Communicating cancer risk
Once assessments have been made and clinical data gathered, the next step is imparting this information to elderly patients. Once again, the rules that apply to the general population may not hold true for older people.
The extent to which people understand what the oncologist is telling them, and can then make informed health decisions, is called health literacy. "We know that older individuals have poorer [health] literacy," Dr. Naeim said. "A study from the U.S. National Center for Education Statistics showed that, in general, as people grow older, the proportion of people who have below basic, or just basic, health literacy increases. Among those age 65 and over, about one-third have below basic skills" ("Adult literacy in America: Report of the National Adult Literacy Survey," 2003).
In addition to the regular health literacy, there is also quantitative literacy, or the ability to understand and comprehend numbers. This includes the knowledge and skills to apply arithmetic operations, either alone or sequentially, by using numbers in printed materials or in oral format. And numeracy skills, which are already quite poor in the U.S. population, also degenerate with age, Dr. Naeim said. A 2008 study showed that the percentage of correct answers on any sort of standardized numeracy tests decreased with age (Ann NY Acad Sci 1128:1-7, 2008).
Sufficient numeracy is key for communicating treatment risks and uncertainty to all patients. "You have to be able to weigh the strengths of the current evidence. You need to be able to weigh the risks and the benefits and weigh them and the likelihood of the different outcomes," Dr. Naeim said. "From patients' perspective, they need to acquire the information; they need to make some calculations or inferences; they need to remember the information, which requires aspects of short-term and long-term memory. They need to weigh factors to match their own means and values. And then they need to be able to make a trade-off in order to be able to make a health decision" (Health Aff [Millwood] 26:741-748, 2007).
Older patients often have difficulty working with numbers, and they may have little to no experience with assessing probability, he added. "Numeric scales may not be the best way to go, especially if you're trying to see if patients understand the risk for cancer vs the risk from their other comorbidities. Maybe comparative scales are better that numeric scales. You can say ‘What do you think your chances are of dying from breast cancer over the next 10 years, compared to dying of something else?' Posing the data comparatively can help the oncologist determine if the patient at least understands the relative magnitude of difference between the two without actually getting the number right," he explained.