During the COVID pandemic nurses were involved in a social problem with clear repercussions on health care. Discrimination due to "ageism", a term coined by Robert Butler back in 1969, suddenly became more visible. The World Health Organisation (WHO) warns that half the world's population is "ageist" towards older people, with greater discrimination in Europe.1
We were shocked that our so-called developed country's advanced healthcare system saw a loss of fundamental rights, inequity, inequality, and injustice, in access and healthcare for the elderly during the pandemic. Age was used as a classification that caused discrimination and harm, particularly for the highly dependent who were not entitled to these fundamental rights.1 It is evident that ageism was already latent and present in the social and health setting, the pandemic acted as a catalyst, allowing it to surge.
What are the components of ageism? The first is the cognitive component that shapes our mental concepts and how we conceive what it is to be older. It shapes the stereotypes that transcend the social perspective to the personal perspective, therefore, the meaning we attach to our activity of caring for an older person. Defined qualitatively this perception reflects their labour activity; the elderly person is less productive, more passive and therefore more dependent on others, whether caregivers or health professionals. The second component comprises emotional constructs and shapes prejudice, because we feel that ageing is negative, we emotionally distance ourselves as "oldism" is associated with mental and physical loss, less vigour and capacity, decrepitude, and approaching end of life. Finally, there is the behavioural component, which directly involves discriminatory behaviour towards the elderly person; in other words, care can be provided later, because their chronic condition can wait to be treated, health visits can be postponed, delayed, or even cancelled. The right for healthcare needs to be met is generally being undermined, with fewer or lower quality resources allocated to healthcare for the elderly patient.2 These discriminatory behaviours or actions emerged as the "tip of the iceberg" during the first two years of the pandemic, but the rest of the iceberg is still dangerously submerged below the water level.
Cancer is a collection of several diseases under one heading. Cancer is inherent to life, and markedly inherent to ageing. In fact, the longer the life expectancy, the greater the probability of developing a neoplasm.3 In all developed countries, the most frequent diagnosis for all types of cancer occurs in people under the age of 70.4 At the national level, each Spanish citizen has an overall risk associated with cancer of one in four people. There are differences between genders: 1 in 3 men and 1 in 5 women, with poorer data for the male sex. The majority of cancer patients are between 65 and 75 years of age.5 These figures highlight the pressing need to adapt our oncology services and care to the demographic situation and the needs of onco-haematological patients and their families.2
The strategies that we as nurses must implement to reduce this age discrimination include addressing the cognitive component first. We need to encourage a paradigm shift in how nurses view the elderly towards a holistic, real, and ethical vision. In joint responsibility with the family, from primary and secondary schools and universities, with better training and university programmes devoted to ageing. It worries me, as a university professor, when I ask at the beginning of many courses how many students would consider devoting themselves professionally to geriatric care and not a single hand is raised. This is understandable, as the professional offer is not attractive for a new nurse, and the work does not offer compensatory remuneration or prestige. It is well known that there is no level playing field in community or social and health care, or in resources, and geriatric care does not enjoy the social prestige offered by working in an operating theatre, with the most advanced robotic systems, or in paediatrics, or "super-intensive" care. Oncology care does not fare so badly in this comparison, it is known that there is a sense of vocation in working for onco-haematology patients. I firmly believe that oncology nurses, even during the pandemic, have made a supreme effort to care for patients with cancer and COVID, love their profession, and gain emotional satisfaction that compensates for the emotionally draining compassion fatigue.6 Clear regulation and institutional control will curb any hint of risky or clearly discriminatory behaviour.
However, in a worrying turn of events, there has been a shift in cancer care towards classifying the disease as "chronic" due to its high survival rate. There is a wealth of data to support the fact that today's cancer patients have high survival rates. Some tumours such as colorectal cancer, the most prevalent for both sexes in our country, have overall survival rates of <60%, according to the Spanish Society of Medical Oncology (SEOM), around 80% for breast cancer, and haematological tumours and germinal cancer have a survival rate of around 90%. These are fantastic, very hopeful data, but worrying if the discriminatory gap is opened in the allocation of finite health resources or certain policies diverted due to the crisis, replicating the ageist behaviour that presented only 2 years ago.
A cancer patient may have more time to "live with cancer", more time to survive it and to older ages. Increasingly patients aged 80 years and older are candidates for radical treatment because their survival is expected to be about 13 years if healthy. Oncogeriatrics classifies patients into four types of patients according to their state of health or frailty: healthy patients are at the 25th percentile, moderate patients at the 50th percentile, and the rest at the lower percentile (NCCN National Comprehensive Cancer Network Guidelines, NCCN, 2019). Balducci refers to them as fit, vulnerable, and frail, and the onco-geriatrician assesses the patient’s condition beforehand, to tailor decision-making to the expected response. Decision-making is never by age, as this is known to avoid unnecessary under- or over-treatment. The most complicated range of patients will be those in the vulnerable percentile. It is a question of equity.
Our national cancer services can now dispense more second, third, fourth lines for a patient, and more diverse treatments are available than decades ago. Immunotherapy, transplantation, new chimeric antigen receptor T-cell therapies (CAR T-cell) and drugs with specific therapeutic targets of more personalised medicine using biomarkers that help predict whether or not there will be response to each onco-specific therapy.5
The United Nations reports that "ageism" worsens the health of the elderly, increases social isolation, causes premature deaths, and impacts on a state’s overall economy, those at risk must be ensured protective mechanisms. In the same vein, the European Cancer Summit of Cancer Societies issued its European Code of Cancer Practice, to ensure that all cancer patients in Europe have the right to quality cancer treatment and care, regardless of age, gender, ethnicity, socio-economic status, or geographic location. There are glaring inequalities in cost, organisation, access, and professional competence, both within and between European countries. Further information can be found in the link provided.7
As a final reflection, strategies are proposed below in which nurses are key to reducing the problem of oncogeriatric ageism:
▪Always ask the patient for their care preferences. Nursing care for cancer patients, free of prejudice or discriminatory actions based on age alone. Detect situations that carry a risk of undermining rights and play an active role in advocating for the oncogeriatric patient, so that being older does not harm their right to optimal care for themselves and their family. Particularly people belonging to minorities, migrants, or vulnerable groups, such as those who are lonely or lack an effective caregiver.
▪Strengthen the role of the oncology nurse as an educator for the oncogeriatric patient, caregiver, and family. The more education provided to the elderly patient in promoting their autonomy, the better health outcomes will be achieved through the early detection of disease or treatment-related toxicity. Two activities are key to promoting health in older cancer patients: cognitive stimulation and healthy daily exercise.
▪Rethink models, which in 1998 the International Council of Nurses ICN defined as "age-friendly", that combine onco- and geriatric care, with a focus on enhancing health, wellbeing, and quality of life. This requires the inclusion of geriatricians and nurses with advanced oncogeriatric practice competencies in the oncology team.8
▪Prepare and educate nurses in oncogeriatrics. Various international scientific societies are already working on competencies in oncogeriatrics, such as the nursing group of the International Society of Geriatric Oncology SIOG and the American Oncology Nursing Society (ONS), with clinical practice guidelines to help prepare these nurses to care for the elderly cancer patient.9,10
“Growing old is mandatory, but growing up is optional”, life exists to grow old, but how one grows old is what gives meaning to life.
Carroll Bryant