It is well known that there is a demographic transition all over the world. The most important explanation to this is the change from previously large groups of children in a family to now commonly only one or two children in most countries. This decrease in birth giving together with improved longevity means that most countries have some very large cohorts of people born during or right after the Second World War now reaching the age of retirement and the period thereafter. That means that large groups of people have already, or will soon reach the age where chronic diseases including cancer, and later in the aging process, functional decline develops. Integrating the knowledge from geriatrics and oncology is needed in order to provide high quality care and treatment in these last phases of life.
The transition towards an older population is often regarded as a threat and a challenge for societies whilst in fact it is a story of success. The mortality among newborns has decreased substantially and the longevity and the survival rate improved for most severe diseases. Most people can foresee to still live a long period after retirement. However, the older they get the more vulnerable they will be. This long period, is marked by phases in which the life condition differs significantly. Thus getting cancer may take on a different meaning depending on when in the aging process it develops. The phases are marked by a period after retirement when most of the older people are healthy, mobile and live an active life with a high quality of life.1 Their expectations may be to now take the opportunity and do all those things people have not had the time or opportunity to do earlier on. The expectation would be to remain healthy as long as possible. During the next phase diseases slowly occur, mainly chronic diseases, of which cancer is one. Also health complaints of various kinds develop: chronic pain, communication difficulties, mobility restrictions and so on. Quality of life can still be very good but the fact that life is not endless is coming closer. In longitudinal studies a paradox can be seen in that during this process from retirement to death the number of diseases increases significantly and so does medical treatment. However, mobility, working ability and quality of life was found to improve.2 Thus the picture is mixed, seemingly life is better but costs in terms of health care and medical treatment are higher. The phase meaning a true blow to quality of life is when the person becomes increasingly dependent on others due to limitations in functional ability and health complaints and this is the time when it becomes obvious that life is moving towards its end.3 When at this stage, the person in most cases is suffering from several diseases, complex treatments and the reserve capacity to handle mental and physiological challenges is restricted.
In essence this means that the aging process means a continuous transition and getting cancer may take on a very different meaning depending on when in this process it develops. Thus providing cancer treatment means entering into different and very complex health situations. It has been reported that those around 75–80 years old had a significantly poorer quality of life compared to other age groups with cancer indicating that the existential blow may be harder in a stage were people still hope for a healthy and active life.4 Also developing cancer after the age of 65 meant a sudden awareness of the finiteness of life, painful insights into losses but also awareness of possibilities.5 Similar findings reported cancer in old age as a turning point marking old age, losing control, disturbed family balance and life and death suddenly becoming apparent, and at the same time hope and enjoyment of life becomes vital.6 Haug et al. reported the need for maintaining the activities of a normal daily life. It was also reported to be important to name and handle decline and loss as well as finding a space for existential meaning making.7 In addition the older the person is the more fragile and thus more sensitive to challenging cancer treatment. In summary this means that care and treatment should take into account that the person diagnosed with cancer is a physically fragile person in an existential crisis. The cancer experience will take on a different meaning depending on other complaints related to health per se, other diseases and treatment related to the cancer and the aging process.
Handling cancer in old age is a health care situation in which geriatrics and oncology should go together and merge each other’s expertise in clinical practice and it should be adapted to where in the aging process the person is. In particular, there are two developments in geriatrics that may be useful in oncology for older people throughout the process of diagnosis, treatment and aftercare. These two developments are applying a comprehensive geriatric assessment (CGA) that in turn informs the care and treatment plan,8 and the organizing of care in a case management (CM) model modified to suit the person depending on where s/he is in the process of disease and treatment.