Geographical 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 ageing 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 substantial increase is also anticipated in the number of patients living with cancer who will have significant needs for health and care services following cancer treatment. 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 necessitate individual adaptation of cancer treatment. Older patients may have vulnerability factors that reduce their tolerance for cancer treatment, which are important for 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 when treating elderly patients with cancer. Furthermore, older cancer patients have been significantly underrepresented in oncological studies. Those included are often those with good functional levels and little comorbidity. Evidence-based knowledge regarding 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, disproportionately affects older compared to younger cancer patients.

Equitable cancer treatment means that age alone cannot be a criterion for access to high-quality cancer treatment. Nevertheless, it appears that older cancer patients are both at risk of undertreatment, as they may not receive appropriate and effective treatment based solely 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 characterised by increased vulnerability when the patient is exposed to stressors such as chemotherapy and surgery. To identify patients at increased risk of complications, hospital admissions, and shorter life expectancy, a comprehensive geriatric assessment of older cancer patients is recommended.

Project Objectives

This project aims to uncover whether geographical variation is associated with differing 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 geographical differences in structural conditions, such as the organisation of service offerings, lead to variation in usage. Results from the project may thus provide better insight into which factors can lead to unwanted variation in cancer treatment.

Research Questions

1. Is there geographical 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 recognised guidelines?
2. What factors at the patient, family, municipal, and organisational 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 geographical 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 representatives from northern Norwegian health enterprises provide for geographical and/or socioeconomic variation in the treatment of older cancer patients, and how do they evaluate the research findings against justified and unjustified variation?