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Introduction

Cancer is primarily a disease of older age.1 There are now more than 130,000 people living with cancer in the UK who have survived at least 10 years after being diagnosed at age 65 or over, including 8000 diagnosed with cancer at 80 years or over.2 Six in 10 new cases each year in the UK occur in those aged 65 or over,3 and 13% of the total UK population aged 65 or over have been diagnosed with cancer at some point in their life.4 However, the relative 5 year survival of this group in the UK is 14% lower than the European average.5

While UK patients appear to present with cancer at a later stage than in comparable countries, there are concerns that they do not access effective cancer treatments to the same extent as comparable younger patients. A survey of 101 UK oncologists found that while 81% would prescribe chemotherapy for a high-risk breast cancer patient aged 68, only 47% would recommend the same treatment for an otherwise identical patient aged 73.6 There are a range of possible explanations for this, including: inappropriate assessment of fitness for treatment; lack of support for older people before, during and after treatment; and inadequate training of clinical and non-clinical staff in relation to issues more common in older people, such as falls, incontinence, multi-drug use, and sensory and cognitive impairment.

Older people with cancer increasingly have more than one other comorbidity: one US study reported an average of three comorbidities in cancer survivors aged 70 years and above,7 and one in three older people have existing problems with medication prior to cancer treatment.8 Antihypertensive medication, in particular, is frequently associated with dizziness, falls and renal impairment. Over 70% of those over 70 have a hearing impairment,9 which may be confused with cognitive impairment, complicating communication about treatment choices. Older patients living alone are less likely to accept cancer treatment,10 and people who have more fragile social support networks are not as likely to make favourable treatment decisions.11 One in five of those aged over 75 state it is difficult to get to their local hospital,12 and lack of transportation affects acceptance of treatment. In 2011, 14% of older people living in households in England and Wales provided unpaid care: the largest increase in proportion was for those aged 65 and over, who provided ≥50 h/week of unpaid care.13 Ahead of all other types of care, grandparents were the main child care arrangement for 35% of families where the mother was working or studying when the child was 9 months old.14 Older people may defer management of their own health issues because of such responsibilities.

Of course, overtreatment can be as inappropriate as undertreatment. As well as a lack of older people in cancer treatment clinical trials, there is a dearth ...

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