1. GET A DiAGNOSiS
No matter how "typical" the signs and symptoms, first impressions are sometimes wrong. That unusual vaginal bleeding or pelvic pain that you are having may well be benign. A diagnosis helps you and your family understand what to expect and how to prepare for the future, even if you cannot get curative treatment. Knowing the diagnosis also helps your doctor treat your symptoms better. Many people find "not knowing" very hard and are relieved when they finally have an explanation for their symptoms. Sometimes a frail patient is obviously dying, and diagnostic studies can be an additional burden. In such cases, it may be quite reasonable to focus on symptom relief (palliation) without knowing the details of the diagnosis.
2. know the cancer's stage
The cancer's stage defines your prognosis and treatment options. No one can make informed decisions without knowing the stage. Just as there may be times when the burdens of diagnostic studies may be too great, it may also be appropriate to do without full staging in very frail, dying patients.
Cervical cancer is staged clinically, not surgically. As it is in younger patients, stage is determined based on evidence of the cancer spreading outside the cervix through an exam, chest X-ray, or kidney scan. Factors, such as the depth of the tumor, the presence or absence of cancer in lymph nodes, or spread (metastasis) to other organs not seen on a chest X-ray are important in determining prognosis, but do not affect the cancer's stage. However, in order to predict the impact of cervical cancer on your life expectancy and quality of life, doctors take into account both the cancer's stage and other evidence of spread outside the cervix, even if it does not alter the stage.
Anticancer treatment should be considered if you are likely to live long enough to experience symptoms or premature death from cervical cancer. If your life expectancy is so short that the cancer will not significantly affect it, there may be no reason to treat your cancer.
However, chronological age (how old you are) should not be the only determinant of how your cancer should, or should not, be treated. Despite advanced age, women who are relatively healthy often have a life expectancy that is longer than their life expectancy with cervical cancer. The average 70-year-old woman is likely to live another 16 years. A similar 85-year-old can expect to live an additional 6 years and remain independent most of that time. Even an unhealthy 75-year-old woman probably will live 5 more years, which is long enough to suffer symptoms and early death from metastatic cervical cancer.
It is important to be clear whether the goal of treatment is cure (surgery or radiation therapy, possibly with chemotherapy, for early stage cervical cancer) or palliation (treatment for incurable advanced cervical cancer). If the goal is palliation, you need to understand if the treatment plan will extend your life, control your symptoms, or both. How likely is it to achieve these goals, and how long will you enjoy its benefits?
When the goal of treatment is palliation, chemotherapy should never be administered without defined endpoints and timelines. It should be clear to everyone what "counts" as success, how it will be determined (for example, a symptom controlled or a smaller mass on your CAT scan), and when. You and your family should understand what your options are at each step and how likely each option is to meet your goals. If treatment goals are not clear, ask your doctor to explain them in words you understand.
In addition to the traditional goals of tumor response, increased survival, and symptom control, older cancer patients often have goals related to quality of life. These goals may include physical and intellectual independence, spending quality time with family, taking trips, staying out of the hospital, or even economic stability. At times, palliative care or hospice may meet these goals better than active anticancer treatment. In addition to the medical team, older patients often turn to family, friends, and clergy to help guide them.
Deciding how to treat cervical cancer in someone who is older requires a thorough understanding of her general health and social situation. Decisions about cancer treatment should never focus on age alone.
Your actual age (chronological age) has limited influence on how cancer will respond to therapy or its prognosis. Biological changes and other changes associated with aging are more reliable in estimating an individual's vigor and life expectancy as well as the risk of treatment complications. These changes include malnutrition, loss of muscle mass and strength, depression, dementia, falls, social isolation, and the ability to accomplish daily activities such as dressing, bathing, eating, shopping, housekeeping, and managing one's finances or medication.
Older cancer patients are likely to have chronic illnesses (comorbidities) that affect their life expectancy; the more they have, the greater the effect. This effect has very little impact on the behavior of the cancer itself, but studies do show that comorbidity has a major impact on treatment outcome and its side effects.
Fit older cervical cancer patients respond to treatment similarly to their younger counterparts. However, a word of caution is in order. Until recently, few studies included older individuals, and it may not be appropriate to apply these findings to the diverse group of older cancer patients.
The side effects of cancer treatment are never less in the elderly. In addition to the standard side effects, there are significant age-related toxicities to consider. Though most of these are more a function of frailty than chronological age, even the fittest senior cannot avoid the physical effects of aging. In addition to the changes in fat and muscle you see in the mirror, there are age-related changes in your kidney, liver, and digestive (gastrointestinal) function. These changes affect how your body absorbs and metabolizes anticancer drugs and other medicines. The average older woman takes many different medicines (to control, for example, high blood pressure, high cholesterol, osteoporosis, diabetes, arthritis, etc.). This "polypharmacy" can cause undesirable side effects as the many drugs interact with each other and the anticancer medications.
Healthcare providers and family members often underestimate the physical and mental abilities of older people and their willingness to face chronic and life-threatening conditions. Studies clearly show that older patients want detailed and easily understood information about potential treatments and alternatives. Patients and families may consider cancer untreatable in the aged and may not understand the possibilities offered by treatment.
While patients with dementia pose a unique challenge, they are frequently capable of participating in goal setting and simple discussions about treatment side effects and logistics. Caring family members and friends are often able to share the patient's life story so that healthcare workers can work with them to make decisions consistent with the patient's values and desires. This of course is no substitute for a well thought out and properly executed living will or healthcare proxy.
While it is hard to face the possibility of life-threatening events at any age, it is always better to be prepared and to "put your affairs in order." In addition to estate planning and wills, it is critical that you outline your wishes regarding medical care at the end of life and make legal provisions for someone to make those decisions if you are unable to make them for yourself.
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