy.
Because many of these new fertility procedures are experimental, most are not covered by insurance, and the cost can be as high as $20,000. Even traditional IVF can cost around $10,000 or more. Depending on insurance coverage, some treatments may be provided, especially if they are part of a necessary medical procedure being performed anyway.
For Older Patients
For many common cancers, the development of a tumor takes considerable time, dependent upon a series of often unrelated events at the cellular level. Over the course of years, genetic and environmental toxins, such as tobacco, can cause DNA-damaging effects on cells. Meanwhile, the body’s ability to repair damaged cells appears to decline with advancing age. At the same time, the aging tissue around those damaged cells appears to play a role, creating a more conducive environment in which malignancies can grow. As cells age and stop dividing, it’s speculated that they develop a microenvironment that fosters cancer’s development. Another potential contributory factor, researchers say, is the declining immunity that naturally occurs with advancing age.
To complicate matters, many older people who receive a cancer diagnosis already suffer from at least one other illness, or comorbidity, such as heart disease, diabetes, hypertension or arthritis—some of which can be life-threatening.
Comorbid illness affects all aspects of cancer care, from early diagnosis to treatment options and prognosis. In fact, as cancer patients live longer than ever, comorbid illnesses have an even greater impact on long-term health.
A recent study showed that cancer patients with pre-existing illnesses were less likely to survive their cancer and were also at greater risk for recurrence. This was true for all types of cancer, but particularly for breast and prostate cancer, for which an overall survival rate of 50 percent in otherwise healthy individuals dwindles to 3 to 5 percent in those with severe comorbid illnesses.
To get appropriate and effective cancer treatment, each patient should be evaluated as a whole person, including any other health issues he or she may have. This “whole-patient” approach is important in part because cancer drugs often have side effects that exacerbate pre-existing medical conditions, and drug contraindications can create other problems.
For example, one proteasome inhibitor is effective at treating multiple myeloma and mantle cell lymphoma, but can also cause pain and numbness in the hands and feet—a condition known as neuropathy—that may be made worse in people with diabetes, who are prone to nerve damage.
Hormone therapy, such as aromatase inhibitors for breast cancer, may cause problems if patients have osteoporosis. Aromatase inhibitors block the production of estrogen, but since estrogen helps maintain healthy bones, blocking it can lead to a higher risk of developing osteoporosis.
Other cancer drugs, including monoclonal antibodies for HER2-positive breast cancer and anthracyclines for leukemia and some solid tumors, may exacerbate heart conditions, which are prevalent among older people. These drugs can injure the heart muscle, so patients must be monitored closely, and the dose of the drug may be limited according to heart function.
Side effects do not mean certain cancer drugs cannot be given if patients have another illness. Instead, their doctor may adjust the dosage of medication—both for the cancer and comorbidity—so they can receive the most effective cancer therapy.
Older cancer patients should not automatically receive less aggressive therapy than younger patients. Despite the prevalence of comorbid illness and the perception that older people are less likely to benefit from and cope with the stress of potent treatment, clinical trials have shown that older patients fare equally well in terms of overall survival and quality of life as their younger counterparts.
Every patient faces unique issues during and after treatment. In the past, oncologists focused primarily on treating the cancer, overlooking some issues related to the patient’s age. But now, doctors are increasingly concerned with the impact of treatment on a person’s future, including treatment-related long-term effects.