Originally published as JCO Early Release 10.1200/JCO.2009.22.4352 on April 29 2009

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Providing Cancer Care to a Graying and Diverse Cancer Population in the 21st Century: Are We Prepared?

Department of Medicine, Division of Geriatric Medicine, Northwestern University Feinberg School of Medicine; and Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL

Athena T. Samaras

Department of Medicine, Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine; and VA Center for the Management of Complex Chronic Conditions, Jesse Brown VA Medical Center, Chicago, IL

Charles L. Bennett

Department of Medicine, Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine; VA Center for the Management of Complex Chronic Conditions, Jesse Brown VA Medical Center; and Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL

Cancer incidence will increase dramatically among older individuals and racial and ethnic minorities in the 21st century. From 2010 to 2030, the total projected cancer incidence will increase by 45%, from 1.6 million to 2.3 million.¹ This increase will be driven largely by cancers diagnosed in older adults and minorities. By 2030, the elderly will bear 70% of all cancer diagnoses, and elder minorities will fall victim to 28% of all cancers.¹ As projected by Smith et al,¹ a greater than 100% increase in cancer incidence will occur among racial and ethnic minorities by 2030 for most of the individual cancer sites assessed.

The management of cancer incidence among a diverse and aging population presents daunting challenges. Shifting cancer demographics and age-, race-, or ethnicity-associated genetic, molecular, cellular, and physiologic effects influence treatment effectiveness. Age-related physiologic changes affect the renal and hepatic systems of older cancer patients, resulting in pharmacokinetic and pharmacodynamic changes, putting them at risk for serious adverse reactions from many cancer drugs. Moreover, several barriers to treatment may exist within the elderly and minority populations. These barriers include poverty, lack of transportation, illiteracy, cultural taboos regarding cancer, and poor language communication.² Because of the many factors that contribute to cancer incidence within the aging and minority populations and the many barriers to treatment faced by these patients, it is especially important that these populations have access to proper care. Smith et al¹ posit that "unless substantial improvements in cancer therapy and/or prevention strategies emerge, the number of cancer deaths may also grow dramatically over the next 20 years." Although advances in cancer therapeutics and prevention are essential, we also believe that it is imperative to provide more effectively current cancer treatment options and prevention strategies to cancer patients, regardless of age, wealth, or racial or ethnic status.

Efforts to reduce age-related disparities in cancer care have been heavily supported. Through the use of validated measures such as the Comprehensive Geriatric Assessment and the use of a comprehensive cancer care team, including social workers, geriatric nurses and nurse practitioners, the oncologist is able to perform in-depth analyses to determine an older patient's fitness for contemplated oncologic therapy.² In addition, in 2007, the fledgling Cancer and Aging Research Group met for the first time to contemplate barriers to well-designed and collaborative geriatric cancer research. After 2 days of deliberation, they concluded that a geriatric assessment should be included in all clinical trials accruing patients 70 years of age and older. The assessment should aim to evaluate all-cause mortality and morbidity and identify factors other than age that are associated with toxicity risk with cancer treatment, including treatment tolerance and the effect of cancer treatment on functional status, existing comorbidity, mood, and cognitive function.³

As the aging population increases, the need for trained geriatric clinicians is imperative. The American Society of Clinical Oncology (ASCO), in conjunction with the John A. Hartford Foundation, has supported 10 fellowship programs in geriatrics and oncology, which have resulted in the successful training of 28 geriatric oncologists and the formation of the Cancer and Aging Research Group.³ In 2005, the American Association of Medical Colleges, in concert with ASCO, launched a comprehensive study to assess the adequacy of the oncology workforce. The study, completed in 2006, projects a shortage of 2,550 to 4,080 oncologists by 2020.⁴ This dire shortage must be addressed as quickly as possible and will need to be at the forefront of the expected health care reform package of the Obama administration.

To address differences in cancer care experienced by minorities, Congress approved the Patient Outreach Navigator and Chronic Disease Prevention Act of 2005. Patient navigation programs, introduced by Harold Freeman in 1990 at Harlem Hospital Center (New York, NY), have been implemented by the American Cancer Society, the Center for Medicare and Medicaid Services, and the National Cancer Institute in an effort to ensure that racial and ethnic minorities with cancer efficiently navigate an increasingly complex health care system. In addition, the Center to Reduce Cancer Health Disparities, established under the Patient Outreach Navigator and Chronic Disease Prevention Act of 2005, has led to renewed efforts to bring about parity in diagnosis and treatment of cancer among ethnic minorities, the elderly, and those with disabilities.⁵

The next decade will be a true test of the efficacy of these various initiatives. Fortunately, we expect that the benefits of recent age-, racially, and ethnically focused initiatives, in conjunction with an anticipated increase in the number of culturally competent geriatric, geriatric oncology, and oncology clinicians, will aid the changing cancer demographics. President Obama's proposal to fund a center for evaluating comparative effectiveness of medical therapies is an important ally in these efforts. Although this center will help to identify which cancer therapies work best and represent the best value to society, it will also be important that the aging and minority cancer populations have access to these therapies. Because our health care system has become increasingly costly and difficult to navigate, efforts by the Obama administration to provide health insurance and access to health care for the American population are critical.

Hence, whereas Smith et al¹ address the need for significant investments to address the changing demographics of cancer incidence, ensuring that these populations have access to the existing tools is integral to achieving progress. Improvements in cancer survival statistics should and must be extended to the entire cancer population. The upcoming years will be an important test as to whether our changing nation can address the needs of our increasing elderly and diverse population.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

AUTHOR CONTRIBUTIONS

Conception and design: June M. McKoy, Charles L. Bennett

Financial support: June M. McKoy, Charles L. Bennett

Administrative support: Athena T. Samaras

Collection and assembly of data: June M. McKoy, Athena T. Samaras, Charles L. Bennett

Manuscript writing: June M. McKoy, Athena T. Samaras, Charles L. Bennett

Final approval of manuscript: June M. McKoy, Athena T. Samaras, Charles L. Bennett

REFERENCES

1. Smith BD, Smith GL, Hurria A, et al: Future of cancer incidence in the United States: Burdens upon an aging, changing nation. J Clin Oncol 27:2758–2765, 2009.[Abstract/Free Full Text]

2. Wolf MS, Knight SJ, Lyons EA, et al: Literacy, race, and PSA level among low-income men newly diagnosed with prostate cancer. Urology 68:89–93, 2006.[Medline]

3. Hurria A, Balducci L, Naeim A, et al: Mentoring junior faculty in geriatric oncology: Report from the Cancer and Aging Research Group. J Clin Oncol 26:3125–3127, 2008.[Free Full Text]

4. American Society of Clinical Oncology. Forecasting the supply of and demand for oncologists: A report to the American Society of Clinical Oncology (ASCO) from the AAMC Center for Workforce Studies. http://www.asco.org/ASCO/Downloads/Cancer%20Research/Oncology%20Workforce%20Report%20FINAL.pdf.

5. Freund KM, Battaglia TA, Calhoun E, et al: National Cancer Institute Patient Navigation Program: Methods, protocols, and measures. Cancer 113:3391–3399, 2008.[CrossRef][Medline]

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