August, 2017

Age Before Duty

By Michael J. Katin, MD

They say that age is just a number, although at times I would like to request a different number. Society has changed to the point that nearly every stereotype has been shattered. We have reached the point that discrimination on the basis of race, religion, gender, sexual orientation, and age is virtually unknown. .

It was therefore somewhat unexpected that the July 15, 2017, issue of the Red Journal (the International Journal of Radiation Oncology, Biology, and Physics) was a special edition dedicated to "Radiation Therapy In the Elderly." The title of the introductory editorial was the very uplifting statement that "Frailty Is our Destiny." After that beginning, especially since they're written by the usually ebullient Anthony Zietman, it's not certain whether there's a point to keep reading or just put on the pine overcoat. The rest of the issue consists of a number of studies which can generally divided into two categories: 1. yshowing that older people don't live as long as younger people, and 2. how to justify more rapidly treating older people to get them off the schedule.

It should be observed that the definition of "elderly" moves around somewhat. Some of the papers define it as greater than 65 years old, some 70 years old, and some even 75 years old, with the youngest being 57, the same age as Antonio Banderas, Bono, and John Elway. Certainly anyone who is 30 would be willing to consider a 57-year-old elderly, whereas a person who is 60 might have a different opinion. What should be the proper definition and, if there is one, why isn't it enforced in this special edition? Perhaps the proper definition is from the United States Government, the source of all knowledge. The Department of Justice considers 65 to be the age to qualify to be a victim of elder abuse, meaning that you can't be abused if you're 64½. Interestingly, the World Health Organization has had a Project on Minimum Data Set for Ageing in Africa, recommending that in Africa one becomes elderly at age 60. It is also noteworthy that of the world's oldest heads of state, the winner is President Robert Mugabe of Zimbabwe, who is now 93½ years old.

Regardless, is it difficult to argue that older people live longer than younger people, but at least it allows publications to be generated. The most profound conclusion is from Sommers, LW, Steenbakkers, RJHM, Bijl, HP, et al., "Survival Patterns in Elderly Head and Neck Squamous Cell Carcinoma Patients Treated With Definitive Radiation Therapy," that "Age is a prognostic factor for overall survival, mainly due to an increase in non-cancer-related mortality rather than to causes related to the index tumor." Many of the other articles conclude that performance status is a good prognostic factor, which we have already known for decades. The majority of papers then go on to show that accelerated treatment techniques may have similar efficacies and toxicities to standard fractionation programs. It can be presumed that these were piloted on elderly patients considering that long-term toxicity would not be an issue and since the anatomy and physiology were very similar to those of real patients. It is probable that the original intention was to get elderly patients finished as soon as possible rather than take up the remaining few months of their lives, possibly not remembering that the average 80 year old, according to the Social Security actuary tables, has a life expectancy of 8.28 years for men and 9,73 years for women. There probably should be as much incentive to cure an 80-year-old and not cut corners on treatment, although it is ironic that probably all patients can be treated on a more rapid schedule and get as good results. It is certainly not taken for granted that the extra years given to a 45-year-old are more valuable than for an 80-year-old. It may be an exaggeration to say that 80 is the new 60, but there are certainly people even older who are more active than the 50- and 60-year-olds of the past. Only a few weeks ago I went to 80's Night at the Brews Brothers Lounge and all the patrons were in their 80's! I heard that at age 77 Chuck Norris is resuming his series, Walker, Texas Ranger. It'll be called Walker, Texas Ranger--with a Walker! 23 United States Senators are over 70 and five of these are over 80!

Despite the implied concern about overtreating older patients, there is regardless a "brief report" (six paragraphs) with 12 authors regarding "Using Proton Beam Therapy in the Elderly Population," concluding that "it is time to consider the inclusion of comprehensively assessed elderly men and women in clinical trials of PT (proton therapy)." I hadn't realized that they had been excluded!

This special edition of the Red Journal contained valuable information about oncologic treatment in general even if the intention was to address treatment of "the elderly." It is hoped this distinction does not lead to any repercussions, however, since the legal world is very active in pursuing complaints of workplace discrimination against the elderly and treatment discrimination might attract some attention. Could there be conclusions that trying to speed up treatment or encouraging active surveillance rather than treatment could be viewed as a holding action until the death panels start having regular meetings? Are even preventive measures being considered for restriction for certain classes of persons, and will there be crackdowns on physicians who order "excessive" screening? That may already be happening.

One last spin on this topic---as our patients are getting older, physicians are also getting older. Willlie Nelson wrote, "there are more old drunks than there are old doctors," but this may no longer be true, depending on how you count drunk doctors. Although 13.96% of the population in the United States is older than 65 years, the percentage of physicians over age 60 is 27.6%! Will there be age discrimination against physicians? There are already studies assessing patient outcomes with older versus younger physicians, although so far it still appears that volume of activity rather than age is more closely associated with outcomes. Ageing is a topic that is ignored by almost everyone until too late, but this special edition has called attention to it. So much for sleeping at night -- thank you, Dr. Z. Fortunately, there still may be a solution for both patients and doctors.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including August 1, 2017, this leaves 5,631 days to his goal.