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ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 22-27

Sociodemographic and clinicopathologic characteristics of 249 elderly cancer patients seen at the Radiotherapy and Oncology Department, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria


1 Department of Radiotherapy and Oncology, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna State, Nigeria
2 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna State, Nigeria
3 Department of Pathology, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna State, Nigeria
4 Department of Chemical Pathology, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna State, Nigeria
5 Department of Nursing Services, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Kaduna State, Nigeria
6 Department of Radiotherapy, National Hospital, Abuja, Nigeria

Date of Web Publication28-Jul-2016

Correspondence Address:
Prof. Sunday Adeyemi Adewuyi
Department of Radiotherapy and Oncology, Ahmadu Bello University Teaching Hospital (ABUTH), PMB. 06, Shika, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.187194

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  Abstract 

Background: The rate of cancer incidence is expected to rise in the ageing population. The objective of this study is to evaluate the sociodemographic and clinicopathologic characteristics of elderly cancer patients as there is a paucity of data in this environment.
Patients and Methods: Elderly cancer patients seen between 2006 and 2009 were studied retrospectively. The patient's folders were reviewed for relevant clinical information using standardized structured pro forma. Data were analyzed and results were presented in a table.
Results: A total of 249 patients were analyzed (mean age 67 years, M:F = 2:3). There is no formal education in 70.7% of the patients. Only 20.5% of the patients had history of alcohol ingestion and 14.1% smoke cigarette. Ten (4%) patients had family history of cancer and 1.2% was seropositive for HIV antibodies. The most common cancer in males was head and neck cancer (14.1%) followed by prostate cancer (10%). In the females, the most common cancer was cervical cancer (31.3%) followed by breast cancer (12.4%). Only 8.4% of the patients presented with early stage disease. Hypertension was the most common comorbidity seen in 35.3% of the patients followed by diabetes mellitus (7.6%). The surgery was done in 36.9% of the patients, while 63.5% of the patients had diverse chemotherapy and 42.2% had radiotherapy. Chemotherapy-induced morbidity and mortality were seen in 36.9% and 26.9% of the patients, respectively. Similarly, radiotherapy-induced morbidity and mortality were seen in 8.8% and 0.4% of the patients, respectively.
Conclusion: More female elderly patients are seen. Cervical cancer and head and neck cancers are the most common cancers seen in elderly female and male patients, respectively. Most patients presented with advanced disease, and hypertension is the most common comorbidity. There should be a cautious use of chemotherapy in order to reduce mortality.

Keywords: Clinicopathologic characteristics, elderly cancer patients, pattern of cancers, sociodemographic


How to cite this article:
Adewuyi SA, Oguntayo AO, Samaila MO, Akuyam SA, Adewuyi KR, Igbinoba F. Sociodemographic and clinicopathologic characteristics of 249 elderly cancer patients seen at the Radiotherapy and Oncology Department, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Arch Int Surg 2016;6:22-7

How to cite this URL:
Adewuyi SA, Oguntayo AO, Samaila MO, Akuyam SA, Adewuyi KR, Igbinoba F. Sociodemographic and clinicopathologic characteristics of 249 elderly cancer patients seen at the Radiotherapy and Oncology Department, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Arch Int Surg [serial online] 2016 [cited 2020 Feb 29];6:22-7. Available from: http://www.archintsurg.org/text.asp?2016/6/1/22/187194




  Introduction Top


The traditional African definition of an elderly person correlates with the chronological ages between 50 years and 65 years.[1] While the most developed countries accepted 65 years as a definition of an elderly person, the United Nations agreed on a cutoff of 60 years.[2],[3] The progressive aging of the population is an epidemiologic hallmark of our times; elderly people represented 12% of the population in 1990 and is expected to grow to 20% in 2030.[4] Similarly, in the developed world, 60% of all malignancies occur in elderly persons and this is expected to rise to 70% by the year 2030.[4],[5]

The incidence of some cancers has increased with age, suggesting enhanced carcinogenesis and susceptibility than younger ones to new environmental carcinogens.[4],[5] The association of cancer and age may be explained by three mechanisms that are not mutually exclusive. Carcinogenesis is a time-consuming process and is more likely to develop at an advanced age. Similarly, aging is associated with molecular changes that mimic carcinogenesis and environmental phenomena such as immune senescence or proliferative senescence that favor the onset of cancer.[4],[5],[6]

The biology of cancers may change with age. In some cases, the tumor may become indolent, whereas in others it becomes more aggressive.[7] The peculiarity of elderly cancer patients includes guided tolerance of the various treatment options, increased comorbidities, and a progressive reduction in the functional reserve of multiple organ systems that influences the outcome of the treatment.[3],[8],[9] The mechanisms may include increased prevalence of chronic diseases; progressive accumulation of catabolic cytokines; and reduction in the stem cell reserve of different tissues.[8],[9] From the standpoint of cancer treatment, the most significant changes include gastrointestinal, renal, hepatic, hematopoietic, and mucosal changes, which may alter the pharmacokinetics of antineoplastic agents and may increase the risk of complications from cancer treatment.[5] Old age is not contraindication to aggressive treatment with chemotherapy but needs adequate optimization and supportive treatment. Tolerance for radiation therapy seems to remain high, even for individuals aged 80 years and older due to its being a localized treatment.[10] The evaluation of the risks and benefits should play significant role in making management decision especially regarding chemotherapy.

To reduce morbidity and mortality, all elderly patients must be adequately evaluated; the assessment related to old age is done because personal and social resources to cope with stress and old age may become more limited especially in this environment. A comprehensive geriatric assessment (CGA) in a multidisciplinary setup, which evaluates the patient's function, comorbidity, cognition, nutrition, medications, and living resources, is a reliable instrument for predicting life expectancy and the risk of treatment-related complications, and it may unveil preexisting conditions such as undiagnosed disease, poor nutrition, depression, or lack of adequate social support that are remediable and may influence the outcome of treatment and reduce morbidity and mortality.[11],[12]

Currently, there is a paucity of data on the pattern of cancer in the elderly in this environment. This study will bring to the fore the peculiarities and contribute to the process of establishing treatment protocol and optimal care for this group of patients in this environment. The aim of this study was to evaluate the sociodemographic and clinicopathologic characteristics of cancer in the elderly population as a reference for further study.


  Patients and Methods Top


This study was conducted retrospectively at the Radiotherapy and Oncology Department, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. Between January 2006 and December 2012, elderly cancer patients with histologically confirmed malignancies referred to the unit for further management were analyzed. The biodata and all relevant clinical information were obtained from the patients' folder. For the purpose of this study, the stage of disease was considered “early stage,” if there is no extension into adjacent structures or regional lymph node involvement; “locally advanced,” if there is involvement of adjacent structures, regional lymph node involvement, inoperable, or bilateral; and “metastatic,” if there is evidence of distant metastasis.[13] Similarly, the elderly cancer patients are defined as any patient who is at least 60 years old having cancer.[2],[3] The patients in this study included those referred from other clinical departments within the hospital and those referred from other teaching and specialist hospitals within and outside the geopolitical zone. Data were collected using a structured pro forma, and information retrieved included age, sex, educational status, social habits, duration of symptoms, HIV status, comorbidity, site of cancer, histology, stage of disease, treatment received, and treatment-induced morbidity and mortality. Data were analyzed using Epi Info software version 3.4.1 (2007 edition) and the results are presented in a simple table.


  Results Top


A total of 249 (19.5%) elderly cancer patients of 1,277 new patients seen during the study period were analyzed with the mean age of 67 years (range: 60-90 years, median age was 65 years). The sex ratio was M:F = 1:1.5. All the patients presented with an attending caregiver. There is no formal education in 176 (70.7%) patients and only 73 (29.3%) had formal education. Only 51 (20.5%) patients had history of alcohol ingestion and 35 (14.1%) patients smoke cigarette in the past. Only 10 (4%) patients had family history of cancer. The duration of symptoms at presentation ranges from 1 months to 120 months with a mean of 14.7 months (median 9 months). Three (1.2%) patients were seropositive for HIV antibodies and 230 (92.4%) patients were negative, and the screening was not done in 16 (6.4%) patients. The most common malignancy in the elderly male patients was head and neck cancers (14.1%) followed by prostate cancer (10%) and gastrointestinal cancers (3.2%) [Table 1]. In the females, the most common malignancy was cervical cancer (31.7%), followed by breast cancer (12.4%) and head and neck cancers (6.8%). Only 21 (8.4%) patients presented with early stage disease, 123 (49.4%) patients presented with locally advanced disease, and 105 (42.2%) patients with metastatic disease. The aim of the treatment was curative in 133 (53%) patients and palliation in 116 (47%) patients. Hypertension was the most common comorbidity in the elderly cancer patients (35.3%) followed by diabetes mellitus (7.6%). No recognizable comorbidity was seen in 154 (61.8%) patients. The surgery was done in 92 (37%) patients, while 158 (63.5%) patients had diverse chemotherapy, 105 (42%) patients had radiotherapy, 45 (18%) patients had diverse hormonal therapy, and no definitive treatment was given to 43 (17.3%) patients. Chemotherapy-induced morbidity and mortality were seen in 92 (37%) and 67 (27%) patients, respectively. Only 72 (29%) patients developed grade 3 or 4 toxicities. Similarly, radiotherapy-induced morbidity and mortality were seen in 22 (8.8%) and 1 (0.4%) patients, respectively. Only 89 (56.3%) of 158 patients completed 6 cycles of chemotherapy and 29 (18.4%) patients received none. Similarly, 93 out of 105 patients completed prescribed dose of radiotherapy.
Table 1: Types of tumor according to sex

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  Discussion Top


The risk of cancer increases with age, and with aging population, the number of older adults being diagnosed with cancer and seeking treatment is increasing dramatically.[4],[5] The clinicopathologic characteristics of the elderly cancer patients differ from that of the younger adults because of the differences in tumor biology, age-related host physiology, comorbidity, and psychosocial issues, which might impact the disease presentation and cancer therapy.[3],[5],[6]

The result of this study revealed that elderly cancer patients accounted for 19.5% of the total number of cancer patients seen in the unit. This is grossly short of the findings in the literature where the majority of cancer patients are elderly.[13],[14] This may be due to the fact that many are treated in other departments and are not referred or patient does not require radiotherapy and chemotherapy. Similarly, this may reflect already established facts in the study environment that includes poor utilization of health-care services, apathy for orthodox treatments, preference for herbal and faith treatments, and widespread refusal of treatment.[15],[16] Also, many patients attend peripheral hospitals where histological confirmation cannot be made due to deficient diagnostic facilities. The sex distribution of the patients shows a dominance of female patients. This is different from the results from the developed countries where the number of males was more than females.[13] The reason may be due to differences in lifestyles, socioeconomic factors, and the pattern of malignancies seen in the developed countries where cervical cancer is very low due to effective screening programs.

Formal education is not common as majority (71%) of the patients have Islamic education. Uptake of Western education is very low in the study environment. In view of low educational status, the presence of an enlightened caregiver becomes very important in caring for the elderly.[17] In this study, all patients have people living with them either as immediate family members or distant relatives.

Alcohol ingestion and cigarette smoking are not common as 80% and 86% of the patients had no history of ingestion of alcohol or cigarette smoking, respectively. Only 10 (4%) patients have family history of cancers affecting close family members. This may be influenced by religious believe, dislike for postmortem, and high rate of illiteracy in the study population.[15]

Unlike the result of another study on gynecological malignancies,[15] the proportion of patients that are seropositive for human immunodeficiency virus (HIV) is very low in the elderly population. Only three patients tested positive for HIV antibodies. This may be related to low sexual activity in elderly cancer patients.

The commonest malignancies seen in elderly male and female patients shows similarities with data from other developing countries.[14] Among the male patients, head and neck cancers is the most common cancer, followed by prostate cancers. Among the female patients, cervical cancer is the most common cancer followed by breast cancer [Table 1]. In the United States and Europe, prostate and breast cancers are the most common malignancies in both males and females. Cervical cancer is very common in the study environment due to poor uptake of screening programs, early age at sexual intercourse, low socioeconomic status, and multiple sexual partners.[14],[15],[16]

Majority of the patients presented with locally advanced and metastatic disease that is the norm in the study environment and this is not peculiar to elderly patients alone.[15],[16] This is due to low uptake of screening program and late presentation. The average duration of symptoms prior to presentation was 15 months, which is late and may reduce the chances of curative treatment. Considering the stage of the disease at presentation (early and locally advanced stages), the aim of the treatment was curative in half of the patients. This may be a measure of degree of indolence of the disease. Significant proportion of the patients (47%) received palliative care. Supportive treatment was given using infusions, analgesics, and blood transfusion as the need arises in 17% of the patients. A total of 101 patients with hemoglobin level of less than 10 g/dL had blood transfusion due to anaemia in the course of treatment. The prevailing poverty could not allow the routine use of prophylactic granulocyte colony stimulating factor. Anemia is among the confounding factors because its incidence and prevalence increase with age and it is an independent risk factor for death, for functional dependence, and for myelosuppression from cytotoxic chemotherapy.[18],[19]

The presence of comorbidity is a common situation in the elderly patients, making them prone to a lot of medical and social problems that can affect the pattern of presentation, stage of disease, and the response to treatment.[19] The most common comorbidity was hypertension, which was seen in one-third of the patients, followed by diabetes mellitus. Majority of the patients have no established comorbidity. Comorbidity, a major cause of polypharmacy, is an independent cause of mortality for elderly cancer patients and is associated with reduced tolerance of treatment.[5],[19] This necessitates the need for a multidisciplinary team in view of many comorbidities and age-related syndromes as age alone is not a contraindication to effective cancer treatment.

Diverse treatment modalities were used in the management of these patients. Most patients received cyclical chemotherapy followed by radiotherapy. Highest mortality, abandonment, and noncompletion of treatment were seen in the patients who received cyclical chemotherapy. It was less in the patients receiving radiotherapy. The mortality relating to surgery was not known as patients were mostly referred to the oncology department after surgery. Modern and recent advances in surgery and anesthetic agents has made surgery in elderly patients safe.[20] The mortality resulting from radiotherapy was very low as only one patient died amongst 22 patients who developed significant side effects. Two large patient series from Europe and one from the United States attest to the feasibility and safety of radiation therapy in patients of all ages with minimal risk of complications.[21],[22] In the chemotherapy arm, mortality was one in every four elderly cancer patients. This is very high and efforts are ongoing to minimize aggression with chemotherapy and to reduce the mortality. The poor tolerance of chemotherapy in the elderly cancer patients is associated with declining organ function with resultant changes in the pharmacokinetics and pharmacodynamics of cytotoxic drugs and increased susceptibility of certain organ systems to therapeutic complications.[23] Oral drugs are particularly appropriate for older patients because of the convenience of administration and adjustability of doses.[24],[25],[26] Neutropenic infection is potentially fatal that may occur after the first course of treatment, a fact that prompted the recommendations to use growth factors prophylactically in patients aged 65 years and above. Hormonal treatment when indicated is considered much safer and well tolerated compared to chemotherapy and poses little threat to life even in the very old patients.[27]

Chemotherapy is indicated if patient has a chemotherapy-responsive disease that may shorten her survival. The National Cancer Center Network (NCCN) guidelines for the management of older cancer patients with chemotherapy advise dose adjustment according to individual glomerular filtration rate (GFR), for patients aged 65 years and older, prophylactic use of granulocyte colony stimulating factors (filgrastim or pegfilgrastim) and maintenance of hemoglobin level of 12 g/dL or greater.[26] These are not readily feasible in most of the patients in our environment and may account for the high morbidity and mortality in patients receiving chemotherapy. The authors recommend the use of chemotherapy, which is less toxic but more effective, for the elderly patients and need for adequate supportive treatment using infusions, analgesics, blood transfusion as the need arises within the available resources.

A major limitation of this study is that CGA involving a psychiatrist and psychologist was not done. A prospective study to analyze the psychosocial challenges of cancer patients is underway to overcome this shortcoming.


  Conclusion Top


Cancer is commoner in elderly female than male patients. Cervical cancer is the most common cancer in females while head and neck cancer is the most common cancer in males. Most patients presented with locally advanced and metastatic disease, and hypertension is the most common comorbidity seen. There should be a cautious use of chemotherapy in the elderly patients in view of high chemotherapy-induced mortality.

Acknowledgment

We wish to acknowledge all the staff of Health Information Management in Oncology Department for their assistance in retrieving the patients' folders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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