FACET - European Journal of Cancer Care

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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
Perspective BAILEY, C.1 CORNER, J.
Slide One
Notes

• Older people and cancer the demographic picture
• In Western societies the number of older people
  is growing, and older age groups represent an
  increasing proportion of the population.
• Cancer disproportionately affects those aged 65
  and over, so the number of older people diagnosed
  with cancer is expected to rise in the future.
• Older people have been described as bearing the
  brunt of the cancer burden.

Demographic and epidemiological arguments
pointing out the potential consequences of a rise
in the number and proportion of older people in
our society have been well publicised. However,
some writers have questioned the way in which
older people have been represented. Victor (1994)
argues that the increase in the number of older
people in the UK is relatively modest, and that
the numerical size of the increase does not seem
to merit the panic aroused in those responsible
for health and social policies (p.90). Perhaps
our beliefs about older people have given us a
distorted view of the future. One article, for
example, asks whether the elderly are an
oncologic time bomb (Anon, 1991). How many of
our views involve such damaging classifications?
Do we think of increasing age as a source of
fundamental difference that sets us apart from
our fellow citizens? What might the consequences
be for caring practice?
Slide Two
Notes

• Old age and science
• The characteristics of old age may not seem to be
  in question, because we often think of them as
  having been scientific discoveries.
• For the purposes of research and academic study
  in health care, terms like old and the
  elderly are often given objective reference
  points.

It is common to see elderly defined as 65 years
and older, and to find categories like
young-old (65-74 years), middle-old (75-84
years), and old-old (85 years and
over). However, the chronological age used to
define old age is largely arbitrary and varies
culturally and historically (Victor,
1999). Definitions and categories of old age
could be thought of as part of a specifically
statistical or demographic way of looking at
things. It is sometimes argued that this
viewpoint is constructed or ideological. It
serves to make a scientific or objective point of
view possible, but may obscure experienced or
personal and individual aspects of ageing.
Caring for a person involves subjective knowledge
of them, as well as knowledge of them as an
instance of objective scientific fact. Estes
Binney (1989) argue that the biomedical model
equates the elderly person with his/her disease
category and thus considers only part of what
makes him/her human (p.588).
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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
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Slide Three
Notes

• Age and functional status
• Older age is often presented in the health care
  literature as part of a process of deterioration
  and decline.
• Older people are statistically more likely to
  experience functional disability.
• This may make it easier to justify the
  association of an older person with his or her
  disease category.

There is a risk of making primary sense of older
age as a period of increasing functional
impairment, physical limitation, and psychiatric
disorder. Older people may be thought of as
adding to the burden of health services that
are already stretched to their limits. Older
people, as a group, are sometimes interpreted as
a problem with severe consequences for the
economy and health and social care care
systems. Once defined as a problem, some people
argue, it is easier for social groups to be
thought of as the responsibility of experts
academics and professionals whose task it is to
develop policy and strategy. The focus shifts
from the individual to the expert. One view of
health care is that the power to define need and
establish expectations is largely in the hands of
professionals and academics whose knowledge gives
them expert status. Problematised groups are
vulnerable, and may be marginalised in terms of
their contribution to our understanding of
well-being.
Slide Four
Notes

• An example from research
• Koch Webbs (1996) study of older people in
  hospital describes care that resembles a
  routine or conveyor belt approach.
• Individual requirements were not acknowledged.
• Patients disliked being segregated or labelled as
  different on the basis of their age.

Baker (1983) argues that the routine geriatric
style of care is based on a notion of the older
person as a stigmatised individual
(pp.110-111), and that it puts orderliness above
individual need. Baker refers us to Goffman
(1968), who explains that someone who is
stigmatised is reduced in our minds from a
whole and usual person to a tainted or discounted
one (p.12). Koch Webb (1996) associate routine
care with a single set of norms that are
determined by the requirements of an
institutional schedule. Needs are defined not by
referring to the individual, but by referring to
a series of standard values and associated
nursing practices that include hygiene, pressure
area care, medication and food. They quote from
Ada, who has metastatic cancer I am sitting out
of bed but I dont want to be here. They just
sit everyone out of bed They are all resolved
to put everyone in their chairs. That is the
important thing (p.955).
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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
Perspective (continued)
Slide Five
Notes

• The biomedical construction of old age
• The biomedical view has been associated with
  the idea of the person as a machine or container
  for the mind.
• As a machine, the body can be repaired, but can
  also wear out over time.
• This view tends to confirm the idea of ageing as
  a time of deterioration and decay.

Interpretations of the body as a machine or
mechanism that is separate from the mind (or
self) may have important consequences for
caring practice, and for the care of older people
in particular. If we view our bodies as machine -
or object -like, it seems normal to allow
specialists in the repair of bodies a wide
degree of control over them. As a machine,
Koch Webb say, the body can be entered,
studied and tampered with in order to be
repaired (p.957). Attention to the objective
body means that the patient as subject fades
into the background, and the individual is left
with a diminished role in the process of setting
the agenda for care and well-being. The ageing
machine/body is subject to increasing amounts of
wear and tear, so that it becomes, in effect, a
failing mechanism. This, Koch Webb believe,
has contributed in health care to the negative
stereotyping of old age as a time of decay and
deterioration (p.958).
Slide Six
Notes

• Is old age just a way of thinking?
• Bytheway (1995) has argued that old age and
  ageism are no more than ways of thinking.
• He believes that we cannot rethink ageism
  without questioning the presumption that old
  age exists.
• The elderly or the old could be thought of as
  socially constructed categories that make it
  legitimate to separate and manage people on the
  basis of their chronological age.

According to Bytheway (1995), ageism is an
ideology, a shared system of ideas or beliefs
that justifies the interests of dominant groups
(GIddens, 1989). Bytheway explains that in health
care, doctors may, having taken account of
symptoms and clinical evidence, aim more for
amelioration than cure in their treatment of
older people (pp.127-8). If this practice is
based on clinical judgement and takes full
account of the benefits and risks of the
alternatives, it reflects a recognition of the
physical realities of age rather than the power
of ageism (p.128). If, however, treatments are
systematically barred to people over a certain
age because of a presumption that there will be
no benefit, or because younger people are
systematically given priority, or because limited
success could lead to a continuing burden, then
this is institutionalised ageism (p.128). To
take on ageism, we must, in effect, abolish the
idea that age is a legitimate basis for distance
or separation between individuals.
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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
Perspective (continued)
Slide Seven
Notes

• Images of older people
• Johnson Bytheway (1997) reviewed photographic
  images of care work with older people from a
  popular magazine.
• The most common image was the caring about
  photograph.
• This image suggests that health care aspires to
  care about as well as to care for older
  people.
• The images also suggest a view of older people as
  passive, controlled, and dependent.

In the caring about photographs, Johnson
Bytheway found that both the younger carer and
the older cared about person were often women
(79 and 87 respectively). In a majority of the
photographs, the younger person is leaning
towards the older person (55) or taking up more
space (57). In some photographs, the younger
person is making a conscious effort to face the
older person on the same level. In others, the
younger person is more prominent, or the older
person appears to be on show, or an exhibit, to
be inspected by the younger person and the reader
(Johnson Bytheway, 1997, pp.136-7). This,
Johnson Bytheway believe, shows that the images
reflect the aspirations of health care to care
about as well as care for older people, as
well as a view of older people as passive,
controlled, and dependent (pp.137-8). Images
like these, they suggest, contrast sharply with
more realistic and challenging images that
ignore the association between age, care, and
dependence (p.141).
Slide Eight
Notes

• Non-persons and social death
• The very old and the sick have been identified as
  categories of non-person.
• A non-person is someone who is treated as if
  they were not there.
• Hospital patients can become non-persons before
  their actual death, if other peoples behaviour
  towards them reflects a recognition they they are
  dying in a clinical sense.
• Being treated as a non-person in this way has
  been likened to a kind of social death.

It is Goffman (1959) who identifies the the old
and the sick as kinds of non-person, by which
he means people who are treated as if they were
not there. Mulkay Ernst (1991) say that the
sequence of physical decline that we call
dying is accompanied by a sequence of social
decline In many cases, although the patients
basic physiological requirements continue to be
met he or she ceases to exist as an active,
individual agent some time before biological
termination takes place (p.174). Mulkay Ernst
point out that older people are likely to find
themselves subject to a general physical
aversion which is akin to the revulsion caused
by dead bodies (p.181). They point to research
by Sudnow (1967) in which hospital staff are seen
to deal with all their elderly patients in a
special way which follows from the latters
proximity, as elderly persons, to biological
death ( p.181). In other words, elderly people
in hospital are already located in a social
death sequence.
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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
Perspective (continued)
Slide Nine
Notes

• Older people and acute illness
• Latimer (1997) describes the case of 91-year-old
  Jessie, who has had a stroke, and argues that she
  is classed by hospital staff as an old person
  not an acutely ill person.
• Her problems are interpreted as the natural
  consequences of getting older.
• She is therefore not the responsibility of
  medical staff, and falls outside the legitimate
  scope of health care.

Latimers ethnographic research was carried out
on an acute medical unit of a large British
hospital. Her account of Jessie is based on
conversations with a ward sister. She argues that
the category older people is absurd but
inescapable. We are all part of the process of
creating this distinction, because we all fear
increasing age. At the same time we are all
always already becoming older. The ward sister,
Latimer says, has refigured or redefined
Jessie by removing her from the category of
acutely ill person, and placing her in the
category of old person. Because ill health in
old age is seen as biologically inevitable, it is
part of the natural order of things. Jessie is
out of place in the medical ward because as an
old person, she is subject to progressive decline
until death, and is unlikely ever to fulfil
medical ambitions of an heroic recovery. The
primary association of ageing with physical
decline means that older people fit uneasily into
the domain of professional care.
Slide Ten
Notes

• Older people and cancer treatment
• Questions have been raised about certain aspects
  of the treatment of older people with cancer.
• Some research suggests that differences in
  treatment received for cancer may be age-related.
• Is there a rational explanation for the
  differences in treatment received by older people
  with cancer, or are the differences due to
  ageism?

In 1991, Fentiman et al published a paper called
Cancer in the Elderly Why So Badly Treated? Even
ten years later, the question posed by this paper
sets us an important challenge to ensure that
older people are given the same opportunities as
their younger counterparts when they have
cancer. Some commentators believe that older
people with cancer can be subject to age bias
age-related differences in post-diagnostic
treatment suggest a deep social ageism
influencing who receives aggressive treatment
(Mor et al, 1985). Others believe there are good
reasons for age-related differences in treatment.
Guadagnoli et al (1997) conclude that in early
stage breast cancer, for example, the decline
with age in the frequency of adjuvant
chemotherapy is consistent with the diminished
efficacy of the treatment in older patients.
What is important is that we all take the
question of age-related differences in treatment
seriously.
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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
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Slide Eleven
Notes

• Chemotherapy
• Some research has shown that older people with
  cancer do not receive adjuvant chemotherapy as
  often as younger people.
• Fear of increased toxicity may discourage doctors
  from offering this kind of treatment to older
  people.
• Some studies suggest that older people, in
  general, do not tolerate chemotherapy less well
  than younger people.

Newcomb Carbone (1993) found that women aged
gt65 received radiotherapy and adjuvant
chemotherapy for breast cancer less often than
women aged lt65, and that chemotherapy for
colorectal cancer was less common in the older
age group. In their study, De Rijke et al (1996)
found that stage of disease was unknown in a
larger proportion of older patients, that older
patients were more likely not to be treated, and
that older patients were more likely to receive
single modality treatment. Popescu et al (1999),
who studied palliative and adjuvant chemotherapy
for colorectal cancer in patients aged gt70 years,
concluded that chemotherapy is well tolerated by
older patients, that the palliative benefits are
similar for fit older and younger patients, and
that adjuvant chemotherapy should be offered
using the same criteria that are applied to
younger patients. Schrag et al (2001) ask why
elderly patients do not receive potentially
curative adjuvant chemotherapy, and raise the
possibility of nonmedical barriers to care.
Slide Twelve
Notes

• Final thoughts
• The extent to which nonmedical barriers to care
  affect older people with cancer should be
  carefully considered.
• We do not yet fully understand the influence of
  age itself, social resources, cultural barriers,
  professional attitudes, or patient preferences on
  treatment decisions in older people with cancer.
• Could better patient outcomes be achieved if we
  could overcome some of these barriers?

There is an increased likelihood, with age, of
functional disability (Silliman et al, 1993), and
this might affect patients decisions not to
proceed with adjuvant treatment, for example.
The role of functional status and comorbidity in
decisions about adjuvant treatment is not fully
understood, however, and we need to know more
about exactly how important these factors are
when such treatment is either not offered or not
pursued. The question of whether patients do not
proceed with treatment because they judge
themselves ill-suited to do so, or whether they
are in effect prevented from doing so because of
some (potentially) remediable lack of necessary
support, is a particularly crucial one. We need
to ask ourselves whether, if comprehensive
support were to be more readily available, more
older people would choose to receive extended
treatments for their cancer. We might also ask
ourselves what, in these circumstances, the
effect on patient outcomes might be.
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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
Perspective (continued)

• References
• Anonymous (1991)The elderly an oncologic time
  bomb? Annals of Oncology, 2(2) 82-83.
• Baker, D. (1983) Care in the geriatric ward an
  account of two styles of nursing. In Nursing
  Research Ten Studies in Patient Care, edited by
  J. Wilson-Barnett, John Wiley Sons, Chichester.
• Bytheway, B. (1995) Ageism. Open University
  Press, Buckingham.
• Cancer Research Campaign (1992) Factsheet 5.1
  Cancer in the European Community. Cancer
  Research Campaign, London.
• Estes, C.L. Binney, E.A. (1989) The
  biomedicalisation of ageing dangers and
  dilemmas. The Gerontologist, 29(5) 587-596.
• Fentiman, I., Tirelli, U., Monfardini, S.,
  Schneider, M., Fersten, J.F., Aapro, M. (1990)
  Cancer in the elderly why so badly treated?
  Lancet, 3351020-1022.
• Giddens, A. (1989) Sociology. Polity Press,
  Cambridge.
• Goffman, E. (1959) The Presentation of Self in
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• Goffman, E (1968) Stigma Notes on the Management
  of Spoiled Identity. Penguin Books,
  Harmondsworth.
• Guadagnoli, E., Shapiro, C., Gurwitz, J.H.,
  Silliman, R.A., Weeks, J.C., Borbas, C.,
  Soumerai, S.B. (1997) Age-related patterns of
  care evidence against ageism in the treatment of
  early-stage breast cancer. Journal of Clinical
  Oncology, 15(6)2338-2344.
• Johnson, J. Bytheway, B. (1997) Illustrating
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• Katz, S. (1996) Disciplining Old Age The
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• Koch, T. Webb, C. (1996) The biomedical
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• Latimer, J. (1997) Figuring identities older
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• McCaffrey Boyle, D., Engelking, C., Blesch, K.S.,
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• Mor, V, Masterson-Allen, S., Goldberg, R.J.,
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• Mulkay, M. Ernst, J. (1991) The changing
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FACET - European Journal of Cancer Care March 2003
Older People, Care, and Cancer A Critical
Perspective (continued)

• References (cont.)
• Popescu, R.A., Norman, A., Ross, P.J., Parikh, B.
  Cunningham, D. (1999) Adjuvant or palliative
  chemotherapy for colorectal cancer in patients 70
  years and older. Journal of Clinical Oncology,
  17(8)2412-2418.
• Silliman, R.A., Balducci, L., Goodwin, J.S.,
  Holms, F.F., Leventhal, E.A. (1993) Breast
  cancer in older age what we know, dont know,
  and do. Journal of the National Cancer
  Institute, 85(3) 190-199.
• Sudnow, D. ((1967) Passing On The Social
  Organization of Dying. Prentice-Hall, Englewood
  Cliffs, NJ.
• Victor, C.R. (1994) Old Age in Modern Society A
  Textbook of Social Gerontology. Chapman Hall,
  London.
• Victor C. (1999) What is old age? In Nursing
  Older People, edited by S.J. Redfern F.M. Ross,
  Churchill Livingstone, Edinburgh.

Footnotes 1Chris Bailey is Research Advisor for
the Wessex Primary Care Research Network, Primary
Medical Care, University of Southampton, and a
lecturer in the School of Nursing and Midwifery,
also at the University of Southampton. Jessica
Corner is Professor of Cancer and Palliative
Care, School of Nursing and Midwifery, University
of Southampton. Correspondence address
C.D.Bailey_at_soton.ac.uk
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