Old patients can handle cancer surgery - I did

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http://www.newsday.com/news/columnists/ ... columnists

November 19, 2005

This was my unspoken fear when I was diagnosed earlier this year with esophageal cancer, a fear I'm sure I share with other older cancer patients: That the surgeon of my choice, one of the finest in the country, would not take me as a patient because I was too old.

There was reason for my fear. Cancer in the elderly is not treated with the same aggressiveness as cancers in the young. Consequently, an organized effort to encourage curative therapy - including surgery where appropriate, for the older cancer patient, and not just palliative care - has become the mission of a relatively new medical specialty, geriatric oncology.

Also, the fragmented health care system practices a kind of unacknowledged triage, separating the insured from the uninsured, the affluent from the poor, the young from the very old, white from black. And an HMO network may keep a potentially costly older patient from the best doctor and hospital.

I am fully insured by Medicare and a good supplemental policy. Yet, I could not be sure that Dr. Stephen C. Yang, a brilliant young thoracic surgeon at Baltimore's Johns Hopkins Medical Center who specializes in lung and esophageal cancers, would help me.

The standard of care for my kind of cancer is at least five weeks of interactive radiation and chemotherapy, followed by radical surgery to remove most of the esophagus. And Yang says openly that he invites hopeful older patients to his office for what he calls his "eyeball test," assessing whether they can withstand the rigors of the treatment, especially hours of surgery.

Yang does not discriminate against the elderly. Rather, the Johns Hopkins magazine describes him as "surgeon to the seniors." He told me he's operated on about 400 patients older than 70, including an 85-year-old woman with lung cancer who three years later is cancer-free. In fact, the older patient has become his specialty and his challenge.

"There is a big push toward geriatric surgery in general," he said, aided in part by major advances in post-operative care and a larger aging population. "It's a field that should grow quickly over the next few years as aging boomers swell the ranks of senior citizens."

And, unfortunately, the incidence of cancer is growing alarmingly among seniors and aging boomers. The Geriatric Oncology Consortium, a group of specialists dedicated to changing attitudes about treating cancer in the elderly, notes that cancer is primarily a disease of older adults with 60 percent of all new cancers occurring in persons over 65. Yet the consortium says "older adults with cancer are underserved. Compared with younger adults, those 65 or older are less likely to be screened for cancer and, when a diagnosis is made, are less likely to be offered curative therapy or participation in clinical trials ... . As a consequence ... older patients with cancer often experience a diminished quality of life and an increased burden."

Older patients with, say, prostate cancer, often go untreated because of their age when the cancer is slow-growing, but often the cancer kills, and they die in pain. I heard a doctor tell a patient in her 70s that her lung cancer was inoperable, but she'd probably die of something else. Her will to live collapsed into depression, and she died of the cancer in a nursing home.

The consortium reasoned that older patients often are not treated aggressively because it's believed that "older adults do not tolerate such therapies as well as younger patients." But a recent journal of the American Cancer Society reported that "elderly lung cancer patients tolerate combined chemotherapy and radiation therapy with no higher risk of death than younger patients." And the two- and five-year survival rates were not significantly different for patients younger or older than 70.

Yang says that lung cancer is not necessarily a death sentence, if it's caught early and surgically removed. As I learned, the same can be said for esophageal cancer. But it's vital, Yang says, that patients (especially the elderly) find a surgeon who has done more than an occasional operation, and a hospital team that specializes in the combined attack on the cancer - chemotherapy, radiation and surgery.

Unfortunately, not everyone has the choice on which their lives may depend. A recent study by the Dana Farber Cancer Institute in Boston found that African-American patients with esophageal cancer were less likely than white patients to be seen by a surgeon and receive the treatment required.

Only 35 percent of the black patients underwent surgery compared with 59 percent of whites. And the survival rate among blacks was only 18 percent compared with 25 percent for whites.

On the brighter side, the American Geriatric Society says that older Americans are swelling the ranks of cancer survivors, as a result of advances in early detection and treatment techniques. But because surviving cancer and the aggressive treatments produce physical side-effects and emotional problems, geriatricians are studying oncology and oncologists are learning about geriatrics.

As the oncology consortium reported, the treatment and management of cancer in older persons includes not only how to deal with the symptoms of the disease but the potentially nasty effects of the treatment - nausea, loss of weight and hair, and the psychological trauma of living with cancer.

Much of the battle against cancer must be fought by the patient, and a fighting attitude is everything. There may be some help from one of the hundreds of clinical trials dealing with cancer, testing new drugs and techniques. I found 200 such trials for lung cancer and 75 for esophageal cancer, and there are many for other ailments. You can begin your own search at www.clinicaltrials.gov.

WRITE TO Saul Friedman, Newsday, 235 Pinelawn Rd., Melville, NY, 11747-4250, or by e-mail at saulfriedman@comcast.net.