Prevalence of aging population in the Middle East and its implications on cancer incidence and care

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Annals of Oncology 23 (Supplement 7): vii11–vii24, 2013 doi:10.1093/annonc/mdt268

Prevalence of aging population in the Middle East and its implications on cancer incidence and care R. R. Hajjar1, T. Atli2, Z. Al-Mandhari3, M. Oudrhiri4, L. Balducci5 & M. Silbermann6* 1 Department of Medicine, American University of Beirut Medical Center, Beirut, Lebanon; 2Department of Geriatric Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey; 3National Oncology Center, The Royal Hospital, Muscat, Sultanate of Oman; 4Service de Medecine Interne, Mohamed Sekkat Geriatri Hopital, Casablanca, Morocco; 5Medicine and Oncological Sciences, University of South Florida, College of Medicine and Moffitt Cancer Center, Tampa, USA; 6Middle East Cancer Consortium, Haifa, Israel

The Middle East is a diverse and heterogeneous region where politics and religion pervade most aspects of life including health and health care. Countries of the Middle East (even microcosms within countries) can differ widely in religious practices, economic privileges, social structures, and cultural traditions. It is imperative that health care researchers have a seasoned understanding of the nuances that unite or separate different communities. Western stereotypes of the region are just that—characterizations that borrow from the collective psyche but seldom represent any single community or reflect government policies. More recently, sociopolitical unrest and evolving societal attitudes toward women’s rights, family structure, and urbanization have further stirred the mix. These factors inevitably have bearing on the health of the population, making a collective analysis of the region difficult and somewhat noncohesive. The challenge lies not in providing guidance necessary for managing the impending aging boom, but in broadening data collection in order to obtain a credible database on which these recommendations can be made. Nestled within this diversity, however, are certain generalizable truths—facts that call out for attention and dictate healthcare policy—not least of which is the demographic shift encompassing the region. Compared with developed countries, the population of the Middle East is young (Figure 1) [1–7]. The percentage of the population over the age of 65 in the Middle East and Northern Africa (MENA) is estimated at 4.7% (of a total population of 336 million) according to the World Bank

*Correspondence to: Prof. M. Silbermann, MECC, 15 Kiryat Sefer Street, Haifa 3467630, Israel. Tel: +972-4-8244794; Fax: +972-4-8346338; E-mail: cancer@mecc-research. com

2012 report [4]. The range varies from under 2% in the United Arab Emirates (UAE) to ∼10% in Lebanon. Over the past half century, the Middle East, along with Central Africa, has experienced the highest rate of population growth of all other regions worldwide. Fertility rates worldwide have declined over the past half century, but the onset of declining fertility in the Middle East has lagged behind the rest of the world and is a relatively recent trend. This has resulted in a ‘youth bulge’ which will have significant ramifications for health care provision in the not too distant future. At the same time, life expectancy has steadily increased in the Middle East. It was risen from ∼60 years in 1980 (58 years for men, 62 years for women), to over 70 years in most Middle Eastern countries presently (range: 69 years, Iraq – 80 years, Israel), although in some deprived communities, life expectancy falls far short of the mean. The projection is that in 35–40 years, the youthful masses will work their way up the population pyramid, and the geriatric population in the Middle East will surge. Not surprisingly, as in aging populations elsewhere, the fastest rate of growth will be in the very old. The World Health Organization (WHO) estimates that from 2000 to 2050, the rate of growth of the population above age 65 is projected to be 4%–5%, and the average annual growth rate of the oldest old (85 years and older) will exceed 5% in eleven Arab countries. In countries like Lebanon, the proportion of the elderly is already relatively high and will double by the year 2050. Other countries such as Qatar, Kuwait, and United Arab Emirates (UAE) should anticipate a fivefold or greater increase in the proportion of their geriatric population [7] and should allocate resources accordingly. An aging population gives rise to a shrinking workforce available to support the dependent elderly. However, with prudent foresight, sound economic policies, and political

© The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: [email protected].

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The Middle Eastern population is aging rapidly, and as aging is the main risk factor for cancer, the incidence and prevalence of that disease are increasing among all the populations in the region. These developments represent huge challenges to national and community-based health services. At the current state of affairs, most Middle Eastern countries require the cooperation of international agencies in order to cope with such new challenges to their health systems. The focus and emphasis in facing these changing circumstances lie in the education and training of professionals, mainly physicians and nurses, at the primary, secondary and tertiary levels of health services. It is imperative that these training initiatives include clinical practice, with priority given to the creation of multidisciplinary teams both at the cancer centers and for home-based services.

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stability, the current population structure of the Middle East can be turned into a demographic bonus. This demographic dividend refers to a population transition from a high birth rate to a low birth rate coupled with increased life expectancy (low death rate) as the developing nation evolves into an industrialized economic system. For a brief period of time in a nation’s history (typically lasting 20–40 years), the young dependent (age 1–14 years) enter the workforce at a similar or faster rate than the old dependent (over 65 years) exit it into retirement. A large population of younger people who are healthy, educated, and employed are capable of contributing to the national economy, thus the term ‘population dividend’. During this ‘window of opportunity’, the geriatric population increases without a corresponding increase in the support ratio or the cost of dependent care; in fact, the dependency ratio may decrease. The window of opportunity, however, does not last forever. In time, the age distribution changes again. As the growing middle-aged and older population moves into the dependent-age bracket, they are no longer replaced by younger productive cohorts due to descending fertility rates. According to the WHO Department of Aging 2000 report, most Middle Eastern countries will be entering the window of opportunity during this decade, and the window is expected to last until midcentury. It is during this lucrative period that the groundwork for future geriatric services should be firmly established and nurtured. Such services are varied and include retirement and rehabilitation centers, pension plans, home care agencies, palliative care programs, investment in geriatrictrained professionals and other human resources, public awareness campaigns, and much more. As other regions in the world, the Middle East is also undergoing marked changes in its population and its healthrelated issues. Once-dominant infectious diseases are now being replaced by chronic non-communicable diseases, which comprise 47% of the region’s burden of disease, and anticipated to rise to 60% by 2020 [8]. Hence, with the aging of the Arab countries’ population, maintaining health and independence in old age will become increasingly challenging.

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In a recent survey in nine Arab countries, the percentage of older adults suffering from at least one chronic disease ranged from 13.1% in Djibouti to 63.8% in Lebanon, with a rate of ∼45% in the majority of countries [9]. Cancer rates vary in the region, with elevated rates of lung and bladder cancer noted among men in Tunisia, Algeria, Jordan, Egypt, and Lebanon, and of breast cancer among women in Israel [10] and Lebanon [11]: age-standardized-rate (ASR) 91.9 and 71, respectively. Longevity brings with it chronic disease and increased resource utilization, and the Middle East is currently illprepared to handle either. Longevity also increases the lifetime cumulative risk for many types of cancer. Epidemiological studies show that all-cause cancer incidence peaks around age of 70. Over the next few decades, the incidence of cancer in the Middle East is expected to surge in parallel with the aging population. In fact, registry data already indicate an increasing regional burden of cancer. Naturally, it is not age alone that shapes cancer prevalence and outcome. An indolent preventive care culture and a lackadaisical approach to cancer screening, coupled with a high prevalence of cancer-promoting behavior such as smoking and a sedentary lifestyle, mean that many cancers present at an advanced stage when the only reasonable treatment option is palliative care. Behavioral risk factors also play an important role in the health and epidemiological transition. Missed opportunities to prevent or deal with risk factors earlier in life leads to an increase in the incidence and prevalence of cancer and its complications in old age. Wide variations have been reported in the prevalence rates of cigarette smoking across Arab countries: older men in Bahrain, Egypt, Jordan, Lebanon, Morocco, and Tunisia reveal a high prevalence of smoking (30%–50%); while it is much lower in Oman and the UAE (7%–15%) [12]. In several Middle Eastern countries, civil organizations and charity and religious associations have assumed a prominent role in care for older people; yet, their role has traditionally focused on institutionalized older people despite a culture that is unreceptive and intolerant regarding placing older parents in nursing homes and care centers [13]. The majority of vulnerable frail, severely ill or disabled older people remain in their homes. Consequently, there is an increasing demand for home-based care, yet this service remains underdeveloped and is rarely recognized by either the state or civil society in the region [13]. Unfortunately, cancer is often undiagnosed or is poorly controlled until serious complications arise, and paradoxically, use of hi-tech interventions for prolongation of life, is pushed beyond reasonable limits and is not matched by reasonable palliative care services. The current situation calls for initiatives for strong primary health care and the promotion of educated and well-trained health professionals willing to work in the community. The Middle East needs to develop models of holistic polyvalent integrated patient-centered health care provided at primary health care centers, which will be supported by a good referred to specialized care in tertiary medical centers. Moreover, emphasis should be placed on home-based services, which will involve informal caregivers such as family members. Cancer survival rates vary greatly in different populations, but generally fall short of Western standards. Only with a comprehensive approach that proactively combines national

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Figure 1. Past and projected growth of population over age 65 years by region. Compiled from multiple sources, and rounded to nearest half percent. 1–6 MENA: Middle East and Northern Africa.

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Owing to these changes in fertility and mortality rates since the 1970s, the proportion of the Turkish population aged 65 and over has increased. The ratio was 3.5% in 1940, 4.4% in 1970, and 7.3% in 2011. Projections predict a ratio of 10% for the year 2025, and 17% for 2050 [15, 16]. With the increase in the elderly population, old age dependency ratio has also increased over the years, from 6.5% to 8.2% between the years 1940 and 1970 reaching 10.8% today. The 2010 statistics indicate an elderly population of over 5 million within the total population. According to population projections for 2025, population size will reach 85 million and the share of elderly in this population will be 8.4 million. These data show that by the year 2025, 10% of the population will be age 65 and over and the old age dependency ratio will rise to 14.5% [15, 16]. In terms of population pyramids and changing age structures, Turkey has shifted from a high fertility rate society to a low fertility rate society. Its population pyramid has a wide base at the bottom between 1935 and 1985, while, after the year 1985, the pyramid began to narrow toward to the top, indicating a transition from a high fertility rate to a low fertility rate. From the first decade of the 2000s onward, the share of the young age groups within the population were quite static and predicted is that the population structure will remain static at least until the year 2023 (Figure 4). The ability to handle the challenges brought on by an aging population depends on the preparedness of the society. While developed countries gradually age within a time frame of 100 years, this pace of aging is faster in developing countries. With an increasingly elderly population, and the accompanying chronic diseases, disability, and dependency, the need for care and support will also increase. This situation calls for new arrangements in health care and social security systems [17]. The most common diseases of the elderly are hypertension, cardiovascular diseases, diabetes, chronic obstructive pulmonary disease (COPD), and cancer. With a rate of 22%,

Figure 2. Change in population and population growth rates (1935–2023).

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policies, stigma reduction, mass screening, early detection, education of professionals and of the public, and access to effective treatment will we begin to combat the increasing prevalence of cancer in the Middle East. Major strides are being taken by professional organizations such as the Middle East Cancer Consortium (MECC) and others to achieve just that, and early signs of success are already evident [14]. Sustained efforts over many decades are necessary to ensure that future generations will benefit from this fruitful endeavor. As many other countries in the world, Turkey is going through a demographic transition. With the influence of pronatalist policies, the population of Turkey doubled between 1927 and 1960, increasing from 13.6 to 28 million. During this period, the population growth rate peaked at 2.8%, and the total fertility rate was around six children per woman. After 1960, with the influence of anti-natalist population policies aimed at controlling fertility, the fertility rate began to decline and the population growth rate decreased to 2.5% in 1970, 2% in 1980, 1.5% during the first decade of the 2000s, and 1.35% in 2012. Projections predict a 0.8% population growth rate by the year 2023. Despite the decrease in the population growth rate since 1960, population size has increased constantly, reached 56 million in 1990 and 74 million in 2011. Projections show that the population will reach 85 million by the year 2023 [15, 16] (Figure 2). After the 1980s, the total fertility rate rapidly declined from five children to 2.16 with the influence of improvements in maternal and infant health, increased education levels, increased female participation in the labor force and heightened internal migration from rural to urban residence beginning in 1950s and accelerating in the last 30 years. In addition to these declining fertility rates, life expectancy at birth increased due to mortality rates and increasing longevity. Between the 1940s and the present, life expectancy at birth for men has increased from 30 to 71 and for women from 33 to 76. In 2023, this number is expected to reach 73 for men and 79 for women [15, 16] (Figure 3).

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Figure 4. Change in population pyramids (1935, 1985, 2008, 2023).

cancer is the second most common reason for death after cardiovascular diseases [18].

implications of aging on cancer and care Turkey As of 2012, Turkey’s population was 75 million, with 7.5% of the population 65 years old and over. With the aging of it is high young population, which is an advantage at present, Turkey will eventually have an older demographic structure [19]. Aging is one of the fundamental factors in the development of cancer. Given the fact that almost 60% of cancers are connected to aging, health policies in Turkey should be reconsidered in this context. Taking into consideration, the changing demographic structure of Turkey projected for the next 20–30 year period, this issue gains even greater importance.

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Both worldwide and in Turkey, cancer is the second leading cause of death after cardiovascular diseases. According to estimations for Turkey in Globocan 2008, the five most frequently seen cancers for males are lung, stomach, bladder, prostate, and colorectal, and for females, breast, colorectum, stomach, corpus uteri, and lung cancer. For both sexes, the most common cancer types are breast, lung, prostate, stomach, and colorectum [20]. According to the Turkish Ministry of Health Department of Cancer Control Database, the population aged 60 years or older accounts for 49.8% of total new cases by age group based on 2005 data. New cases in this age group constitute 41.7% for in women and 55.7% for men. The population aged 40 years or older accounts for 87.5% of total new cases, with new cases in this age group constituting 83.4% for women and 90.6% for men. These results clearly show that the most frequent cancer cases in Turkey are observed over 40 age group [21]. It was

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Figure 3. Change in life expectancy at birth (1935–2023).

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Lebanon Among Middle Eastern countries, Lebanon carries the distinction of having the oldest population. It is estimated that 10% of the population is above the age of 65 years, and 2.5% above the age of 85 – a small proportion compared with the

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United States and Western Europe, but quite high regionally [23–25]. With a total population of 4.2 million, Lebanon hardly lays claim to the largest absolute number of elderly residents, but it is the proportion of older persons that ideally guides healthcare policy and geriatric services in their journey towards maturity. It is projected that in 35 years, the number of Lebanese older than 65 will double. Life expectancy in Lebanon lags only slightly behind that of the US and currently stands at approximately 73.7 years for men and 76.9 years for women [24]. With a rapidly growing population and ever increasing life expectancy, a surge in illnesses that afflict the elderly is expected to follow, including many types of cancer. In fact, an increasing annual incidence of new cases of cancer in Lebanon has already become evident over the past decade. For many reasons, accurate demographic data are difficult to obtain in Lebanon. The last government population census was in 1932 – over 80 years ago! Internal surveys inevitably have political, sectarian, or economical agendas attached to them, and risk disturbing the delicate balance of power. Who is counted also counts. Palestinian refugees, accounting for 10% of the population, are variably included in demographic surveys, as are permanent migrant workers. Expatriates and part-time residents, who also account for no small number of Lebanese, vary seasonally and are a further statistical predicament. In lieu of government surveys, data collected by non-governmental organizations, academic institutions, and foreign interest groups are utilized. Such agencies include the World Bank, World Health Organization (WHO), International Red Cross, and US Census Bureau (International database), among others, and may carry their own biases. Not surprisingly, the data collected by diverse organizations for varying purposes can differ, sometimes by wide margins. The number of new cases of cancer in Lebanon has increased steadily over the past decade, according to the National Cancer Registry of the Ministry of Public Health and WHO [26]. In 2004, the most recent year for which data was provided, 7197 new cases of cancer were reported, representing a modest increase over the previous year. Cancer prevalence was split equally between the genders. The median age at time of diagnosis was 56 for women and 63 for men, and the combined gender age mode was around 70 years. The most common malignancy was breast cancer (19.7%), constituting almost one fifth of the total cancer load, followed by lung (10.8%), bladder (9.3%), colorectal (8.2%), and prostate cancer (7.7%) [26]. The great majority of these cases suffered needlessly (whether their disease was cured or not) and most likely did not get adequate pain relief or palliative care. The annual increase in cancer incidence over the past decade is a disturbing trend and is clearly not due to aging alone. Age-standardized rates in both sexes indicate other factors are involved. Expanded and improved registration methods likely explain the annual increase in incidence. The sharp increase in more recently collected estimates (over 9700 new cancer cases in 2009) is primarily attributed to inclusion of nonmelanoma skin cancer into the figures, a policy implemented after the 2004 data collection. This practice also ‘dilutes out’ other cancer cases, giving the appearance of declining incidence. Nevertheless, as the population ages, age itself becomes an independent and significant risk factor. It is estimated that in 2030, the number of

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calculated and assumed that the incidences of cancer between 2006 and 2030 in the mid-to long-term would increase by 1.5%–1.7% annually due to the aging population and by 1.6%–1.7% annually due to the effects of individual and environmental risk factors. In conclusion, it was estimated that the incidences of cancer would increase at an average of 3.1%–3.4% due to factors related to an aging population and individual and environmental risk factors [21]. In 2000, 13.1% of all deaths in Turkey were due to cancer and it is estimated that cancer-related deaths will rise to 14% in 2010, 15,2% in 2020, and 16.2% in 2030 [22]. Direct expenditures for cancer treatment constituted 11% of overall health expenditures in 2006 [18]. The expected rise in the prevalence and frequency of cancer will increase the financial burden of cancer treatment costs and the need for an efficient long-term cancer control strategy. The increase in number of new cases of cancer and of patients living with cancer will lead to an increase in the cost of treatment. Moreover, the cost of labor loss and economic productivity, especially the loss of qualified labor force, also increases the treatment cost. International studies show that the indirect costs of cancer far outweigh the direct costs of cancer. Turkey should consider this situation and take the necessary steps regarding cancer control programs in the coming decades in addition to other significant risk factors affecting cancer incidence. Cancer cases increase each year, yet with the new developments in medicine, effective cancer therapy is improving and life expectancy for cancer is increasing. This situation results in the prolongation of physical, mental, moral, social, and financial problems of the chronically ill patient. Palliative care, functioning on the basis of a multidisciplinary and holistic approach to alleviate the symptoms of cancer patients, constitutes a viable solution. Currently, however, there are very few specific palliative care units in Turkey. Home care for terminal stage patients is generally provided by the relatives in the Turkish-family structure. Specific clinics that currently provide palliative care support are found only in a few centers. With the increase in urbanization in the 2000s, and the growing number of people entering work force, the country’s socioeconomic structure has changed. Women find it difficult to combine work and caring for a patient. As in many developing countries, the current state of palliative care is not yet at the desired level in Turkey. A large proportion of cancers are potentially preventable. The most obviously available modalities in this regard are the avoidance of known and suspected carcinogenic exposures such as to tobacco smoke, occupational and environmental chemicals, excessive sunlight, as well as dietary factors such as excessive fat and smoked, salted and pickled foods. Although older individuals have potentially acquired a lifetime exposure to such carcinogens, they can still accrue benefits from lifestyle changes.

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physicians reported informing terminally ill patients about their diagnosis [30]. One third of physicians (33.3%) said they do not inform patients of the diagnosis, and 37.7% said they will only do so if the family wished them to. This lack of communication creates a missed opportunity to initiate the palliative process, and represents a more serious upstream problem: the belief that palliative care represents a failure of modern medicine. The family bond in Lebanon may be stronger than in Western countries, but on the other hand the emotional response to terminal illness and the inability to accept treatment failure may push physicians to futile overtreatment in many instances. When palliative care is well developed and well understood, it provides a viable alternative to such extreme terminal measures. However, education alone is meaningless without a supportive context. Palliative care is still not recognized as a proper discipline by the Lebanese health authorities. Consequently, no government reimbursement system exists for palliative care services, even as they pay for futile interventions. This jeopardizes sustainability and growth of the two privatelyrun palliative care programs, which are sustained by volunteers, grants, charity, and NGOs. Consequently, it is estimated that 5%–10% of patients who need palliative care in Lebanon receive it. Additionally, a growing number on non-cancer patients with chronic progressive conditions require pain management and palliative care. Lebanese law currently restricts the medical use of narcotics to cancer patients. They can only be ordered by a registered oncologist, after co-signature of a prescription provided by the Ministry of Health by a second oncologist, and only a two week supply can be dispensed. The opiate use per capita per year is a frequently used measure for availability and acceptability of pain management by country. In Lebanon, morphine use is at 1.1 mg/capita/year, compared with a world average of 4.9 mg/capita/year, and US use of over 70 mg/capita/ year [31, 32]. For obvious reasons, it is imperative to involve policy makers in the development of pain relief and palliative care services. But hope is not far. On 4 May 2011, a National Committee for Pain Relief and Palliative Care was established by the Ministry of Health. This committee built on previous workshops and symposiums dating back to 1995. It is working towards delivering a national comprehensive palliative care plan in Lebanon through implementing changes to current attitude and legislation towards pain relief and palliative care. Its members reflect the interdisciplinary approach to pain management and palliative care, and represent the commitment of multiple academic institutions and community organizations. The committee focused on four broad areas: education, practice, research, and public policy, and these sub-committees have been active in championing the message of palliative care. With this renewed energy, our goal is to influence the legislative system in Lebanon to recognize palliative care as an indispensible specialty and integrate it into mainstream medicine.

Sultanate of Oman Oman has undergone a significant demographic transition since the 1970s. Life expectancy has increased from 50 years of age in

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new cases of cancer in Lebanon will approach 12000, excluding non-melanoma skin cancer [20]. It will be necessary to have an integrated palliative care system in place that functions across disciplines and settings, and qualified personnel to lead the effort. To meet that goal, significant obstacles must be overcome today. The worldwide increase in aging patients and cancer cases has been met with a severe shortage of geriatricians and palliative care specialists. In Lebanon, the problems is further amplified by the absence of fellowship training programs in geriatric medicine or palliative care. Only recently have medical schools introduced geriatric instruction to their curricula. All medical and nursing schools now offer some form of instruction on death and dying, but this is only a recent development and provides nominal exposure at best. Formal training in end-oflife care continues to be overlooked by the majority of training programs. Even well-intentioned programs do not have the human resources to achieve their goal. The Lebanese healthcare system is primarily dominated by the private sector. Nationwide, there are seven medical schools, nine nursing schools, over 130 medical oncologists, 15 radiotherapists, 12 geriatricians, and only one board certified palliative care specialist (though other qualified professionals practice palliative care). The magnitude of the deficit can be put in perspective by examining the doctor-to-patient ratio. In the United States, there is currently one geriatrician for every 2600 Americans over the age of 75; by the year 2030, this ratio is projected to drop to 1:4200 [27]. By way of comparison, current estimates in Lebanon indicate a ratio of one geriatrician for every 9000 person over 75 … and one lonely palliative care specialist. For many reasons, too few physicians-in-training are exposed to geriatric medicine and palliative care early and often enough to experience their rewards. Compounding insufficient human resources is the culture in which medicine is practiced in Lebanon. Most cancers are diagnosed in advanced stages; when symptoms alert to the presence of disease and the cancer is incurable. Outcome studies indicate a worse prognosis in Lebanon compared with western standards, and early diagnosis is essential if we are to improve cancer outcome [28]. The concept of regular cancer screening is yet to be ingrained into the disposition of clinicians and patients. Enhanced, early, and persistent (re)education is necessary to achieve this goal. It is the duty of all health care providers to promote preventive care. Reinforcing the value of implementing standards of primary and preventive measures (and rewarding clinicians who abide by these standards) is an easily achievable start. From the patient standpoint, highly visible and culturally sensitive public awareness campaigns are effective and affordable. High risk behavior, primarily smoking, must urgently be addressed. The prevalence of smoking in Lebanon is among the highest in the world – 46% in men, 28% in women [29]. Cumulative risk, coupled with longevity, makes smoking by far the single most modifiable cause of cancer. Another serious deficit of the education system is the attitude of professionals towards the dying process. The inability or refusal of clinicians to discuss terminal issues with patients and their caregivers has become part of the culture resulting in unnecessary anguish and suffering. In a survey of 1205 practicing Lebanese nurses and physicians, only 19.1% of

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Oman is currently in a grace period where all these measures can be implemented and proper planning can be accomplished. At some point, though, cost of care will be too high to be sustainable, and introducing these measures may require resources not available then. To conclude, the Omani population is aging, which impacts on the cost of health care delivery and economic development. Cancer as well as other chronic diseases will increase significantly as a result. Minimizing the cancer impact is possible only with a comprehensive cancer control program. Implementing this program in good time will decrease the future cost of health delivery and guarantee a sustainable and efficient health economy.

Morocco The trends in the demographic changes in Morocco are shown in Figures 5–7. Characteristics of senior citizens’ living conditions in Morocco are shown in Table 1. Characteristics of public nursing homes are shown in Table 2. The Moroccan Gerontology Association has established Teams of Hope, comprising geriatricians, pharmacists, nurses, physiotherapists, dieticians, psychologists and social workers who work in the nursing homes. A recent survey by the Team of Hope examined the residents of these homes and revealed the following data:

• Average age: 72.8 years (female 74.1, male: 71.5 years) • Marital status: 50.6% of woman are widows and 39.7% of men • • • •

are single Illiteracy: 76.3% 32.8% of residents have children Only 42.4% are visited by their families Rae of participation in activities in the center: 14.4% (gardening, cooking, embroidery, hairdressing … )

Of the inhabitants in the nursing homes, 53.4% suffered from two or more chronic diseases, 33% suffered from one disease,

Figure 5. In Morocco Evolution of the population aged 60 years and over 2004–2034.

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1970 to 73.9 years in 2010. With this, infant mortality has significantly decreased from 190 deaths per 1000 live births in 1962 to 7.3 deaths in 2010. Fertility rates have fluctuated from 7.2 births per woman in 1962 to 8.3 in the early 1980 s, decreasing significantly there after to 2.1 in 2010. Nevertheless, the population in Oman still remains young with 44% of the population below the age of 15 years today, and only 4.2% of the population above age 60. Aging data in Oman shows different trends depending on the index used. Elderly Dependency Ratio EDR, for example decreased from 6.3 in 1970 to 3.6 in 2010 while the Aging Index, which was 6.9 in 1970 dropped to 4.9 in 1990 but started to rise again, reaching o 9.3 in 2010. These changes are mainly due to the change in fertility rates in Oman. A tool that may be more useful in showing the aging trends in Oman is the Median Age, which steadily rose from 18.9 years in 2008 to 24.4 in 2010. A significant increase in cancer incidence is projected in Oman due to aging. Globocan predicts an increase theren from 949 cases in 2010 to 2451 cases by 2020 and 3792 cases by 2030. Factors such as changes in smoking habits, diet and lifestyle, are not included in this analysis. Economic development will be impeded and the cost of health care delivery significantly increased as a result of the demographic change in aging. In order to minimize this impact, long-term strategic planning is paramount. In relation to cancer, a comprehensive cancer control strategy is required. We need to minimize the incidence of cancer through preventive measures (such as tobacco control programs), detect cancer earlier (notably 50% of Breast Cancer cases in Oman is diagnosed in stages III & IV, when compared with 20% in the US), plan for infrastructure, manpower & equipment; and expand palliative & community care services. Palliative care is the only service that can increase the quality of health care while decreasing cost. Monitoring the success of any of these programs requires a comprehensive cancer registry with mortality data and cost of care analysis.

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Annals of Oncology Table 1. Characteristics of the elderly population in Morocco HOW DO OUR SENIORS LIVE IN MOROCCO? Residence: 52.4% of people live in urban areas Marital status: 65% are widows and 8% are widowers Illiteracy: 83% (94.5% of women) Pension: 16% Medical Coverage: 13% Chronic Diseases: 59% of seniors suffer from at least a chronic disease Societal activity: 31% are still active (business, sales, agriculture, etc … ) Family environment: 92.2% maintain an ongoing relationship with their children 6.8% live in isolation 63.2% are reported to be suffering from loneliness Survey of the High Commission for Planning HCP 2008

Figure 6. Evolution of the Moroccan population.

Elderly social protecting institutions ‘Nursing Home’ Number: 40 which hosts 2500 residents Our institutions are offered especially to the elderly who are homeless, poor or in difficult situations Resources: Subsidies for national solidarity Important contributions from the National Initiative for Human Development (NIHD) and from other charities Common points: Insufficient staff not much trained in gerontology Health care not completely covered Lack of social and cultural activities

Figure 7. Evolution of life expectancy at birth 1987–2034 (CSDR).

and 13.6% had no complains. Figure 8 shows the most common diseases diagnosed in the survey, while Figure 9 shows the most prevalent geriatric disorders diagnosed. Treatment given in the wake of the survey is listed in Table 3. The Moroccan Gerontology Association plans to develop medical as well as social facilities throughout the country. The first one has been established in Casablanca, planned with an awareness of the dominant role of the family in Moroccan society and allowing for easy visiting access by the family. Recent data about cancer incidence in Morocco are given in Tables 4–10.

Figure 8. The most common diseases.

the implications of aging on cancerogenesis: cellular, physiologic and clinical The key to an effective program for cancer prevention and cancer treatment in the elderly is the determination of physiologic age that is a patient’s life expectancy and tolerance of stress. An 85-year-old woman who is living independently and has no life limiting comorbidity may merit to be screened for colorectal and breast cancer, as she has a life expectancy in excess of five years and is clearly able to tolerate cancer

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Figure 9. Geriatric Syndromes.

treatment of these conditions. Yet, a 70-year-old man with a life expectancy of <2 years due to congestive heart failure would be harmed by the treatment of localized prostate cancer or of asymptomatic low grade lymphoma. These examples indicate

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Table 2. Institutions for the aging population in Morocco

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Annals of Oncology Table 3. Improving care for the elderly in Morocco

Table 7. Distribution (%) of cancers in both sexes (Rabat, 2006–2008)a

Actions done to improve care for the elderly Several reforms have been developed including a pension system and a basic medical coverage An action plan was elaborated by WHO missions (1999, 2005 and 2009) aiming at caring for the elderly population Training of medical staff specialized in geriatrics Hospital geriatrics units will be operating in 2013 in Rabat, Fes and Agadir Several seminars in favor of General Practitioners Inauguration of the first day care center in Casablanca

Males 1 2 3 4 5

Females

Lung Prostate Bladder Non-Hodgkin Lymphoma Colon

19.0% 15.5% 6.9% 6.0% 5.9%

1 2 3 4 5

Breast Uterus Colon Non-Hodgkin Lymphoma Thyroid

39.9% 11.4% 4.5% 3.4% 3.4%

a

Incidence of Cancers in Rabat 2006–2008, Cancer Registry of Rabat, Morocco, June 2012. Table 8. Incidence of breast cancer in females in Rabat in years 2006– 2008)a

Table 4. Total cancer cases registered in Rabat, Morocco in years 2006–2008a Females

Total

1241 (98.8%) 14 (1.1%) 1 (0.1%) 1256

1232 (96.6%) 35 (2.7%) 8 (0.6%) 1275

2473 (97.7%) 49 (1.9%) 9 (0.4%) 2531

a

Incidence of Cancers in Rabat 2006–2008, Cancer Registry of Rabat, Morocco, June 2012.

Table 5. Median age of cancer patients in Rabat, Morocco in years 2006–2008a Year

Males

Females

2006 2007 2008 2006–2008

62 64 63 62

52 54 54 54

a

Incidence of Cancers in Rabat 2006–2008, Cancer Registry of Rabat, Morocco, June 2012.

Table 6. Age-standardized incidence rates (ASR)a of cancer patients in Rabat, Morocco in years 2006–2008b

Number of cases

2006 Males

Females

2007 Males

Females

2008 Males

Females

134.9 401

112.1 394

137.0 410

120.7 434

138.5 430

110.9 404

a

Per 100 000. Incidence of Cancers in Rabat 2006–2008, Cancer Registry of Rabat, Morocco, June 2012.

Total number

Median age at diagnosis

ASR per 100 000

Standardized per Moroccan population

2006–2008

491

50

43.4

38.7

a Incidence of Cancers in Rabat 2006–2008, Cancer Registry of Rabat, Morocco, June 2012.

Table 9. Comparisons of female breast cancer incidences (ASR per 100 000) Belgium France, Gironde Israeli Jews USA Italy, Piedmont Lebanon Canada, Alberta Cyprus Egypt, Aswan Israeli Arabs China, Hong Kong Turkey, Izmir Morocco, Rabat Japan, Osaka Jordan Tunisia, Nord Saudi Arabia Oman United Arab Emirates, Tawan Hospital

106 102.5 91.9 89.9 86.2 86.0 80.9 76.6 63.9 56.6 52.7 49.3 43.4 32.9 32.0 29.6 21.6 21.3 17.1

In order to provide personalized cancer care, the basic questions necessary in managing cancer in the older aged person should include:

b

• Is the person going to die of cancer or with cancer? • Is the patient likely to experience the complications of cancer during her/his lifetime?

that physiologic age is poorly reflected in chronologic age. Though aging is universal, it occurs at different rates in different individuals and patients should be managed according to their physiologic rather than chronologic age.

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• Is the patient able to tolerate cancer treatment? • Does the patient receive the social support necessary for cancer treatment?

• Exploring these issues require defining aging in biological, functional and clinical terms.

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Invasive cancers In situ cancers Borderline Total

Males

Years

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Annals of Oncology

Table 10. Comparisons of lung cancer incidences (ASR per 100 000)

China, Hong Kong Belgium France, Gironde Italy, Piedmont USA Canada, Alberta Japan, Osaka Morocco, Rabat Egypt, Aswan Oman Saudi Arabia

Males

Females

58.4 56.3 53.3 47.3 45.7 40.6 39.8 24.8 11.2 10.4 6.9

25.2 18.1 14.6 15.5 33.2 33.8 12.8 2.5 3.8 1.6 1.9

Molecular aging involves a number of genomic alterations that may block cell reproduction, increase cell deaths or alter cell function. Some of these changes may prevent the risk of cancer in the aged and others may increase it. Of special interest is the expression of p16 (Ink4a) in senescent cells, a cyclin- dependent kinase inhibitor and tumor suppressor that causes growth arrest [33, 34]. Genomic changes may increase cell susceptibility to environmental carcinogens and partially explain the agingassociated increased incidence of cancer. The best defined of these changes are the epigenetic ones that affect the expression of a number of genes. These include hypermethylation (silencing) of anti-proliferative genes, hypomethylation (activation) of oncogenes, histone de-acetylation (activation) of oncogenes, and alterations in microRNA that controls gene post-transcription [35, 36]. The causes of these changes may be both hereditary and environmental. The best studied environmental causes include the formation of free radicals or reactive oxygen species (ROS) [37]. Progressive tissue cell loss is the final result of these quantitative and qualitative changes. While it is unclear whether the number of tissue stem cells declines with age, it is clear that the ability of these elements to repopulate the tissue is limited. The hemopoietic stem cells are among the best studied of the tissue stem cells. Both in rodents and in humans hemopoietic stem cells undergo qualitative changes that favor myeloid differentiation [38, 39]. Age seems to enhance the risk of atherosclerosis, cardiovascular diseases and diabetic complications. It is reasonable to expect that aging will lead to stromal dysfunction, which may include reduced ability to allow the homing of tissue stem cells. In hemopoietic tissue the homing of stem cells appears compromised with age [38]. A number of important systemic changes occur with aging as well, especially immune senescence, endocrine senescence, and chronic inflammation. With aging there is a decline of both cellular and humoral immunity with increased risk and severity of infections and reduced response to vaccination. A decline in cellular immunity may also contribute to the age-related increased incidence of cancer [40]. The most consequential endocrine changes of aging include increased insulin resistance,

vii | Hajjar et al.

assessment of physiologic age The assessment of physiologic age is an assessment of a person’s functional reserve, that is of the risk of death or functional dependence. A number of laboratory and clinical tests have been proposed for this purpose (Table 11). The expression of p16 (InKa) in peripheral blood T lymphocytes correlates with chronologic age, tobacco use, and inactivity [49]. The advantages of this test include easy performance and tissue availability, but whether it reveals a person’s functional reserve is not clear. The length of lymphocyte telomeres decreases with age in each person, and this decrement is correlated with the risk of age-related events, including death, cancer and the presence of certain geriatric syndromes [50]. The length of telomeres is highly variable from one individual to another and consequently it cannot be used to compare the physiologic age of different persons [51]. Since aging involves a progressive chronic inflammation, some researchers have tried to correlate the concentration of inflammatory markers in the circulation with the risk of death or functional dependence. Cohen et al. demonstrated that among home dwelling elders ages 70 and older the concentration of Interleukin 6 and D-Dimer in the circulation predicted the risk of death and functional dependence within the following two years [52]. Other researchers confirmed the association between the concentration of inflammatory markers, mortality, and functional dependence in older individuals [53, 54]. Currently however none of these tests has proven sufficiently sensitive or specific for e assessing a person’s physiologic age. The issue is

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biological and functional aging

with increased circulating levels of insulin; decreased production of growth hormone; and increased circulating levels of corticosteroids and cathecholamines [41, 42]. These alterations are associated with an increased risk of death and contribute to a number of age-related manifestations including frailty, sarcopenia and memory loss. Increased levels of circulating insulin are also associated with an increased risk of certain cancers. Metformin, a drug that reduces insulin resistance, may arrest the growth of some cancers [43]. The origin of chronic inflammation is multifactorial [44]. The concentration of inflammatory markers in the circulation correlates with the risk of death, functional dependence, and geriatric syndromes [45–47]. Some of the molecular, cellular, and physiologic changes of age may increase cancer risks, and others may reduce these risks. All the changes brought about by aging conjoin to reduce the number of functional cells in the tissues, creating a catabolic status that leads to a progressive decline in the amount of lean body tissue (sarcopenia) generally reducing the functional reserve of an organism (that is the ability to withstand environmental stress) and increasing the risk of death. These changes also favor the development of the so called ‘geriatric syndromes’ [48]. These conditions that are more common, albeit not unique, in the aged, include dementia, severe depression, delirium from infections or medications, falls, dizziness, failure to thrive, and circumstances of neglect and abuse. These conditions are associated with an increased risk of mortality and functional dependence.

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Annals of Oncology Table 11. Comprehensive geriatric assessment and clinical implication

Table 12. Prediction of the risk of chemotherapy related toxic effect

Functional status Activities of Daily (ADL) and Instrumental Activities of Daily Living (IADL) Comorbidity Number of comorbid conditions and comorbidity indices Mental status Folstein Minimental status

CRASH model (42) A. Hematological model Scoring system Item Diastolic Blood pressure IADL LDH

Emotional conditions Geriatric Depression Scale (GDS)

Relation to life-expectancy, functional dependence and tolerance of stress Relation to life-expectancy and tolerance of stress Relation to life-expectancy and dependence Relation to life-expectancy; may indicate motivation to receive treatment

further complicated in older cancer patients, as the cancer itself is generally associated with chronic inflammation. In these individuals the inflammatory markers may well reflect neoplastic activity rather than the person’s physiologic age. The clinical assessment of age may involve different instruments including the allostatic load, the frailty index and the comprehensive geriatric assessment (CGA). The allostatic load is based on the assumption that age represents a loss of homeostatic control that is of the ability of an organism to reverse to basic levels of function after a stressful incident. It requires an assessment of physical, laboratory, and functional parameters. Chronic inflammation is a form of allostasis and the determination of inflammatory markers in the circulation is a form of assessment of the allostatic load. The allostatic load is correlated with the risk of death and functional dependence. Its accuracy in determining a person’s functional reserve, however, has not been established. Another clinical test, the frailty index, and its many variations, is based on the number or degree of functional deficits accumulated by the individual. In its original form the frailty index may provide a highly accurate determination of physiologic age [55]. However, this instrument appears too laborious for clinical use, as it involves the assessment of about 70 parameters including disease, loss of physical function and of social support. The frailty index has not been studied in the context of cancer patients. The comprehensive geriatric assessment (CGA) involves the evaluation of function, comorbidity, presence of geriatric syndromes, polypharmacy, and social support and has been widely utilized for the management of older individuals with

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1 point >72 10–25

MAX2 0.0–0.44 0.45–0.57 Score and risk of grade 3–4 hematological toxic effect Score Incidence of toxic effect 0–1 4% 2–3 19% 4–5 44% >5 89% B. Non hematological Model Scoring system Item 0 point 1 point ECOG PS 0 1–2 Mini Mental Status 30 1 Mini-nutritional assessment >27.5 MAX2 0.0–0.44 0.45–0.57 Score and risk of grade 3–4 non-hematological toxic effect Score Incidence of toxic effect 0–1 28% 2–3 42% 4–5 59% >5 92% CART model (43) Scoring system Item Score Age >73 2 GI/GU cancer 3 Standard chemotherapy 3 dose Polychemotherapy 2 Hemoglobin (man <11 g/dl; 3 woman <10 gm/dl) Creatinine clearance 3 (Jelliffe) <34 One or more falls in last 6 3 months Hearing impairment (fair 2 oe worse) Limited in walking 1 block 2 Assistance medication 1 intake Decreased social activity 1 Score and risk of grade 3–4 toxic effect Score Incidence of toxic effect 0–5 27% 6–11 53% 12+ 83%

2 point

Above normal >0.57

2 point 3–4 <30 <27.5 >0.57

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Nutritional Status Mininutritional assessment (MNA) Reversible condition; possible relationship to survival Polypharmacy Risk of drug interactions Geriatric syndromes Delirium, dementia, depression, Relationship to survival falls, incontinence, spontaneous Functional dependence bone fractures, Neglect and abuse, failure to thrive, vertigo.

0 point >72 26–29 Normal

symposium article

• Is the patient going to die with cancer or of cancer? • Is the patient going to suffer the consequences of cancer during his/her lifetime?

• Is the patient able to tolerate the treatment of cancer/ Table 13. Geriatric assessment for cancer patients Assessment of physiologic age Laboratory Tests P16 Expression Telomere length Concentration of inflammatory markers Clinical assessment Allostatici load Frailty index Comprehensive Geriatric Assessment (CGA)

Based on these answers, the treatment of cancer may be tailored to the individual characteristics of each patient (Figure 10). The implementation of this approach may go a long way toward providing effective care, minimizing the risk of toxic effect, and preventing unnecessary economic and human cost. As a basis to clinical decision related to cancer prevention and treatment in the older age person, the CGA, may be utilized in all medical contexts.

cancer control on the elderly in the middle east To achieve this goal, setting a vigorous agenda to support the achievement of regional targets for cancer control for the elderly is recommended. Important aspects will be to explore what works, in what context, why it works (or why not), and what relationships need to be developed for it to work. Through participation in the current NCI-MECC-ASCO initiative, we hope to learn about what needs to be done and how to do it in the context of each country’s circumstances, in order to improve geriatric oncology practice in countries in the region. Taking into account the foreseeable demographic developments in the coming years, governments and civic organizations should adopt a holistic geriatric philosophy for the care of elder cancer patients. Furthermore, primary health care professionals should play a central role in such programs through the integration of elder care in community health services. In this context national and international NGOs are expected to work closely to promote integrated models to achieve these goals while supporting national authorities in the planning, implementation and assessment of national needs and efforts. The Middle East is a region experiencing increases in life expectancy concomitant with he challenge of treating cancer in elders and the scarcity of both geriatricians and geriatric oncologists. Special efforts are required to expand the cope of specialists in these disciplines along with well trained community nurses in order to bring about an effective approach to family-based care. This will include an innovative

Figure 10. Factors affecting decisions related to cancer treatment.

vii | Hajjar et al.

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and without cancer [56–58]. The national Comprehensive Cancer Center Network (NCCN) [59] guidelines for the management of cancer in the elderly recommend that some form of geriatric assessment be conducted in all cancer patients age 70 and older in order to direct these patients’ treatment. A CGA summary is illustrated in Tables 12 and 13. In addition to reveling medical and social conditions that may interfere with cancer treatment, the CGA provides an estimate of an individual’s risk of mortality and complications from antineoplastic treatment. Several CGA-based instruments predict the risk of mortality of older individuals at 1, 2, 4 and up to 9 years from the time of assessment [60]. These instruments maybe utilized www.eprognosis.comfree of charge on the site Elements of the geriatric assessment have been integrated in the preoperative evaluation of cancer patients age 70 and older in the Preoperative Assessment of Elderly cancer Patients (PACE) [61]. Two recent studies, summarized in Table 4, have created a CGA based score to predict the risk of chemotherapy related toxic effect in the aged [62, 63]. While these instruments need to be fine-tuned, they may provide at least a partial answer to the basic questions in Geriatric oncology:

Annals of Oncology

Annals of Oncology

culture-oriented modalities of interventions, while reinforcing the family role [6].

funding Supported in part by the Center of Global Health, National Cancer Institute (NCI), National Institutes of Health, Bethesda, MD, USA, by the Omani Cancer Association (OCA), Muscat, Sultanate of Oman, by the American Society of Clinical Oncology (ASCO), Alexandria, VA, USA, and the International Union for Cancer Control (UICC), Geneva, Switzerland.

disclosure The authors have declared no conflicts of interest.

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