Geographic variation in cancer treatment for the elderly

About the project:

The risk of developing cancer increases with age. The significant rise in the number of new cancer cases expected in the future will particularly occur among the elderly due to an aging population in Norway. Approximately 17,600 individuals over 70 years old were diagnosed with cancer in 2018, while it is estimated that the number of new cases in this age group will exceed 25,000 by 2030. A large increase in the number of patients living with cancer who will have significant needs for health and care services after undergoing cancer treatment is also expected. This will place demands on capacity and quality in both specialist and primary healthcare services, on the collaboration between service levels, and on relatives as caregivers.

Significant differences in health status among elderly cancer patients require individualized adaptation of cancer treatment. Older patients may have vulnerability factors that reduce their tolerance for cancer treatment, which affects treatment choices and follow-up. Comorbidity, medication use, functional level, cognitive function, social network, and treatment goals are among the factors that should be considered in the cancer treatment of older patients. Furthermore, older cancer patients have been significantly underrepresented in oncology studies. Those included are often those with good functional levels and little comorbidity. Evidence-based knowledge about treatment choices for older cancer patients is therefore lacking. A possible consequence is that variation in clinical practice, with the risk of under- and overtreatment, affects older cancer patients more than younger ones.

Equitable cancer treatment means that age alone cannot be a criterion for access to high-quality cancer treatment. Nevertheless, it seems that older cancer patients are both at risk of undertreatment, as they do not receive appropriate and effective treatment based on chronological age, and overtreatment when insufficient consideration is given to frailty. The prevalence of frailty and comorbidity is high among older patients with cancer. Frailty is a clinical condition characterized by increased vulnerability when the patient is exposed to stressors such as chemotherapy and surgery. To identify patients at increased risk for complications, hospitalizations, and shorter life expectancy, a comprehensive geriatric assessment of older cancer patients is recommended.

Project Purpose

This project provides an opportunity to uncover whether geographic variation is associated with different morbidity among patients in various catchment areas, whether the patient's or family's socioeconomic status or travel distance to treatment has an impact, or whether geographic differences in structural conditions such as service organization lead to variation in usage. Results from the project can thus provide better insight into which factors may cause unwanted variation in cancer treatment.

Research Questions

1. Is there geographic variation in the use of minimally invasive surgery, adjuvant chemotherapy, and curative radiotherapy for older patients? Does the use of adjuvant chemotherapy and curative radiotherapy align with professionally recognized guidelines?
2. What factors at the patient, family, municipality, and organizational levels contribute to explaining variation in the use of minimally invasive surgery, adjuvant chemotherapy, and curative radiotherapy for older patients? Is there socioeconomic variation, differences in offerings, or other systematic differences indicating unjustified variation?
3. What explanations do northern Norwegian doctors in oncology and geriatrics provide for geographic and/or socioeconomic variation in the use of minimally invasive surgery, adjuvant chemotherapy, and curative radiotherapy for older cancer patients? How do the doctors assess the research findings against justified and unjustified variation? What explanations do user councils at northern Norwegian health enterprises provide for geographic and/or socioeconomic variation in the treatment of older cancer patients, and how do they evaluate the research findings against justified and unjustified variation?