Overprotective caregivers of elderly cancer patients: a case report.
ABSTRACT The essential role of the caregiver in the management of elderly cancer patients is still poorly documented. This case report concerns a woman with metastatic lung carcinoma who was sincerely informed and successfully treated with chemotherapy and gefitinib only after gaining the trust of her overprotective daughter. Devoting time to the relatives represents a key element to create a communicative and efficient relationship with older cancer patients.
Geriatric oncology is characterized by a multidimen-
sional approach to the older patient with cancer because
of the great relevance of various psychosocial issues,
such as the multifaceted role of family members as ca-
regivers. The elderly, in fact, may be strongly disadvan-
taged in their access to the healthcare system if not ade-
quately informed and supported by their relatives, and
are unlikely to search for innovative therapies and/or
second opinions on their own. On the other hand, over-
protective relatives may inappropriately assume defen-
sive attitudes and strongly compromise a frank commu-
nication of diagnosis and discussion of treatment choi-
ces with elderly cancer patients.
During the summer holidays, a 66-year-old woman
developed acute confusion, headache and dizziness and
presented to the peripheral hospital, where a contrast
CT scan showed multiple brain metastases with diffuse
edema. Since she had been operated on for breast can-
cer 18 years before (pT2N0, hormone receptor nega-
tive) and had an elevated CA 15-3 level (73 kU/L), the
doctor on duty made a diagnosis of late recurrence of
breast cancer and communicated a very dismal progno-
sis to the daughter. The patient was not informed at all.
She was then transferred to our medical oncology de-
partment, where whole brain radiotherapy (30 Gy in 10
fractions) was promptly started after some days of ag-
gressive anti-edema therapy with dexamethasone and
osmotic agents. The patient rapidly recovered and was
discharged. Staging was planned in the outpatient clin-
ic, but, unexpectedly, the patient did not show up at the
appointed date for the next visit.
Some days later we received a call from the daughter
who asked to be received alone. She categorically re-
fused to bring her mother back to our division unless
she was told in advance what were her therapeutic op-
tions. We therefore met the daughter, a well-educated
woman of 45 years, who was extremely concerned
about the hypothesis of her mother undergoing “toxic”
chemotherapy. Total body CT scan showed a 6 cm tu-
mor at the base of the left lung without mediastinal
lymphadenopathy, while bone scintigraphy was positive
at two lumbar vertebrae but no fractures were detected
on standard x-ray examination. The daughter had be-
come convinced that her mother’s survival would be a
few months at best, and therefore was rather skeptical
about any further treatment.
We had a long talk with her about our multidiscipli-
nary geriatric oncology program, which is specifically
intended to evaluate the global health of the elderly can-
cer patient in order to adapt treatment to each individual
and to withhold it from those not able to tolerate it. We
repeatedly assured her that her mother would be in-
formed with utmost delicacy and that any treatment
would be clearly explained and promptly stopped in
case of unacceptable toxicity. She then agreed to bring
her mother to the next visit, and a full geriatric assess-
ment was thus performed1.
The patient was indeed in optimal health and lived
alone, fully independent in her daily activities, with
no relevant comorbidities. She was already aware of
bearing brain metastases because she asked us if “her
brain nodules” were connected to her previous breast
cancer. Since she was a smoker and an increase in CA
15-3 may occasionally be associated with lung cancer,
we decided to perform a CT-guided biopsy of the tho-
racic nodule, which proved to be a classic lung adeno-
Tumori, 92: 362-363, 2006
OVERPROTECTIVE CAREGIVERS OF ELDERLY CANCER PATIENTS:
Umberto Basso, Antonella Brunello, Cristina Magro, Adolfo Favaretto, and Silvio Monfardini
Department of Medical Oncology, Azienda Ospedaliera, Istituto Oncologico Veneto, Padua, Italy
Key words: communication, elderly, informed consent.
The essential role of the caregiver in the management of el-
derly cancer patients is still poorly documented.This case re-
port concerns a woman with metastatic lung carcinoma who
was sincerely informed and successfully treated with
chemotherapy and gefitinib only after gaining the trust of her
overprotective daughter. Devoting time to the relatives repre-
sents a key element to create a communicative and efficient
relationship with older cancer patients.
Correspondence to: Umberto Basso, MD, Department of Medical Oncology, Istituto Oncologico Veneto, Via Gattamelata 64, 35128 Padua,
Italy. Tel +39-049-8215931; fax +39-049-8215932; e-mail firstname.lastname@example.org
Received August 23, 2005; accepted September 19, 2005.
INFORMED CONSENT IN THE ELDERLY
Systemic chemotherapy was proposed and promptly
accepted by the patient and her daughter after overt
communication of the diagnosis and detailed discussion
of the possible benefits and toxicities. Six cycles of cis-
platin (60 mg/m2 day 2) and gemcitabine (1000 mg/m2
days 1 and 8) every 21 days were delivered without sig-
nificant delays and no G3-G4 toxicities, although 8th-
day gemcitabine had to be withheld in all cycles due to
transient thrombocytopenia. Irradiation to L2-L3 (20
Gy, 5 fractions) was performed concomitantly with cy-
cle 2. Both lung and brain nodules were stable after
completion of therapy, CA 15-3 was 63 kU/L. Both the
patient and her daughter gave a globally positive score
to their experience of chemotherapy.
After 4 months of follow-up, small bilateral multiple
lung nodules appeared on CT scan, while brain imaging
was still unchanged. The patient was put on the novel
tyrosine kinase inhibitor gefitinib at the standard oral
dose of 250 mg/daily, which was very well tolerated.
CT scan performed after two months showed disappear-
ance of the metastatic lung nodules and shrinkage of the
primary tumor, with a fall of CA 15-3 to 21.6 kU/L. Af-
ter eight months, the patient is still on gefitinib and is
practically asymptomatic, with a normal neurological
examination and a Folstein’s Mini Mental Status of 26.
Only slight impairment of recent memory is evident 18
months after whole-brain irradiation.
This case report underlines the importance of a com-
municative relationship with elderly cancer patients and
their caregivers for the deliverance of current standards
of care and new therapeutic measures also in this age
class. The chances of a response to gefitinib have been
found to be particularly high in women with adenocar-
cinomas2. The choice of gefitinib as second-line treat-
ment was driven by these considerations but also sup-
ported by the optimal compliance of the patient and
cognizant assistance of her daughter.
The degree of therapeutic alliance attainable with el-
derly cancer patients is extremely variable as a result of
different levels of education, cognitive function and
mood disorders of patients along with paternalistic atti-
tudes and minimal disclosure policies adopted by doc-
tors not involved in geriatric oncology programs. Inter-
ference by overprotective relatives with stereotyped
perception of disease status and treatment toxicities
may become a strong hindrance for correct management
of elderly individuals. Family members, especially
women, may experience such a wide range of emotional
reactions, interpersonal dynamics and distort expecta-
tions concerning cancer treatments that they may even
put the patient at risk of not being treated at all, as in
this case. Moreover, caregivers may become distressed
and develop psychiatric morbidity as the illness ad-
vances and treatment is only palliative3.
In our practice, whenever allowed by staff and time
resources, we try to give to family caregivers of elderly
cancer patients as much attention as to the patient and
we believe that separate interviews with relatives are
never a waste of time but may prove essential to lay the
foundations of a sincere, fully communicative and ulti-
mately successful doctor-to-patient relationship.
1. Basso U, Monfardini S: Multidimensional geriatric evalua-
tion in elderly cancer patients: a practical approach. Eur J
Cancer Care (Engl), 13: 424-433, 2004.
2. Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto
RA, Brannigan BW, Harris PL, Haserlat SM, Supko JG,
Haluska FG, Louis DN, Christiani DC, Settleman J, Haber
DA: Activating mutations in the epidermal growth factor re-
ceptor underlying responsiveness of non-small-cell lung can-
cer to gefitinib. N Engl J Med, 350: 2129-2139, 2004.
3. Pitceathly C, Maguire P: The psychological impact of cancer
on patients’ partners and other key relatives: a review. Eur J
Cancer, 39: 1517-1524, 2003.