Aging and Cancer:A Cancer 101 Adaptation to Educate Elders and Their Caregivers on the Importance of Cancer Screening and Early Detection

7th National Changing Patterns of Cancer in Native Communities: The Power of Partnerships

Marie J. Lavigne, LMSW NCI’s Cancer Information Service - Northwest Region September 7, 2007

Participants will learn why cancer is a growing concern for elder Alaskans by:

Identifying the top five most commonly diagnosed cancers in Alaskans,

Describing screening recommendations for cancer prevention and early detection,

Discussing three or more factors contributing to improved cancer survival for elders, and

Stating where to find the latest, most accurate information on cancer.

Cancer 101 Learning Objectives

The risk of cancer increases with age. Close to 60% of all new cancers and 70%

of deaths are in elders over 65. Increases in life expectancy means more

older adults will experience cancer. Cancer is emerging as a chronic disease,

rather than a terminal diagnosis. Advances in research and medical care

have increased the length of time and quality of life of cancer survivors.

Cancer is a Disease of Aging

A Woman’s Risk of Getting Breast Cancer Increases with Age. The risk is 1 in:

>28,000 19,608 911173393622

Teens 20s 30s 40s 50s 60s 70s 80s

Those diagnosed at age 60 or older compromise the majority of cancer survivors. Understanding elders needs and concerns is critical in reducing the cancer burden.

Many older survivors have one or more chronic medical conditions that can mask the signs of cancer recurrence, or the late effects of cancer.

Elders may live alone, or they may lack adequate social and caregiver support to support recovery.

Limitations on Medicare reimbursement, along with out of pocket costs for treatment, medication and transportation, are a significant burden for those on fixed incomes.

Source: The NCI Strategic Plan, January 2006 www.cancer.gov

Cancer Burden in the Elderly

Cancer survivors over age 65: Tend to be in poorer health (30% vs. 10% general

population),

Have two or more chronic conditions (12% vs. 5%),

Experience greater functional limitations (60% vs. 30%),

Are more likely to experience other serious illnesses: Alzheimer’s disease, arthritis, diabetes, previous cancers,

heart-related diseases, strokes and hypertension.

Experience lengthier hospitalizations and treatment complications,

Face unique caregiver issues when their primary caregivers (spouses, older adult children) have serious health problems.

Source: National Institute on AgingCancer Survivorship: Pathways to Health After Treatment

Elders face unique cancer challenges

Potential factors include:

Early detection Access to quality cancer care Compliance with recommended

treatment Overall health status prior to cancer Nutrition and physical activity Family history and genetics Social support

Improved Cancer Longevity in Elders

Potential factors include: Late detection and advanced stage of

cancer Inability to comply with recommended

treatment Difficulty accessing care Existing chronic health conditions Advanced age and frailty Genetic risk factors Type of cancer

Decreased Cancer Survival in the Elderly

Cancer Rates In Alaska

All Alaska Alaska Natives

Estimated New Cases in 2006 2,010 300Estimated Cancer Deaths in 2006 810 134Cancer Prevalence 21,000 *

2,325 **

Source: Cancer Facts and Figures, 2006

* Based on NCI estimates for US** Alaska Native Tumor Registry

Cancer In Alaska

Alaska Native Alaska White US White1. Colorectal 1. Prostate 1. Breast2. Lung 2. Breast 2. Prostate3. Breast 3. Lung 3. Lung 4. Prostate 4. Colorectal 4.

Colorectal5. Stomach 5. Bladder 5. Bladder

Alaska Native Tumor Registry, 1999-2003Alaska Cancer Registry, 1999-2002

US SEER, 1999-2002 http://seer.cancer.gov/

Five Leading CancersMen and Women Combined

Age at first diagnosis

Ages 0-19 1%Ages 20-44 13%Ages 45-64 44%Ages 65 + 42%

(n=9,652)

86% cancers are diagnosed in adults ages 45 and older

Source: Alaska Cancer Registry

Age Distribution of Cancers in Alaska 1997-2001

Age Specific Cancer Incidence Rates, Alaska Natives and US

Whites*, 1999-2003

0

500

1000

1500

2000

2500

3000

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70+

pe

r 1

00

,00

0

AK Native US White

•US White rates for years 1998-2002

Source: Alaska Native Tumor Registry

50-59 Years 60-69 Years 70+ Years

Breast 21.0% Lung 23.0% Colorectal 25%Colorectal 19.5% Colorectal 19.1% Lung 22.4%Lung 15.6% Breast 11.9% Prostate 8.8%Oral 5.4% Prostate 8.8%

Breast 7.4%Prostate 5.3% Stomach 5.0%

Stomach 4.4%

(n=789) (n=964) (n=1158)

Source: Cancer in Alaska Natives, 1969-2003

Five Leading Cancers By AgeAlaska Natives, Men and Women Combined, 1989-2003

Age Cancer Risk

0-9 1 in 6,25010-191 in 6,05420-291 in 2,36130-391 in 98340-491 in 37550-591 in 14560-691 in 6570+ 1 in 43

Source: NCI SEER Program Data, 1994-1998

Cancer Risk By AgeUS Men and Women, All Races

Site RiskAll sites 1 in 2Prostate 1 in 6Lung and Bronchus 1 in 13Colon and Rectum 1 in 17Non-Hodgkin Lymphoma 1 in 46Melanoma 1 in 52Kidney 1 in 64Leukemia 1 in 67Oral Cavity 1 in 73Stomach 1 in 82

2000-2002

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

Lifetime Probability of Developing Cancer - Men

Site RiskAll sites 1 in 3Breast 1 in 8Lung and Bronchus 1 in 17Colon and Rectum 1 in 18Uterine Corpus 1 in 38Non-Hodgkin Lymphoma 1 in 55Ovary 1 in 68Melanoma 1 in 77Pancreas 1 in 79Urinary Bladder 1 in 88Uterine Cervix 1 in 135

2000-2002

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

Lifetime Probability of Developing Cancer - Women

Cancer Mortality (n=3,270)

Ages 0-19 <1%Ages 20-44 7%Ages 45-64 35%Ages 65 + 58%

92% of cancers deaths are in adults over 45

Source: Alaska Cancer Registry

Age Distribution of Cancers Deaths in Alaska1997-2001

Deaths Due to Chronic Disease in Alaska

Cancer is the leading cause of death in Alaska since 1993

723

582

251173 137

46

0

200

400

600

800

1000

Cancer HeartDisease

Diabetes* Stroke ChronicLower

RespiratoryDisease

ChronicLiver

Disease* Any mention

1,755 deaths combined, or 58% of all Alaska deaths in 2004

Source: Alaska Bureau of Vital Statistics

Reducing Your Cancer Risk

Leading Causes of Cancer

Sedentary Lifestyle, 5%

Environmental Pollution, 2%

Alcohol Use, 3%

Family History, 5%

Occupation Factors, 5%

Other, 16%

Tobacco Use, 32%

Adult Diet, 32%

Source: The Harvard Report on Cancer Prevention

Research is ongoing and early findings suggest healthy lifestyles may reduce your cancer risk:

A diet rich in natural foods, fruits and vegetables, Maintain a healthy weight, Daily physical activity, Abstain from tobacco use, Moderate alcohol use, Limit sun exposure, Avoid known carcinogens, Protect yourself and your partner from sexually

transmitted diseases, Screening and early detection for cancer.

Reducing Your Cancer Risk

What Is Cancer?

Cancer is a disease characterized by:

• A series of changes in the cells and genes leading to abnormal cell proliferation (growth).

• Unchecked local growth (tumor formation) and invasion of surrounding tissue.

• Ability to spread (metastasize).

The term cancer refers to a group of more than 100 different diseases that begin in cells, the body’s basic unit of life.

What is Cancer?

How cancer cells develop

Cancer develops when changes occur within cells that effect the DNA.

DNA contains genes that are programmed to perform specific tasks.

Changes or “mutations” in the DNA lead to the development of cancer.

Abnormal Cell Growth:

Increasing number of

dividing cells

Growing mass of tissues

(Tumor)

Benign Malignant

The gradual increase in the number of dividing cells creates growing mass of tissue called a “tumor.”

Tumors can be benign (non-cancerous) or malignant (cancer).

Benign tumors do not spread to other parts of the body, are usually not a threat to life and are labeled by adding the suffix –oma to the tissue of origin (e.g. lipoma, adenoma)

Malignant tumors are cancerous cells that grow without control and invade or damage other parts of the body.

Benign vs Malignant Tumors

Metastasis is the spread of a malignant tumor from its primary (original) site to another part of the body.

Cancer cells may spread by blood capillaries and veins (most common route), seeding throughout body, or the lymphatic system. The most common sites are:

Bone Lung Liver Central nervous system

When Cancer Spreads

Metastasis: How cancer spreads

If melanoma, a type of skin cancer, metastasizes (spreads) to the liver, the cancer cells in the liver are melanoma cells.

The disease is called metastatic melanoma (not liver cancer).

Screening & Early Detection

Checking for cancer in a person who does not have symptoms of the disease is called screening.

The goal of screening is to improve outcomes – to reduce cancer deaths and enhance quality of life.

Cancer survival can be improved by screening and early detection for cancers of the breast, cervix, colon and rectum.

For other types of cancer, such as the lung, no reliable screening test currently exists.

The Importance of Cancer Screening

The chances cancer will be detected early are greatly improved by having regular health check ups and being aware of changes in your body.

During a physical exam, the provider will look for anything unusual, feel for lumps or growths, inquire about any cancer warning signs you may be experiencing, recommend tests needed and answer your questions.

The goal is to discover a cancerous tumor early before it grows and spreads.

Cancer Early Detection

Pay Attention To Your Body If There Is: Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening, lump, or swelling in the breast or any

other part of the body Indigestion or difficulty swallowing Recent change in wart or mole Nagging cough or hoarseness … along with unexplained weight loss, fever,

fatigue and pain that is present for several weeks or longer.

Possible Symptoms of Cancer:

Screening Rates in Older Alaskans

Older women having pap tests within past three years:

Alaska USAges 55-64 * 86.1% 87.8%Ages 65+ N/A 69.9%

Older women having mammography within past two years:

Alaska USAges 50-59 * 76.5% 79.7%Ages 60-64 * N/A 80.0%Ages 65+ 67.8%

75.1%

Source: Behavioral Risk Factor Surveillance System, 2004

* The Alaska Breast & Cervical Health Check offers free health screenings for women ages 18-64

Screening Rates in Older Adults

Older men and women ever having a sigmoidoscopy or colonoscopy for colorectal cancer screening:

Alaska USAges 50-59 41.8% 42.3%Ages 60-64 N/A 55.7%Ages 65+ 69.6%63.2%

Source: Behavioral Risk Factor Surveillance System, 2004

Screening Rates in Older Adults

Fear of cancer Lack of knowledge Modesty Communication Illness beliefs Access

Barriers to Cancer Screening and Early Detection in Elders

Breast Cancer Screening

Screening for breast cancer has been shown to reduce the risk of dying from the disease.

A high quality mammogram with a clinical breast exam is the most effective way to detect breast cancer early.

NCI recommends women in their 40s and older should have mammograms every 1 to 2 years.

Women at higher than average risk should talk with their health care providers about how often to be screened.

Breast Cancer Screening

Age - most important risk factor for breast cancer.

Personal history of breast cancer Family history Genetic alterations Certain breast changes on biopsy Reproductive and menstrual history:

Age of first childbirth Early menses or late menopause No childbirth experience Hormone Therapy

Breast density Diet and lifestyle factors Radiation therapy

Who Is At Risk for Breast Cancer?

In women ages 65 and older, 68% report having had a mammogram in the prior two years.

Medicare currently covers an annual screening mammogram for all eligible women over 40.

A physician’s referral is not required. There is no Part B deductible, however a

20% co-insurance or co-payment applies.

Source: Federal Interagency Forum on Age Related StatisticsCMS Medicare utilization, accessed May 31, 2006

http://www.medicare.gov/

Breast Cancer Screening and Medicare

Cervical Cancer Screening

It is recommended women of average risk have a Pap test at least once every three years.

Women 65-70 years of age who have had at least three normal Pap tests and no abnormal tests in the last 10 years may decide, upon consultation with their health care provider, to stop cervical screening.

Women who have had a total hysterectomy do not need to undergo cervical cancer screening, unless the surgery was done to treat cervical cancer.

Source: U.S. Preventative Services Task Force

Cervical Cancer Screening

Could I have cervical cancer and not know it?YES--often cervical cancer does not cause pain or other symptoms.

If I've gone through menopause, do I still need a Pap test?Most women still need to Pap tests. This decision depends on your age and past results. Talk with your health care provider about what’s right for you.

If I'm not sexually active now do I still need a Pap test?Women who are not currently sexually active may still need a Pap test. Almost all cervical cancer is caused by a sexually transmitted virus called the (HPV) Human Papillomavirus that can live in the body for many years.

Common Cervical Cancer Questions

High Risk – Annual Screening Medicare covers one Pap test and pelvic exam for women at high risk for cervical cancer, including those with an abnormal pap during the prior three years.

Low Risk – Every Two Years Medicare covers one Pap test and pelvic exam every two years for women at low cancer risk.

Breast Exam - A clinical breast exam is included as part of the Medicare pelvic screening benefit.

There is no Part B deductible and no cost for the Pap lab test, however a 20% co-payment applies for the pelvic and breast exams.

Source: CMS Medicare http://www.medicare.gov/

Cervical Cancer Screening and Medicare

Colorectal Cancer Screening

To find polyps or early colorectal cancer, adults of average risk in their 50s and older should be screened.

A health care provider may recommend one or more of the following tests, based on age, family history and risk factors:

Sigmoidoscopy Colonoscopy Fecal Occult Blood Test (FOBT) Double Contrast Barium Enema (DCBE) Digital Rectal Exam (DRE)

Colorectal Cancer Screening

The optimal interval for screening depends on the test and the provider’s assessment of cancer risk.

For the person at average risk, initial screening begins at age 50 and includes:Annual FOBT with a Colonoscopy every 10 years, or Annual FOBT with a Flexible Sigmoidoscopy every 5 years.

For individuals at high risk, screening needs to begin earlier and take place more often.

Source: U.S. Preventative Services Task Force

Colorectal Cancer Screening

Certain risk factors are associated with an increased risk of developing colorectal cancer:

Age Polyps Family history Familial Adenomatous Polyposis (FAP) Nutrition Physical activity Ulcerative colitis or Crohn’s colitis

Who Is At Risk for Colorectal Cancer?

Medicare coverage for colorectal cancer screening tests is based on the U.S. Preventative Services Task Force recommendations.

Despite coverage, Medicare claims suggest only 31% beneficiaries ever had a colorectal cancer screening test (1998-2002).

The Medicare deductible and coinsurance apply to this benefit. For screenings performed on an outpatient basis, the beneficiary is responsible for 20% of the approved Medicare amount.

Source: Federal Interagency Forum on Age Related StatisticsCMS Medicare utilization, accessed May 31, 2006 http://www.medicare.gov

Colorectal Cancer Screening and Medicare

Prostate Cancer Screening

There are two prostate screening to detect abnormalities:

Digital Rectal Examination (DRE) Prostate Specific Antigen Test (PSA)

These tests can indicate abnormalities, but cannot show if they are due to cancer or another, less serious condition.

Men should discuss prostate cancer screening with their health care providers and together weigh the potential benefits and harms of screening and follow-up procedures.

Prostate Cancer Screening

Medicare coverage includes the Prostate Specific Antigen (PSA) blood test and a digital rectal exam.

An annual digital rectal examination and PSA test is covered every 12 months, beginning at age 50.

Generally, you pay 20% of the Medicare approved amount for the exam after the yearly Part B deductible. There is no co-insurance and no Part B deductible for the PSA test.

Source: CMS Medicare http://www.medicare.gov/

Prostate Cancer Screening and Medicare

Cancer Diagnosis

Diagnosis of Cancer

Cancer Diagnosis

To diagnose the presence of cancer requires looking under a microscope at a sample of the affected tissue and the appearance of the cells to determine if it is benign (non-cancerous) or malignant (cancerous), the type of cancer (eg. sarcoma vs. carcinoma) and its “aggressiveness.”

Tissue can be removed for biopsy by: endoscopy needle biopsy surgical biopsy.

Types of Cancer

Five main groups of cancers:

CarcinomasSarcomasLymphomasLeukemiaMyelomas

Treatment decisions are based on knowing the type of cancer involved.

Diagnosis of Cancer

Once the diagnosis of cancer is made, knowing the “stage” of the disease tells how far the disease has spread and can inform treatment decisions.

In situ Early cancer that hasn’t spread

Local Cancer found only in the organ where it started to grow

Regional Cancer that has spread to surrounding tissues and lymph nodes

Distant Cancer that has spread to other organs and systems of the body

Determining the Stage of Cancer

Diagnosis of Cancer

Cancer Stages

Most cancers can be described as follows:

Stage 1 A cancerous tumor is found to be limited to the organ of origin. Stage 2 Cancer has spread to surrounding tissues and possibly local lymph nodes.Stage 3 There is extensive growth of the primary tumor and it is possible there are other organs involved. Stage 4 The cancer has spread far into the other organs and systems of the body.

Staging describes the extent or severity of cancer. Knowing the stage helps to plan treatments and estimate prognosis.

Cancer Treatment

Diagnosis of Cancer

Cancer Treatment

The cancer treatment may include the following:

Surgery Chemotherapy Radiation Hormone therapy Biological therapy Complementary and Alternative Therapies Clinical Trials “Watchful waiting”

Diagnosis of Cancer

Cancer Treatment Decisions Treatment decisions take into consideration

several factors:

Type of cancer Size of tumor Location Stage of disease Elder’s health status Treatment side effects Prognosis Quality of Life

Diagnosis of Cancer

Coping With Side Effects

Side effects and intensity vary, from person to person and even with each treatment. Eating well, continuing to be physically active, getting rest and support during treatment may ease side effects. Inform your health care team of side effects experienced and ask for assistance in treating pain, nausea, mouth sores, radiation burns and other treatment complications.

Diagnosis of Cancer

Becoming Well Again

Bringing a sense of balance back into life is important:

Getting back into a routine,

Resuming meaningful activities,

Choosing activities that have a purpose,

Spending time with friends and family,

Sharing stories and laughter,

Resting and taking care of themselves.

Elders benefit when they receive support and care.

Cancer Survivorship

Survivorship begins at the time of the cancer diagnosis and continues throughout the life of the elder.

Cancer is emerging as a chronic disease, rather than a terminal disease, for an increasing number of survivors.

In 1971, fewer than half of cancer survivors lived 5 years beyond diagnosis. Today the 5 year cancer survival rate is 65% for adults and 79% for children ages 14 or younger.

Families are also survivors - 3 out of every 4 American families have been impacted by cancer.

Source: NCI Office of Cancer Survivorship http://survivorship.cancer.gov

Cancer Survivorship

Cancer Site 1995-2001All Sites 65%Prostate 100%Melanoma 92%Urinary Bladder 82%Breast (female) 75%Rectum 65%Colon 64%Non-Hodgkin Lymphoma 60%Leukemia 48%Ovary 45%Lung and Bronchus 15%Pancreas 5%

Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 6.0 Statistical Research and Applications Branch, NCI, 2005. http://srab.cancer.gov/devcan

5 Year Cancer Survival Data, US

Ways to lower your cancer risk Importance of screening and early detection Facing a cancer diagnosis Making informed treatment decisions Questions to ask your health care provider Finding the latest, most accurate cancer

information Receiving support during cancer treatment Fears that cancer will come back Accessing palliative care and pain relief Advance directives and end of life planning

Important Cancer Conversations To Have With An Elder You Care For

Resources for Cancer Information

Resources for Cancer Information

National Cancer InstituteWeb site: http://www.cancer.gov/Live help (email) Monday through Friday, 5 AM – 7 PM AST

NCI’s Cancer Information Service:1-800-4-CANCER (1-800-422-6237)TTY: 1-800-332-8615Please Call Monday through Friday, 9 AM – 4:30 PM AST

Offering the latest, most accurate cancer information

Thank You!