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The number of nonagenarians living an independent lifestyle is increasing and, with baby boomers growing older in a more healthy manner, is set to rise proportionally. Neoplastic change increases with age but many cancers in the elderly are occult until a clinically important event causes rapid decline. Drs Gavin Brigstocke, Moshkan Poormolkara and Jonathan Birns set out the social background and illustrate events with a likely case scenario.
In the 21st century people in Britain are living longer, reflecting long-term progress in improving standards of living and health through individual endeavour and social investment.1 The absolute and relative numbers of older individuals are increasing and it has been calculated that there will be an approximately 100 per cent increase of people aged 80 and over in the developed world2 during this century.
Indeed, current demographic estimates suggest the older population are the fastest growing section of the population. The Government Actuary’s Department projects that by 2051 the average 65-year-old will expect to reach almost 90 years1 and, as the baby boomer generation reaches 65 to 70 years of age by 2015, we will experience further societal change with increased numbers of nonagenarians and centenarians.3
Population studies have described a significant proportion of nonagenarians living an independent lifestyle in their own home with important personality characteristics being a sense of responsibility, capability and emotional stability.4 One great risk factor for cancer is ageing and human cancer incidence increases exponentially with age.5
Cellular models of carcinogenesis have demonstrated that ageing predisposes to the convergence of genetic changes, accumulation of tissue damage and an increasingly permissive local environment for tumour growth.6,7 A number of neoplasms either show an indolent course, increase in size or metastasise without causing symptoms initially.8
In the very elderly, these cancers may grow considerably without affecting the individual until a clinically critical event due to a primary or secondary neoplastic lesion causes rapid decline. This important clinical scenario is illustrated by the case described in Box 1.
Despite significant ‘neoplastic disease load’ the very elderly may be relatively asymptomatic. Indeed, studies have shown that up to 29 per cent of elderly cancer patients may be asymptomatic at the time of diagnosis9 . Because the elderly are likely to be less active, it may been argued that occult metastatic disease may continue to develop in them without affecting lifestyle in contrast to a younger individual whose activities would become more obviously limited. While elderly cancer patients may have no overt medical complaints prior to a delayed presentation, unintentional weight loss is not uncommon. Indeed, neoplasia is the most common occult cause of unintentional weight loss in the elderly, accounting for 16–36 per cent of cases, and weight loss is often the only symptom of neoplasia.10-12
Up to one quarter of older patients have unintentional weight loss and it has been documented that a significant proportion of older people do not complain about losing weight or, less commonly, mistakenly attribute weight loss to successful diet or lifestyle modifications.13
Case study of neoplastic change
A male Caucasian nonagenarian presents to the emergency department with a one-week history of left-sided visual deficit, worsening confusion and decreasing independence. Systemic review reveals a year-long history of unintentional but significant weight loss that had not troubled him. He denies any previous medical history, regular medications, cigarette or alcohol use.
A widower, he lives alone and has been functionally independent prior to his presentation. Physical examination reveals decreased expansion, dullness to percussion and reduced air entry over the left hemithorax, a left homonymous hemianopia and an abbreviated mental test score.
Laboratory investigations reveal a normocytic anaemia and a chest x-ray reveals a large lobulated soft tissue density mass projected over the left hemithorax. CT imaging confirms the presence of a primary peripheral bronchogenic carcinoma with mediastinal, abdominal and cerebral metastases, and a haemorrhage into a metastatic lesion in the right occipital lobe. The patient is provided with steroid treatment and supportive therapy but he dies very soon after.
Compared with younger cancer patients, the elderly have been shown to have increased metastatic disease14 but, as described, this is often lacking in symptoms. It has been suggested that elderly patients with occult disease are somewhat ‘meta-stable’ in that they retain functional independence until a clinically important event destabilises the ‘milieu interieur’ causing rapid clinical decline.8
The clinical deterioration is then often exceptionally rapid in keeping with the newly uncovered biological profile. As the proportion of elderly patients increases in society, clinicians need to be aware of occult cancer as an important cause of unintentional weight loss and the potential for very rapid clinical decline subsequent to a delayed presentation of ‘neoplasia in the nonagenarian’
Drs Gavin Brigstocke, Moshkan Poormolkara and Jonathan Birns
References
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2. UN Department of International Economic and Social Affairs, 1985. UN Department of International Economic and Social Affairs. (1985): The World Ageing Situation: Strategies and Policies. E85/14/5. UN, New York
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11. Thompson MP, Morris LK. Unexplained weight loss in the ambulatory elderly. J Am Geriatr Soc 1991; 39: 497– 500
12. Hernandez JL, Matorras P, Riancho JA, GonzalezMacias J. Involuntary weight loss without specifi c symptoms: a clinical prediction score for malignant neoplasm. QJM 2003; 96: 649–55
13. Alibhai SM, Greenwood C, Payette H. An approach to the management of unintentional weight loss in elderly people. CMAJ 2005; 172: 773–80
14. Firvida JL, Vinolas N, Munoz M, Grau JJ, et al. Age: a critical factor in cancer management. A prospective comparative study of 400 patients. Age Ageing 1999; 28: 103–5
