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Introduction

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There is increasing discussion about service needs and developments for cancer care for older people. The topic is not new.1-4 In the USA, the population aged 65 or over will double by 2050, and, in the EU, people over 65 years will outnumber children by 2060.5,6 In the UK, by 2030, about 70% of cancers will occur in people aged over 65 years.7 Studies by the International Cancer Benchmarking Partnership and EUROCARE, the European Cancer Registry, suggest that the survival gap is widening between older and younger patients diagnosed with cancer in Europe.8-10 There are also worrying indications from within these studies that older patients in the UK may be relatively disadvantaged. 8-11

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Improvements in the care of older patients with cancer will ultimately depend on revisiting the biology underlying cancer in older patients. This is because fundamental biological questions about the relationship between ageing and cancer remain poorly understood, requiring a deeper understanding of processes such as cellular senescence, DNA damage and genomic instability, telomere biology, autophagy, and cellular responses to metabolic and oxidative stress.12-14 Currently at a clinical practice level, however, it is very clear that older patients are disadvantaged in their access to systemic therapy, radiotherapy and surgery: the main modalities of anticancer therapy.

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Systemic therapy in the forms of cytotoxic chemotherapy and biological agents has a role to play in most tumour types. Current evidence, however, suggests that older patients are undertreated, as chronological age remains an independent factor for the use of chemotherapy, even when adjustments are made for comorbidity and frailty. This lack of equity in access and uptake of cancer care may lead to worse outcomes in older cancer patients. For example, more than 70% of cancer deaths occur in men aged over 75 with prostate cancer, yet few older patients receive treatment for localized prostate cancer. In the majority of cases, older patients are denied access to chemotherapy for advanced disease, which if carefully selected can confer benefits with avoidable toxicity.15 Colorectal cancer is another disease of the older adult, yet again the evidence suggests that optimal therapy is not always being provided to these patients.16 A significant proportion of older women with triple-negative breast cancer receive less chemotherapy than their younger counterparts, despite the available evidence demonstrating its increased efficacy. Older women may also receive less endocrine therapy than their younger counterparts with breast cancer.17-19 Specifically in the UK, a National Cancer Equality Initiative (NCEI)/Pharmaceutical Oncology Initiative (POI) joint report concluded that 'clinicians may over rely on chronological age as a proxy for other factors, which are often but not necessarily associated with age, e.g. comorbidities, frailty'.20 An NHS England publication21 entitled Are older people receiving cancer drugs? (published in 2013) demonstrated considerable variation in the use of systemic anticancer therapy in older people and concluded: 'It does not seem plausible that differences in referral ...

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