594
Determinants of Cancer Therapy in
Elderly Patients
James S. Goodwin, M.D., William C. Hunt, M.S., and Jonathan M . Samet, M.D.
Background. Older patients with cancer are less
likely to receive definitive therapy, but the reasons for
this are unclear.
Methods. All people aged 65 years or older living in
six counties in New Mexico and diagnosed with breast,
prostate, or colorectal cancer between May 15, 1984 and
May 15,1986(N = 669)were interviewed to obtain infor-
mation on demographics, socioeconomic status, func-
tional status, social support, other medical conditions,
and cognitive status. Cancer treatment information was
obtained from the New Mexico Tumor Registry.
Results. In univariate analyses, the following vari-
ables were associated significantly with nonreceipt of de-
finitive therapy for cancer: advanced age, impairment in
activities of daily living, low physical activity, decreased
mental status, impaired access to transportation, and
poor social support. In a multivariate analysis with the
above variables along with measures of comorbidity,
only advanced age and decreased mental status remained
significant predictors of nonreceipt of definitive surgery,
whereas the effects of impaired access to transportation
and low physical activity remained relatively large but
no longer were statistically significant. When receipt of
surgery and receipt of radiation therapy were considered
separately, alder age, limited access to transportation,
impaired functional status, and impaired mental status
all significantly predicted nonreceipt of radiation ther-
apy, but not surgery.
Conclusions. There is a decline with age in the per-
centage of adults with cancer who receive definitive ther-
apy independent of other potentially explanatory factors
such as comorbidity. In addition, decisions about radia-
tion may be influenced by nonmedical, potentially
Presented in part at the American Society for Clinical Investiga-
tion, Washington, DC, May 5, 1990.
From the Department of Medicine and the New Mexico Tumor
Registry, Cancer Center, University of New Mexico School of Medi-
cine, Albuquerque, New Mexico.
Supported by a grant (CA 36592) from the National Cancer
Institute and by a Contract (NO "55426) from the Biometry
Branch, National Cancer Institute.
Address for reprints: James S. Goodwin, M.D., Geriatrics Divi-
sion, The University of Texas Medical Branch, 3.324 Jennie Sealy
Hospital, Galveston, TX 77555-0460.
Accepted for publication March 1, 1993.
correctable factors such as impaired access to transporta-
tion. Cancer 1993;72594-601.
Key words: cancer therapy, geriatric oncology, cancer,
dementia, functional status, comorbidity, access to care.
The incidence of most cancers increases with age, with
approximately half of all cancers diagnosed in those
older than 65 years of age.' The increasing importance
of cancer in the elderly has stimulated research on the
diagnosis and treatment of cancer in older people.
These studies have found problems of potential clinical
importance, comparing older and younger patients.
Specifically, several studies have suggested that cancer
at many sites is less likely to be diagnosed at a local
stage in elderly compared to younger subject^,^,^ and
that older patients with cancer are less likely to receive
definitive treatment than are younger patients after the
diagnosis of ~ancer.~-'O
Diverse reasons for age-related patterns in the
diagnosis and treatment of cancer can be postulated
readily. One plausible explanation is the increase in the
frequency and severity of comorbidity in elderly cancer
patients, which could both impair recognition of early
signs and symptoms of cancer and reduce the aggres-
siveness of diagnostic workups and treatment. Green-
field et a1.6found that the presence of comorbidity was
associated with less treatment of breast cancer in el-
derly women, but a substantial age effect on treatment
persisted after control for comorbidity. Other factors
that might affect treatment choice for cancer in the el-
derly include decreased social support, low economic
status, lack of information on efficacy and toxicity of
common cancer therapies in the elderly, and physician,
patient, or family bias against treating the elderly.7~''-'3
In a series of analyses using data on more than
22,000 patients in the New Mexico Tumor Registry, we
have shown that elderly patients tended less often to
receive "definitive treatment" for cancer-that is, treat-
ment generally accepted as potentially ~ u r a t i v e . It
~,~
was not possible using tumor registry data, however, to
Cancer Therapy in the Elderly/Goodwin et al.
determine if the changes in therapy with age were re-
lated to aging per se or to specific patient characteristics
such as comorbidity or decreased social support that
might accompany aging. To assess the role of patient
characteristics in the choice of definitive treatment, we
interviewed 800 residents of six New Mexico counties
aged 65 years or older and newly diagnosed with cancer
at selected sites.I4
The subjects in this population-based study com-
pleted an extensive interviewer-administered question-
naire designed to obtain information on living arrange-
ments, social support, functional status, cognitive sta-
tus, activity level, health status, use of health care
resources, economic status, and insurance coverage. In-
formation on stage of cancer at presentation and the
choice of cancer treatment was available from the New
Mexico Tumor Registry. This report describes the rela-
tionship between patient characteristics and choice of
cancer treatments in these elderly patients.
Methods
Case Selection
Subjects were ascertained through the New Mexico Tu-
mor Registry, which provides population-based cover-
age of all incident cancer cases, other than nonmelan-
oma skin cancer, in residents of New Mexico.I5People
selected for interview met the following criteria: age 65
years or older; resident in Bernalillo, Sandoval, Cibola,
Valencia, Dona Ana, or Santa Fe counties at the time of
diagnosis; race other than Native American; and diag-
nosed between May 15,1984 and May 15,1986 with an
incident cancer of colon, rectum, breast, uterus, uterine
cervix, prostate, thyroid, or buccal cavity, or with ma&-
nant melanoma. These sites were selected on the basis
of previous analyses of age and stage at diagnosis,*and
on the basis of availability of screening tests and effec-
tive therapy.I4
During the 2-year enrollment period, 1054 subjects
met the eligibility criteria for this investigation. We ob-
tained physician consent to interview 942 of the sub-
jects, and interviewed another 6 subjects for whom a
physician was not available. Of the remaining 106 sub-
jects, the physician refused to give consent for 67, and
consent was not obtained for some other reason for 39.
Of the 948 subjects or next-of-kin approached for inter-
view, completed interviews were obtained from 799.
We encountered 94 refusals; 28 subjects or their next-
of-kin were unavailable for interview; and 27 subjects
were not interviewed for some other reason. Detailed
comparisons of participants and nonparticipants have
been reported previ~usly.'~ For the analysis in this re-
port, we considered only the 669 patients with cancer of
595
the breast, prostate, and colon or rectum. The remain-
ing sites had too few cases for analytic purposes.
Data Collection
After physician consent was obtained, subjects or their
next-of-kin were interviewed in person in their homes.
Written informed consent was obtained at the time of
interview. All interviewers were bilingual; the inter-
view was conducted in Spanish for 32 of the 799 sub-
jects. Next-of-kin were interviewed if the index subject
was deceased (N = 53) or mentally incompetent (N =
60); the remainder of subjects were interviewed directly
(N = 686). The determination of whether the subject
was mentally competent to be interviewed was made
by a global impression of the interviewer and the next-
of-kin. To assess the validity of the information ob-
tained from the next-of-kin interviews, we obtained in-
formation on selected items on social support networks
and functional status from next-of-kin for all subjects.I6
There was good agreement between the answers from
the subjects and their surrogates on most items; there
was no evidence of bias in the surrogates' responses
and no effect of the subject's age or cognitive status on
level of agreement.I6 Most of the questions in the stan-
dardized questionnaire were referenced to the year be-
fore the development of symptoms related to the pres-
ent cancer. For subjects who reported no symptoms re-
lated to their cancer, the year before diagnosis by a
physician was used as the reference period. The year
before diagnosis also was used for subjects who had
symptoms longer than 2 years before diagnosis.
For the reference year, we assessed the living situa-
tion, social support, activity level, functional status, ac-
cess to transportation, health status, insurance cover-
age, use of health care services, and health practice^.'^
The subjects also completed a brief mental status exami-
nation.
The total physical activity score was computed by
first assigning scores of 0 through 6 for 17 specific activi-
ties based on the frequency that each was performed
during the reference year (e.g., cooking, housework,
grocery shopping, gardening, swimming, calisthenics).
A score of 0 was assigned for a frequency of less than
once a month, a score of 6 for daily; scores of 1 through
5 were assigned for intermediate frequencies. Scores of
6 for full-time employment, 4 for part-time employ-
ment, and 0 for not employed also were assigned. The
individual scores were summed to form the total activ-
ity score. The total activity score ranged from 0 through
57, with a median of 22. The 20th percentile was 14.
The social support network index was based on
that described by Berkman and Syme," and used pro-
cedures provided by Schoenbach et al. to compute the
596 CANCER July 15, 1993, Volume 72,No. 2
index." The social support index combines information
about the frequency of contact and the number of close
friends, children, grandchildren, siblings, and other rel-
atives living in the vicinity. The index also includes in-
formation on marital status and activity in church and
clubs. In our sample, the social support index ranged
from 1 through 12, with a mean of 5. The 25th percen-
tile was 2.
Functional status, the ability of the individual to
function independently in a variety of areas, was as-
sessed in several ways. We assessed activities of daily
living (ADLs) by the method of Katz et a1." The index
counts the number of the following activities that the
respondent required help with during the reference
year: bathing, dressing, going to the bathroom, getting
in or out of bed or a chair, and feeding himself or her-
self. We also obtained instrumental ADLs, which as-
sesses ability to cook, shop, do housework, and use
transportation.'* Information also was obtained on use
of assistive devices such as canes.
The brief mental status test was abridged from that
of Jacobs et al.," and assessed orientation, knowledge,
judgment, and short-term memory. It contained nine
items and was similar to that used in The Establishment
of Populations for Epidemiologic Studies of the Elderly
(EPESE) in East Boston, New Haven, and rural Iowa.23
Therapy for Cancer
All information concerning site, stage, and treatment of
cancer was obtained from the registry files. Registry
staff routinely visit all hospitals and radiation therapy
facilities in New Mexico and several outpatient clinics
in Albuquerque that administer chemotherapy. We des-
ignated as "untreated" those people who were without
a record of treatment in the registry file. We also devel-
oped lists of "definitive" therapies for local and re-
gional stage cancers of major sites, as detailed in a pre-
vious r e p ~ r t The
. ~ definitive therapies for the major
sites in this study were as follows:
Breast: subcutaneous mastectomy; complete simple
mastectomy; radical or modified radical mastec-
tomy; local stage also included lumpectomy, exci-
sion of lesion of breast, or excisional biopsy with
radiation within five months after diagnosis.
Colon: excision of lesion or intestine; ileocolectomy;
partial colectomy; complete proctectomy or abdo-
minoperineal resection.
Rectum: excision of lesion of rectum or intestine; ileoco-
lectomy or enterectomy; partial colectomy; com-
plete colectomy; partial proctectomy; complete
proctectomy.
Prostate: partial prostatectomy; radical prostatectomy;
complete prostatectomy; transurethral resection of
prostate; local stage also included all radiation ther-
apy within 5 months after diagnosis.
Data Analysis
Odds ratios for nonreceipt of definitive therapy were
computed for a variety of patient characteristics using
logistic regression as implemented in the SAS proce-
dure LOGIST.'4 For analyses of determinants of receiv-
ing definitive therapy, we further limited the analyses
to cases of colorectal, breast, and prostate cancer with in
situ, local, or regional stage at diagnosis (N = 565). Anal-
yses of determinants of not receiving any surgery or of
not receiving any radiation included the same subset of
subjects. "Any radiation" was defined as receiving any
beam radiation therapy within 4 months after initiation
of cancer-directed therapy. In an additional set of analy-
ses on the determinants for receipt of radiation, we in-
cluded all cases with cancer sites and stages for which
radiation therapy might be considered, although not
necessarily proven, to be an efficacious treatment. This
was determined by reviewing a handbook of cancer
the rap^,'^ and including all sites and stages where radia-
tion therapy was discussed as a potential therapy (local
or regional breast cancer after less than total mastec-
tomy; distant colon cancer; local and regional prostate
cancer after deleting incidentally found cancer; local
and regional rectal cancer and distant stage rectal
cancer after local surgery).
Initially, we assessed factors potentially influencing
receipt of definitive treatment individually. We used
logistic regression with nonreceipt of definitive treat-
ment as the outcome variable. All models included in-
dicator variables for site of cancer and stage of cancer at
diagnosis. We examined the independent variables
with and without the inclusion of a continuous variable
for age. We then included the variables having the
greatest effects in a single model; as before, terms for
site and stage were included and the model was com-
pleted with and without a variable for age. For these
analyses, we categorized the subjects in the following
manner: those who had difficulty performing any of
the activities of daily living versus those with no diffi-
culty; those scoring in the bottom 20% on the rating of
physical activity versus all others; those scoring in the
bottom 25% in the Berkman-Syme social support index
versus all others; and those listing any other medical
conditions that limited their activities(see above) versus
all others. The other categorizations noted on the Tables
are self-explanatory.
Cancer Therapy in the Elderly/Goodwin et al.
Table 1. Percentage of Patients Not Receiving Definitive
Treatment by Sex, Age, and Site of Cancer:
New Mexico, 1984-1986
~ ________~
Site of % not receiving
cancer Gender Aee (vr) definitive treatment*
Breast Female 65-74
75-84
85+
Prostate Male 65-74
75-84
85+
Colorectal Female 65-74
75-84
85+
Male 65-74
75-84
85+
* Only patients diagnosed at in situ, local, or regional stages are included. The
number of patients in each category is given in parentheses.
Results
Table 1 lists the percentage of subjects not receiving
definitive treatment. For breast and prostate cancer,
there was a clear increase in the percentage of patients
not receiving definitive treatment with increasing age,
in agreement with our earlier analyses of statewide
New Mexico Tumor Registry data.4,5 In the current
study, men with colorectal cancer were more likely to
receive definitive therapy than women; however, we
found no effect of sex on treatment in an earlier analysis
of more than 2800 New Mexico patients with colon
~ancer.~
In further analyses, we examined patient character-
istics other than age that predict not receiving definitive
treatment after a diagnosis of cancer. Table 2 presents
the odds ratios for not receiving definitive treatment in
relation to these specific patient characteristics. Im-
paired functional status, as measured by ability to per-
form ADLs or by a rating of overall physical activity,
was associated with not receiving definitive treatment
both before and after adjusting for age, although the
odds ratio decreased after controlling for age. Another
important predictor was ready access to automotive
transportation; those not driving a car or not living with
someone who drove a car had a more than threefold
risk of not receiving definitive treatment compared to
those with access to transportation. We have reported
previously that married men and women of all ages are
more likely to receive definitive treatment after the
diagnosis of cancer than are unmarried people.26We
again found this association, and a comparable effect of
overall social support on the likelihood of not receiving
597
definitive treatment. These associations decreased in
magnitude and were not statistically significant after
controlling for age.
Low income and low educational achievement
both were associated with increased odds ratios for not
7.5 (106) receiving definitive treatment, but neither of these odds
16.1 (56) ratios was statistically significant, and both declined
56.8 (16) substantially after controlling for age.
9.5 (126) Patient characteristics that were not associated with
14.9 (67) receipt of definitive treatment included ethnicity (His-
23.8 (21) panic versus non-Hispanic), history of depression, re-
7.5 (40) cent loss, alcohol consumption, knowledge about
10.0 (30)
cancer, having a personal physician, and regular use of
7.7 (13)
1.9 (53)
medical checkups or cancer screening. Surprisingly, we
0 132)
found only a small and statistically nonsignificant rela-
0 (5) tionship between the presence of other medical dis-
orders and not receiving definitive treatment (odds ratio
= 1.43; 95% confidence interval = 0.8-2.56 with age
adjustment). The finding, however, that functional sta-
tus as assessed by ADLs or total physical activity was
significantly associated with treatment suggests that the
overall physical condition of the patient did influence
treatment decisions.
Thus far, we have shown that, after controlling for
cancer site and stage at diagnosis, advanced age is asso-
ciated with an increased risk of receiving less than de-
finitive treatment after the diagnosis of cancer (Table 1).
In addition, a number of other patient characteristics
reflecting functional and cognitive status, social sup-
port, and access to transportation predict less than de-
finitive treatment, and several of these predictors act
independently of patient age (Table 2). Table 3 presents
the results of a multiple logistic regression model,
which estimates the independent effects of the more
strongly predictive or most plausibly predictive vari-
ables in the initial univariate analyses (Table 2). In this
model, advanced age was associated with increased
odds for receiving less than definitive treatment inde-
pendent of other patient characteristics.Access to trans-
portation also significantly predicted receipt of defini-
tive treatment. When age was included in the model,
the magnitude of the odds ratio associated with the
transportation variable decreased somewhat and was
no longer significant. Impaired cognitive status re-
mained a strong predictor of not receiving definitive
treatment regardless of the inclusion of age in the
model. Income, functional status, social support, and
the presence of other medical conditions were not sta-
tistically significant independent predictors of not re-
ceiving definitive therapy.
We further examined patient characteristics pre-
dicting choice of therapy by separately considering sur-
gical therapy and radiation therapy for cancer. Table 4
lists odds ratios for not receiving any surgical or any
598 CANCER July 25, 2993, Volume 72, No. 2

Table 2. Odds Ratios for Not Receiving Definitive Treatment After the Diagnosis
of Cancer, as a Function of Specific Patient Attributes, Adjusted for
Cancer Site and Stage, Without and With Adjustment for Age*
Odds ratio (95% CI)

Categories Without age W i t h age

Factor comuared adjustment adjustment
Activities of Some problem 2.08 (1.18-3.70) 1.41 (0.76-2.63)
daily living vs. no problem
Physical Bottom 20% vs. 3.23 (1.82-5.88) 2.1 7 (1.18-4.17)
activity all others
Drives or lives No vs. yes 3.57 (1.85-7.14) 2.22 (1.10-4.55)
with driver
Mental status Incompetent vs. 7.14 (2.86-16.67) 3.57 (1.35-9.09)
no errors
2 2 errors vs. no 4.17 (1.92-9.09) 3.70 (1.67-8.33)
errors
1 error vs. no 2.00 (0.97-4.17) 1.96 (0.93-4.00)
errors
Marital status Unmarried vs. 1.89 (1.06-3.33) 1.16 (0.61-2.22)
married
Social support Bottom 25% vs. 1.82 (1.02-3.23) 1.41 (0.77-2.56)
all others
Income < $10,000 vs. z 1.64 (0.93-2.94) 1.14 (0.61-2.13)
$10,00O/yr
Education < 12 yr vs. z 12 1.59 (0.93-2.78) 1.20 (0.68-2.13)
Y'
CI: confidence interval.
* Includes in situ, local, and regional stages of colorectal, breast, and prostate cancer (n = 565).

radiation treatment as a function of the patient charac- tion, poor functional status, and poor cognitive status
teristics that we had found to predict receipt of less than showed little influence on receipt of surgical therapy,
definitive treatment in the initial univariate analyses but all of these factors were associated with signifi-
(Table 2). Advanced age, impaired access to transporta- cantly increased odds for not receiving radiation ther-

Table 3. Multiple Logistic Regression Model for Predictors

of Not Receiving Definitive Therapy*
Odds ratio (95% CI)

Factor Categories compared Age not included Age included

Age Increase of 10 yr NA 1.95 (1.25-3.05)
Drives or lives No vs. yes 2.26 (1.16-4.83) 1.94 (0.90-4.16)
with driver
Mental status Incompetent vs. no errors 3.55 (1.20-10.53) 2.60 (0.85-7.96)
2 2 errors vs. no errors 3.61 (1.55-8.38) 3.53 (1.51-8.26)
1 error vs. no errors 1.94 (0.92-4.09) 1.93 (0.91-4.10)
Physical Bottom 20% vs. others 1.87 (0.93-3.75) 1.66 (0.82-3.38)
activity
Income < $10,000 vs. 2 $10,00O/yr 0.82 (0.42-1.58) 0.74 (0.38-1.45)
Activities of Some problem vs. none 1.04 (0.40-2.16) 0.90 (0.43-1.90)
daily living
Other medical Yes vs. no 1.03 (0.54-1.95) 1.11 (0.58-2.11)
conditions
Social support Bottom 25% vs. others 1.40 (0.75-2.61) 1.26 (0.65-2.32)
CI: confidence interval; NA: not applicable.
* Includes in situ, local, and regional stages of colorectal, breast, and prostate cancer (n = 565). Terms for site of cancer
and staee were also included in the reeression models.
Cancer Therapy in the ElderlylGoodwin et al.
Table 4.Odds Ratios for Not Receiving Any Surgery or Any Radiation Therapy
After the Diagnosis of Cancer*
Factor Categories compared
Age Increase of 10 yr
Drives or lives No vs. yes
with driver
Activities of Some problem vs. none
daily living
Physical Bottom 20% vs. others
activity
Mental status Incompetent vs. n o
errors
2 2 errors vs. no errors
1 error vs. no errors
CI: confidence interval.
* Includes in situ, local, and regional stages of colorectal, breast, and prostate cancer. Odds ratios computed from
separate logistic regressions with terms for site and stage. "No radiation" means no beam radiation therapy within 4
months after initiation of any cancer therapy. When mental status was categorized as any impairment vs. normal, the
odds ratio for surgery was 0.92 (0.55-1.54) and for radiation was 1.77 (1.13-2.77).
apy. When we included in this analysis only cancer sites
and stages where radiation therapy has been discussed
as a potentially efficacious treatment,25the odds ratios
increased. For example, the age-adjusted odds ratio for
not receiving radiation for people who did not drive or
live with a driver was 4.33 (95% confidence interval =
1.59-11.79) when only those sites and stages for which
radiation therapy was considered possibly appropriate
were included in the analysis.
Discussion
Cancer is a model disease for the study of health care
delivery to the elderly. Because it is a progressive, debili-
tating dwease that generally is fatal if left untreated, few
cases go entirely unrecognized, even in the elderly. Pop-
ulation-based cancer registries provide standardized in-
formation about incidence, stage at diagnosis, patterns
of treatment, and survival with a degree of validity not
readily achieved for other major chronic diseases. Thus,
the expanding literature on potential gaps in the treat-
ment of cancer in the elderly may reflect the availability
of data and not necessarily any unique vulnerability of
the elderly patient with cancer to undertreatment. We
anticipate that similar patterns of risks for delayed rec-
ognition and undertreatment exist for other diseases in
the elderly.
Several recent studies have found that older pa-
tients diagnosed with cancer are less likely to receive
definitive treatment than are younger patient^.^-"
These findings have prompted consideration of the ex-
tent to which age alone should be considered in decid-
ing on optimal treatment for cancer in the elderly."
Three findings of the current study are relevant to this
599
Odds ratio (95% CI)
No surgery No radiation
0.96 (0.66-1.40) 2.14 (1.47-3.12)
0.72 (0.26-1.99) 3.35 (1.28-8.76)
0.80 (0.40-1.60) 2.49 (1.34-4.62)
0.70 (0.37-1.31) 2.46 (1.31-4.64)
0.29 (0.64-1.32) 13.5 ( 1.78- 10 1.6)
1.18 (0.55-2.56) 1.60 (0.78-3.28)
0.99 (0.54-1.80) 1.44 10.86-2.401
discussion. First, advanced age predicts receipt of less
than definitive therapy for cancer independently of
other age-associated patient characteristics such as co-
morbidity, functional status, income, and social sup-
port. Thus, age is not merely a marker for other factors
that determine receipt of definitive therapy. Second,
within the elderly population, functional status, cogni-
tion, access to transportation, and level of social support
all are important determinants of whether patients
diagnosed with cancer receive definitive therapy.
Third, for the sites considered in this paper, these fac-
tors predict definitive treatment primarily through an
influence on receipt of radiation therapy, not on receipt
of surgery.
The choice of therapy after the diagnosis of cancer
is influenced by diverse factors other than site and stage
of the c a n ~ e r . ~ - ~So, me ~ ~ of
-'~these factors, such as the
general health and functional status of the patient, have
evident clinical significance and should be considered
in decisions about therapy. Other factors, not directly
relevant, have been identified as also associated with
choice of cancer therapy, such as marital sta-
t ~ s , ~economic
, ~ ~ ,status,29
~ ~ advanced and place
of r e s i d e n ~ e . ~ ~ , ~ '
The presence of disease conditions other than
cancer was not associated with choice of therapy in the
current study, in agreement with the findings of Mor et
al.' and Greenberg et al.,29but conflicting with the find-
ings of Greenfield et a1.,6who found that women with
moderate to severe comorbidity were less likely to re-
ceive definitive therapy for breast cancer. Greenfield et
aL6 used a more careful assessment of comorbidity, in-
volving chart review, than the assessment used in this
600 CANCER July 25, 1993, Volume 7 2 , No. 2
study, which involved patient report. It may be that
functional status and overall physical activity are better
indicators of the physical status of the patient than our
measure of comorbidity.
One might also postulate intuitively that a major
means whereby the physical status of the patient would
influence receipt of definitive treatment would be
through influencing decisions on surgery, in that the
more frail elderly might not be considered good candi-
dates for surgical therapy.31In actuality, it would ap-
pear that the patient’s condition influences decisions
about radiation therapy more than decisions about sur-
gery (Table 4).
Although several studies now have identified ad-
vanced age as a predictor for less than definitive treat-
ment, the roles of the physician and patient and other
factors in the treatment decision have not been ade-
quately addressed. Mor et al.,’ in their study of factors
influencing choice of cancer therapy, surveyed sur-
geons about their postsurgical treatment recommenda-
tions and found that patient-initiated reasons for not
choosing additional therapy were rare. In most cases,
further therapy was not pursued because the surgeon
did not think it was indicated.
One interesting finding in our study is the associa-
tion between receipt of definitive therapy and access to
transportation. When subjected to further analysis, this
association was explained entirely by the fact that those
who did not drive or live with a driver were very un-
likely to receive external beam radiation treatments.
When the analysis was limited to sites and stages for
which external beam radiation therapy is recom-
mended as a potential treatment, those who drove or
lived with a driver were more than four times as likely
to receive it. Although such an association may seem
understandable or even obvious, it is important to real-
ize the magnitude of the influence that access to trans-
portation has on treatment decisions. One-third of the
patients 65 years of age and older newly diagnosed
with cancer in New Mexico depend on others for trans-
portation; this figure increases to two-thirds for those
aged 85 years or older.” The other risk factors for less
than definitive treatment also are quite prevalent in this
population. More than 40% of the population had some
impairment of cognitive status; 24% had difficulty with
one or more ADLs; and 27% lived a10ne.l~In other
words, the increased risks for less than definitive treat-
ment associated with the factors in Tables 2 and 3 apply
to a large proportion of elderly New Mexicans diag-
nosed with cancer.
Some of these factors are potentially amenable to
intervention, but the treating physicians may not be
aware of these functional limitations in their patient^.^'
Consideration given to nonmedical factors such as pro-
vision of adequate transportation might be expected to
produce benefits for the health of the elderly patient
with cancer.
References
1. Yancik R. Frame of reference: old age as the context for the
prevention and treatment of cancer. In: Yancik R, editor. Per-
spectives on prevention and treatment of cancer in the elderly.
New York: Raven Press, 1983:5-17.
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