Older People: Wisely Navigating Safe and Effective Integrative Cancer Care

Remember the saying: “You’re not getting older. You’re getting better”? We are finally moving past our death- and age-denying mentality to embracing the possibilities of health and vitality into our elder years. We are getting older, as individuals and as a population, so best not to deny that truth. However, with healthy lifestyles and shifts in attitudes about aging, many of us stand to be vibrant and engaged in life for most of our senior years.

If you are older and are diagnosed with cancer, it may be counterproductive to languish too long in the “I’m too old to . . .“ (you fill in the blank with your favorite aging stereotype). Though there are some important considerations and adaptations, cancer treatment doesn’t have to be sub-optimal just because you are “old.”

Three issues often come up for older people and affect their decisions about cancer treatment:

1. Having age-related physical changes, pre-existing conditions and treatments that could negatively affect your ability to safely and/or comfortably take conventionalthe cancer care offered by conventionally trained physicians and most hospitals; examples are chemotherapy, surgery, and radiotherapy and/or complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocialtherapy, and acupuncture treatments. 
2. Being categorically labelled as a “poor candidate” for conventional treatment simply on the basis of older age. 
3. Being pushed (or feeling pushed) by loved ones and perhaps the medical community to take or to soldier on with aggressive treatments that have little chance for benefiting you and great chance of harming you. 

Looking at all these issues through the lens of an integrativein cancer care, a patient-centered approach combining the best of conventional care, self care and evidence-informed complementary care in an integrated plan approach to cancer care may be useful.

The case for healthy living 

By far, cancer is more common in older people. New ACS/NCI statistics say nearly two-thirds of all those with cancer are 65 years or older.¹Miller KD, Nogueira L et al. Cancer treatment and survivorship statistics, 2019. CA: A Cancer Journal for Clinicians. 2019 Jun 11. As we age, our immune systems don’t do their job of scouting and killing cancer cells like they used to. Plus we’ve had more years to be exposed to conditions that help cancer develop and thrive. On the flip side, we’ve had years to become wise as well as become conscious of what makes us healthy and what gives our lives meaning. 

Many cancers are related to longstanding unhealthy lifestyle practices and exposures—so there’s good reason to do what you can to reduce these exposures and adopt a healthier lifestyle.

A pill for every ill 

At least, that’s what the drug infomercials on TV promise. Let’s step back and look at the bigger picture here. 

Polypharmacy 

Because chronic diseases are far more common in older people, there is a preponderance of what we call polypharmacythe simultaneous use of multiple drugs to treat a single ailment or condition (using a lot of drugs). And many older people have multiple chronic illnesses (called co-morbid conditions in “medicalese”). It’s not uncommon to see older people on nine or more drugs at any one time. Chronic illness as well as age-related declines in kidney and liver function put older people at greater risk for serious side effects from the drugs themselves and also from drug interactions. If you see multiple doctors without one running the show and monitoring this polypharmacy, the risk of problems is even greater.²Maggiore RJ, Gross CP, Hurria A. Polypharmacy in older adults with cancer. Oncologist. 2010;15(5):507-22.

Big users of supplements

Compared to other age groups, older people tend to take the most nutritional herbs and supplements for disease prevention or to address health problems. The ease with which we can obtain supplements, the lack of regulation, and robust advertising contribute to a perfect storm for overuse. Some supplements can harm the liver or kidneys or otherwise interact with drugs, thereby increasing the chance of drug side effects or blocking the effects of drugs, including chemotherapy.³Berretta M, Di Francia R. Use of complementary and alternative medicine by elderly cancer patients and risk of drug-drug interactions. Arguments of Geriatric Oncology. 2019;4(1):17-19; Buckner CA, Lafrenie RM, Dénommée JA, Caswell JM, Want DA. Complementary and alternative medicine use in patients before and after a cancer diagnosis. Current Oncology (Toronto, Ontario), 2018 Aug;25(4):e275-e281.

Some supplements might even worsen whatever condition they were intended to help. For example, some supplements that people take because they think it will prevent cancer can actually increase cancer risk.⁴Martínez ME, Jacobs ET, Baron JA, Marshall JR, Byers T. Dietary supplements and cancer prevention: balancing potential benefits against proven harms. Journal of the National Cancer Institute. 2012 May 16;104(10):732-9. At the very least, people could wind up wasting their money taking supplements that may not help.⁵NCI Staff. Vitamin D Supplements Don’t Reduce Cancer Incidence, Trial Shows. Cancer Currents Blog. December 13, 2018. Viewed May 5, 2023.

Complementary therapies may help

On the other hand, some complementary therapies—including herbs, supplements and off-label drugs—may be useful in enhancing your cancer treatment, reducing side effects, improving your quality of life and/or reducing the risk of recurrence. These therapies could possibly mean the difference between continuing to take your conventional treatment or stopping it because of harmful side effects. They may help improve your comfort, the quality of your life, and in some cases even help treat the cancer.

While your oncologist may or may not be knowledgeable or experienced in weaving complementary therapies into your treatment, reputable doctors and practitioners can work with your oncologist to tailor complementary therapies to your needs.

Prehab benefits

“Trimodal prehabilitation”—exercise, nutritional and psychological interventions before surgery—can improve treatment outcomes. In a small pooled analysis, researchers found that patients who participated in a month of prehabilitationimproving the functional capability of a patient prior to a surgical procedure or other medical treatment before colorectal cancer surgery had a significantly higher disease-free survival than those not undergoing prehab. The researchers also point out that frail elderly who do not participate in prehab programs tend to have reduced ability to take care of themselves that can last up to 22 months.⁶Trépanier M, Minnella EM et al. Improved disease-free survival after prehabilitation for colorectal cancer surgery. Annals of Surgery. 2019 Sep;270(3):493-501.

Deciding on treatment options

Choosing more aggressive treatments

In some circumstances, older people have been steered away from taking certain conventional treatments for cancer by virtue of their chronological age. The concern is that the treatment will more likely be harmful, or the older person will not likely tolerate the full dose and/or course of treatment. The research and conventional wisdom is now shifting, as we recognize that a person’s functional and general health status, not age, is better at predicting risks for serious complications and/or intolerance of a treatment regimen. For example, “older women with breast cancer who are in good health tolerate chemotherapy about as well as younger patients.”⁷Muss HB, Berry DA et al. Adjuvant chemotherapy in older women with early-stage breast cancer. New England Journal of Medicine. 2009 May 14;360(20):2055-65. Another study found immunotherapy to be well-tolerated by and more effective in older people with melanoma than younger patients.⁸Perier-Muzet M, Gatt E et al. Association of immunotherapy with overall survival in elderly patients with melanoma. JAMA Dermatology. 2018 Jan 1;154(1):82-87.

Underrepresentation in clinical trials

Though cancer is most prevalent in older people, this group is greatly underrepresented in clinical trials of conventional treatment or complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocialtherapy, and acupuncture therapies.⁹Gubar S. The need for clinical trial navigators. New York Times. June 20, 2019. Viewed June 27, 2019. That means many miss out on a potentially helpful treatment. It also means that when the treatment is evaluated and approved for use, people who are older are not factored into the outcome data. This could have serious implications for dosing and safety.

Reasons for this underrepresentation include that participation criteria may be overly restrictive, patients may fear side effects or be turned off by the burden of travel to participate in a trial, doctors often don’t guide their patients to trials, and “other qualms” based on “persistent delusions. Quite a few people miss out on free, cutting-edge treatment because of spurious suppositions. [Yet] The commonly held view that patients will be given nothing but a placebo is rarely the case.”¹⁰Gubar S. The need for clinical trial navigators. New York Times. June 20, 2019. Viewed June 27, 2019.

If you are considering a clinical trial, clearly understand the purpose of the clinical trial and the details of participating. The trial’s purpose needs to align with your treatment goals. Is your goal to take an experimental treatment that has a chance of benefiting you directly? Or is your goal to benefit future patients by participating in an early stage trial, regardless of the likelihood of its helping you? Some clinical trials study palliativerelieving pain or suffering without dealing with the cause of the condition therapies. These types of therapies might help to manage symptoms such as pain or otherwise improve your quality of life.

When age and wisdom say to forego aggressive treatment

We commonly hear of older people saying that their loved ones are “pushing” them to “do everything” to stop the cancer, including taking very aggressive chemotherapy that seems likely to do more harm than good. Or they are urged to try every alternativein cancer care, alternative practices or therapies such as diets or acupuncture are used instead of conventional treatments such as chemotherapy, surgery, or radiotherapy; if a therapy is used with conventional treatments, it is considered complementary and not alternative therapy that shows up in an internet search or suggested by a well-intentioned friend or family member. We also hear of physicians having a hard time saying there are no more good anticancer treatment options and continuing to prescribe unhelpful and sometimes harmful treatments. Of course, the best of intentions and love often underlie these urgings to leave no stone unturned.

The take-aways

• Recognize that though you can’t stop the passage of time, you can influence your health as you age.
• Take a look at unhealthy exposures and lifestyles that are undermining your health.
• Explore healing practices that will keep you from getting sick or may improve your health if you do get sick.
• If you take multiple drugs, have your doctor or pharmacist evaluate what you’re taking and look for red flags like contraindicationsa symptom, condition or other factor that makes a particular treatment or procedure inadvisable; for example, some complementary therapies are contraindicated during pregnancy or with other drugs, such as diabetes medications or drug-drug or drug-supplement interactions.
• In general, do not take supplements for cancer prevention. When possible, try to meet your nutritional needs through diet.¹¹Cancer Prevention Recommendations. American Institute for Cancer Research. Viewed June 27, 2019.
• If you are thinking about taking natural products such as nutritional supplements or herbs, consult your doctor or a registered oncology dietician. If possible, seek guidance from a licensed professional with expertise in prescribing natural products.
• When discussing your cancer treatment plan with your doctor, ask if he/she intends to offer you the standard treatment at standard doses. If you are being offered “less aggressive” treatment than the standard, ask why. If you are older, but are in good health otherwise, ask your doctor why he/she is not recommending standard treatment.
• If you take conventionalthe cancer care offered by conventionally trained physicians and most hospitals; examples are chemotherapy, surgery, and radiotherapy treatment, consider integrating complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocial therapies, and acupuncture approaches to enhance the treatment, reduce side effects, and improve your quality of life.
• If you are older and have a cancer for which there is no safe, effective standard treatment, you might consider enrolling in a clinical trial. Even if safe, effective standard treatment is available, you may want to look into participating in a clinical trial of a promising conventional or complementary therapy that is likely to enhance the effects or manage the side effects of your standard treatment or improve the quality of your life.
• If choosing standard treatment is counter to your values, goals and intention to explore what matters most to you now, have a conversation with your doctor and your loved ones. You can find help with these conversations and with expert comfort care through palliative/supportive care services.

Don’t let myths, misconceptions and misinformation about aging and cancer prevent you from receiving the best integrative cancer care for you, whether your include or forego aggressive treatment. You are getting older and hopefully wiser as you explore your options for going beyond conventional cancer therapies.

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