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Barriers to cancer care in nursing homes

The Bottom Line

  • An aging population, an increase in cancer incidence with age, and effective cancer treatments that extend life are leading to an increase in the prevalence of cancer among older adults.
  • In nursing homes, the lack of knowledge among staff, as well as organizational, cultural and ethical barriers can hamper the continuum of cancer care.
  • In many situations, the early integration of palliative care in the course of the disease nevertheless contributes to improving the quality of life of elderly patients.

It is common to hear that cancer develops slowly in older adults, or that the side effects of treatment do not justify subjecting them to treatments. Stopping cancer screening programs at a certain age, often around age 75, does not mean that older adults are less likely to develop cancer.

The reality, however, is that the incidence of developing cancer increases with age and that untreated cancer can have negative effects on the quality of life. After a certain age, it is true that screening does not necessarily reduce cancer-related mortality and that the harms may outweigh the potential benefits, but it must be assessed on a case-by-case basis.(1-2)

Thanks to treatments and other therapeutic innovations, cancer has become somewhat of a chronic disease. The fact remains that the management of cancer cases in nursing homes is a major challenge.

As the end of life approaches, whether it is a lack of resources or difficulty communicating with patients with dementia, it can be difficult to provide the medical care required to treat cancer (for example, surgery , biopsy, chemotherapy, radiotherapy, hormone therapy, immunotherapy) and the side effects are more noticeable. Knowing that certain cancer treatments can lead to functional decline and excess mortality in the elderly, the therapeutic strategy is often oriented towards comfort care rather than curative care, which improves the quality of life of patients whose life expectancy is short or already living with other health issues, for example. When cancer is detected and older adults wish to obtain treatments, they are often transferred to a hospital, which brings its share of anxiety, loss of autonomy, and health risks (especially among frail older adults). How can we make decisions that seek to balance the potential benefits and harms of cancer treatment in older adults living in nursing homes?

What research tells us

A recent and moderate-quality systematic review of 65 studies identified the barriers associated with cancer treatment in older adults in nursing homes.(3) Despite the diversity of studies and certain methodological weaknesses, several barriers to cancer care in nursing homes have been identified, linked in particular to organizational, cultural and ethical barriers, but also to a lack of knowledge among nursing home staff.

Despite the high prevalence of this disease in the elderly, early diagnosis seems to be neglected in nursing homes compared to screening recommendations, whether for lack of willingness to perform the necessary tests, the inability to identify signs of cancer during daily care (for example, lesions on the skin or in the mouth), the trivialization of symptoms experience by residents, or the complexity of arranging tests and appointments for nursing home residents.

Ageism is also a cultural barrier that limits access to specific cancer care, often considered as being too invasive, a source of deterioration in quality of life and therapeutic obstinacy. However, when asked for their opinion and when they are able to consent, older patients often accept cancer treatments as much as younger patients, but when they do, it is because they have assessed that benefits outweighed harms: they are not ready to trade their survival for their quality of life.

Caring for residents with cancer

Whether you are an older adult residing in a nursing home, a family caregiver or health professional, it is important to discuss and identify symptoms, to know the screening possibilities adapted to different health conditions, and to get the full picture of the side effects and potential benefits of existing treatments.

To improve the quality of life for residents, professionals working in nursing homes would benefit from continuing education in oncogeriatrics to keep up to date on cancer screening, possible treatments, communication with residents that have cognitive impairments, etc. Such training would help to guarantee any elderly cancer patient access to treatments adapted to their condition through a multidisciplinary and multiprofessional approach.


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Author Details

References

  1. Yancik, R. Cancer in older persons: An international issue in an aging world. Semin. Oncol. 2004, 31, 128–136.
  2. Cook, P.S.; McCarthy, A.L. Cancer treatment decision-making with/for older adults with dementia: The intersections of autonomy, capital, and power. Health Sociol. Rev. 2018, 27, 184–198.
  3. Filteau C, Simeone A, Ravot C, Dayde D, Falandry C. Cultural and ethical barriers to cancer treatment in nursing homes and educational strategies: A scoping review. Cancers. 2021;13(14):3514.

DISCLAIMER: These summaries are provided for informational purposes only. They are not a substitute for advice from your own health care professional. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the McMaster Optimal Aging Portal (info@mcmasteroptimalaging.org).

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