The aging population implies important changes at various levels. From the ancient years to the 19^th century, life expectancy doubled from 20 years to 40 years. However, this life expectancy doubled fast to 80 years from the 19^th century to the 20^th century and continuously increased in the 21^st century ⁽¹⁾. This fact implies important socioeconomic and health challenges. Aging entails a greater need to care for aspects related to primary aging

(physical changes due to aging) and to secondary aging (ailments with risks increase in old age)⁽²⁾.

Based on estimates reported by The World Health Organization (WHO), people aged 65 years and over will be expected to reach 800 million in the year 2025⁽³⁾. Undoubtedly, cancer risk increases exponentially with age. About 60% of cancers occur in people aged >65 years. Furthermore, about 70% of the deaths caused by cancers occur in this stage. Therefore, cancer is a disease of old age⁽⁴⁾. Because of disproportionately high incidence of most cancer types in older adults, cancer care for older patients has attracted increasing attention^(5,6).

Geriatric oncology can be considered a specific expertise within clinical oncology⁽⁷⁾. As most cancers occur in older people, all oncologists and health-care workers should be aware of these particularities. Geriatric oncology presents unique age-specific challenges, including competing health and socioeconomic factors, but also age-related changes in tumour biology that might have an effect on screening, diagnosis, treatment, and outcome.

Based on the report released by WHO, and International Cancer Research Institute in the year 2012, approximately 14 million new cases were seen in the whole world, while this figure will be expected to rise to 22 million within the next 20 years leading to an increase in the global cancer burden. Because of limitations in the application of screening programs, early diagnosis, and access to treatment, further increases in the incidence of cancer, and cancer-related mortality rates have been foreseen^(8,9).

In cancer therapies of geriatric patients, presence of other concomitant health problems of elder individuals (cardiovascular diseases, diabetes etc) can affect treatment decisions. Presence of these medical problems, chemotherapy, radiotherapy, and surgery can increase the risk of post-treatment complication rates. Other additional factors as life expectancy, and drug interactions should be also taken into account⁽¹⁰⁾.

Therefore, this research was planned in the tertiary care centre to study the clinical profile, prognosis and outcomes of various types of malignancies in elderly patients (age> 65 years).

The present prospective observational study was conducted for a duration of 2 years on 80 elderly patients of age ≥65 years (no upper age limit), histologically proven of malignancy and taking standard treatment with either radiotherapy or chemoradiotherapy in a tertiary care centre. Patients of age <65 years and not consenting for the study or refusing for the treatment, were excluded.

A complete history of the eligible patients was taken. History of presenting complaints, addictions, existing comorbid conditions, past history and history of existing medications was noted. The history of planned treatments viz chemotherapy, radiotherapy, hormonal therapy supportive palliative care and 15 surgeries undertaken was noted.

Occurrence of adverse events during treatment and follow up period was noted. Follow up was done till 6 months and major events like death or major adverse events were noted. Charlson Comorbidity Index calculation was performed The scoring of CCI was done using an online calculator Following scoring items were used. The total score of the CCI consists in a simple sum of the weights, with higher scores indicating not only a greater mortality risk but also more severe comorbid conditions.

Calculation of sample size:

Sample size calculated by Fisher’s formula⁽¹¹⁾ Sample Size (n) = Z²PQ/L²

For 99% confidence interval, value of Z=2.576. Calculation of Prevalence/Incidence (P): As per the Cancer Statistics, 2020: Report From National Cancer Registry Programme, India⁽¹²⁾, The projected incidence of patients with cancer in India among males was 679,421 (94.1 per 100,000) and among females 712,758 (103.6 per 100,000). Since we are considering both the genders, we considered incidence of 100 per 100,000. Thus, incidence, P= 0.1%, Q= (100-P) =99.9% and L=Type 1 Error percentage. We considered type 1 error of 1%. Calculated Sample Size was 66.29. To make provision for the incomplete or inaccurate data, withdrawal of consent, drop out and loss to follow up etc an estimated 20% is added to the calculated sample.

Therefore, the final sample size came to 66.29+0.2x66.29=79.55. Rounded off to 80.

Primary data was collected using paper-based Case Report forms. Collected data was entered in the Microsoft Excel spreadsheets 2016. Statistical analysis was performed on IBM SPSS Statistics Version 20. Distribution was represented by pie charts or bar graphs. Continuous variables were expressed in the descriptive statistics tables as means, standard deviation, median, maximum and minimum value. Average values were compared using independent sample t test. P value < 0.05 was considered significant and p value < 0.01 was considered highly significant.

This prospective Study enrolled total 80 Patients of age >65 years of age having Histopathologicaly and radiologically confirmed malignancy. The cases were followed up for six months and the Observations of the study were tabulated as follows.

Table 1. Demographic Profile of the patients:

There was male preponderance with total 58.75% males and 41.25% females. The gender ratio (M:F) was found to be 1:0.7. There were 43.75% of patients who were 65 years old, 33.75% of patients who were 66 to 70 years old, 16.25% were in the age group 71-75 years and remaining 6.25% patients were older than 75 years. Patients living in urban areas represent the majority of the population (63.75%) while 36.25% of patients stayed in rural areas.

Table 2. Distribution of addiction and comorbidities of the study participants.

Alcohol, smoking, and tobacco chewing were the most common addictions among patients, each accounting for 28.75%, 26.25%, and 18.75% of the total. Majority (37.5%) of patients had hypertension, 22.5% were diabetic, and the remaining patients had various comorbid diseases. There was total 87.5% patients with at least one comorbidity. 47.5% had single comorbidity, 25% had 2 associated comorbidities whereas 15% had more than 2 comorbidities. Only 12.5% cases were devoid of any comorbidity.

The minimum score noted was 10 and maximum was 14. 36.35% had CCI Score of 12. 27.5% cases had score of 10 and score of 14 was found among 2.5% cases.

The average CCI in survivors was 11.09±0.9 whereas in mortality group average CCI was 12.55±0.9. The mean difference between average CCI score was statistically significant. (p<0.001)

Table 3. Distribution of chief complaints.

The majority of the patients (40%) complained of weight loss, followed by 23.75% who reported loss of appetite, 28.75% reported fever, and the 18.7% reported being easily fatigued.

Altered sensorium was reported by 11.25% cases. Episodes of hematemesis were experienced by 6.25% cases. Weakness in the limns was reported by 3.75% cases. Abdominal pain and vomiting and dizziness were reported by 2 cases (2.5%) each.

Distribution based on localization of Primary tumor:

The most common malignancy noted (23.75%) was breast cancer. It was distantly followed cases of prostate cancer (12.5%). 11.25% had colorectal and cervical cancer, 8.75%% had bladder and stomach cancer each, and the remaining 6.25% had Lung, 6.25% oral cancer, 3.75% kidney cancer and in 5% cases lymph nodes were involved.

Table 4. Distribution of duration of hospital stay:

Maximum 47.5% of cancer patients admitted to the hospital were admitted for less than a week, followed by 26.25% on a day-care basis, 20% for longer than a week to a month, and the remaining 6.25% for longer than a month.

Details of Treatment:

The majority of the patients (42.5%) received chemotherapy, 31.25% received radiotherapy, 27.5% were receiving the greatest supportive care, 16.25% received hormone therapy, and the remaining 15% patients underwent surgery.

Table 5. Details of Treatment:

After the follow up for nearly 6 months, 13.75% of cancer patients died and 61.25% cases were continuing with follow up visits for treatments whereas 25% cases were lost to follow up. About 25% patients lost weight in the range of 3.1-5 kg during treatment whereas 15% cases lost weight > 5kg. Overall, 49 cases (61.25%) lost weight during the treatment.

88.5% of all patients completed the prescribed treatment without any interruption. Weight loss is more in elderly patients receiving concurrent chemo-irradiation. 10 patients had interruption in the chemotherapy but were able to complete the chemotherapy. 6 patients were initially planned for chemotherapy but were changed to radiotherapy alone after 2 cycles in view of their poor tolerance.

The reason for increasing attention for cancer care for older patients is because of disproportionately high incidence of most cancer types in older adults^(5-6). In cancer therapies of geriatric patients, presence of concomitant health problems of elder individuals can affect treatment decisions. Presence of co-morbidities, chemotherapy, radiotherapy and surgery can increase risk of post-treatment complication rates. Other additional factors as life expectancy, and drug interactions should be also taken into account⁽¹⁰⁾. Therefore, this research was planned in a tertiary care centre to study the clinical profile and various types of malignancies in elderly patients. (Age >65 years) and to study the prognosis and outcomes of malignancy in them.

In our study, there were 43.75% of patients who were 65 years old and 33.75% of patients who were 66 to 70 years old. In a study conducted by Preethi et al (2022)⁽¹³⁾, 32.94% of the cases belonged to the category of 51-60 years, followed by 29.47% of cases which belonged to the category of 61-70 years. Kone et al (2019) ⁽¹⁴⁾ showed that the most represented age groups were 33 - 47 years old with 45.5% and 48 - 62 years old with 39%. In our study, there was male preponderance with total 58.75% males and 41.25% females. Comparable findings are seen in a study conducted by Wilson et al (2021)⁽¹⁵⁾, 62% of the patients were males. Similarly, Vasanth et al (2018)⁽¹⁶⁾, out of 200 patients, 123 were males and 77 were females, which was in concordance with our study.

In our study, patients living in urban areas represent the majority of the population (63.75%) while 36.25% of patients stayed in rural areas. However, in another study conducted by Preethi et al (2022)⁽¹³⁾ most of the cases (120/173 - 69.36%) belong to rural areas, and 30.63% of cases belong to urban areas.

In our study, maximum 47.5% of cancer patients admitted to the hospital were admitted for less than a week, followed by 26.25% on a day-care basis and 20% for longer than a week to a month. Our findings are in accordance with the study by Wilson et al (2021)⁽¹⁵⁾, 80.52% of the patients were admitted to hospital for less than a week, followed by 18.89% patients were admitted for more than a week to less than a month and 0.59% of the cases were admitted for >1 month.

In our study, alcohol, smoking, and tobacco chewing were the most common addictions among patients, each accounting for 28.75%, 26.25%, and 18.75% of the total. Preethi et al (2022)⁽¹³⁾ reported similar findings, majority (82.08%) were smokers. Only 17.9% cases were non-smokers. Similarly, Vasanth et al (2018)⁽¹⁶⁾, it was found that 14% of patients, i.e., 28 out of 200 had a history of active alcohol consumption, and 27% of patients were active smokers.

Majority of the patients (37.5%) of patients had hypertension, 22.5% had diabetes, 18.75% had IHD, 8.75% had CKD and 5% had COPD in our study. In a study by Emilio et al (2019)⁽¹⁷⁾ revealed that comorbidities of cardiovascular origin (hypertension and ischemic heart disease) were most frequent, at 40% patients, followed by diabetes mellitus 19% patients and dysthyroidism in 13%. Another study by Vasanth et al (2018)⁽¹⁵⁾, most of the participants had neurological diseases 51% followed by endocrinological diseases 49%, cardiovascular diseases 48.5%, respiratory diseases 46.5%, genitourinary diseases 36.5%, gastrointestinal diseases 23%, haematological diseases 20.5% and musculoskeletal diseases 15.5%.

The majority of cancer patients (23.75%) had breast cancer, 12.5% had prostate cancer, 11.25% had colorectal and cervical cancer, 8.75% had bladder and stomach cancer each. In study by DeSantis et al (2019)⁽¹⁸⁾ among men aged 85 years and older, prostate and lung cancers are the most common causes of cancer death, together representing 40% of cancer deaths. Among women, lung cancer is the leading cause of cancer death (19%) followed by breast cancer (13%). In a study by Thakkar et al (2014)⁽¹⁹⁾, the many cancer sites and/or histology were studied like colorectal, pancreas, stomach, myelodysplastic syndromes, meningioma, lymphocytic leukaemia etc. Among these thirteen sites, colorectal cancer had the highest IR (376/100,000) followed by cancers of the pancreas and stomach. Statistically, males compared with females had significantly higher IR for colorectal, stomach, myelodysplastic syndromes, lymphocytic leukaemia and soft tissue tumours including heart.

The majority of the patients (42.5%) were receiving chemotherapy, 31.25% were receiving radiotherapy, 27.5% were receiving the greatest supportive care, 16.25% were receiving hormone therapy, and the remaining 15% patients underwent surgery in our study. Similar findings were seen in study by Emilio et al (2019)⁽¹⁷⁾, the treatments used were chemotherapy in 39.2% patients, biological therapies in 6.4% patients, radiotherapy in one patient (0.5%), and all three modalities in 15 patients (7.4%).

After the follow up for nearly 6 months, 13.75% of cancer patients died and 61.25% cases were continuing with follow up visits for treatments whereas 25% cases were lost to follow up. Wilson et al (2021)⁽¹⁵⁾ found that 21.07% of the patients died and 64.81% of the patients were discharged from the hospital. 

This study has explored the significant impact of malignancies in patients above the age of 65. The findings of this study have highlighted the need for early detection, timely treatment, and appropriate management of malignancies in this age group. The Charlson comorbidity Index was found useful in understanding the prognosis of these cases.

Our results showed that treatments in elderly patients was well tolerated with the same regimen used for younger patients. Definitive chemotherapy and radiation therapy in elderly patients was an effective treatment with tolerable number of major-increase in adverse events. Further research is needed to better understand the impact of age-related changes on the diagnosis, treatment, and outcome of malignancies in elderly patients.

1. Estape T. Cancer in the elderly: challenges and barriers. Asia-Pacific journal of oncology nursing. 2018 Jan 1;5(1):40-2.
2. Berger KS. The Developing Person Through the Life., 7th. Edition (Spanish Version) Editorial Médica Panamericana, SA, Madrid. 2014.
3. Kaptanoğlu AY. Yaşlı Sağlığı. T.C. Aile ve Sosyal Politikalar Bakanlığı. 2. Baskı. İstanbul: Nakış Ofset; 2012. pp. 1–144.
4. Marosi C, Köller M. Challenge of cancer in the elderly. ESMO open. 2016 Jan 1;1(3):e000020.
5. Pilleron S, Sarfati D, Janssen‐Heijnen M, Vignat J, Ferlay J, Bray F et al. Global cancer incidence in older adults, 2012 and 2035: a population‐based study. International journal of cancer. 2019 Jan 1;144(1):49-58.
6. DeSantis CE, Miller KD, Dale W, Mohile SG, Cohen HJ, Leach CR et al. Cancer statistics for adults aged 85 years and older, 2019. CA: a cancer journal for clinicians. 2019 Nov;69(6):452-67.
7. Joniau S, Balducci L, Bella M, Emberen M, Fitzpatrick J, Kaftan M et al. SIOG (international society of geriatric oncology) localized prostate cancer guidelines proposals in senior adult men. European Urology Supplements. 2008;7(3):300.
8. McGuire S. World Cancer Report 2014. Geneva, Switzerland: World Health Organization, International Agency for Research on Cancer, WHO Press, 2015. Adv Nutr. 2016 Mar 15;7(2):418-9
9. de Martel C, Ferlay J, Franceschi S, Vignat J, Bray F, Forman D, et al. Global burden of cancers attributable to infections in 2008: A review and synthetic analysis. Lancet Oncol. 2012;13:607–15.
10. Howlader N, Noone A, Krapcho M, Garshell J, Miller D, Altekruse S, et al. SEER Cancer Statistics Review, 1975-2012, National Cancer Institute. Bethesda, MD, 2015.1–101.
11. Vlassara H, Uribarri J, Cai W, Striker G. Advanced Glycation End Product Homeostasis. Ann N Y Acad Sci.2008 Apr; 1126(1):46–52.
12. Berggren J. Scopus preview - Scopus - Document details., Acta Chemica Scandinavica. 1971. 24(3); 3616–24.
13. Soh CH, Ul Hassan SW, Sacre J, Maier AB. Morbidity measures predicting mortality in inpatients: a systematic review. J Am Med Dir Assoc. 2020;21(4):462–468.
14. Extermann M. Measurement and impact of comorbidity in older cancer patients. Crit Rev Oncol Hematol. 2000;35(3):181–200.
15. Read WL, Tierney RM, Page NC, Costas I, Govindan R, Spitznagel EL, et al. Differential prognostic impact of comorbidity. J Clin Oncol. 2004;22(15):3099–3103.
16. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383.
17. Chan CH, Maddison C, Reijnierse EM, Lim WK, Maier AB. The association of comorbidity measures and mortality in geriatric rehabilitation inpatients by cancer status: RESORT. Support Care Cancer. 2021 Aug;29(8):4513-4519.
18. Lucas KV, Christine HF, Noticewala S, Paul JH, Nguyen C, Zakeri K et al. Comparison of Comorbidity and Frailty Indices in Patients With Head and Neck Cancer Using an Online Tool, JCO Clinical Cancer Informatics 2018:2, 1-9.
19. Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL et al. ICMR-NCDIR-NCRP Investigator Group. Cancer Statistics, 2020: Report From National Cancer Registry Programme, India. JCO Glob Oncol. 2020 Jul;6:1063-1075.