Introduction

Geriatric oncology in India is still in infancy and the number of older persons with cancer is increasing exponentially as “age” is an established risk factor for cancer. In 2011, older persons constituted 8.6% of India's total population, equaling 103 million. This proportion is expected to increase exponentially and is projected to reach 19.5% by 2050, equaling 319 million people. The proportion of the oldest-old, that is, those aged 75 years and over, is projected to rise by 340%. Cancers in elderly mainly include cancers of the breast, lung, prostate, cervix, esophagus, and ovary. Further, age-related comorbidities, treatment intolerance, and toxicities often affect treatment decisions for older cancer patients, who may receive less aggressive therapies or nonstandard protocols.1 Current status of geriatric oncology in India lacks specialization and multidisciplinary approach. Geriatric oncology involves not just oncologists but also geriatricians, social workers, nutritionists, and psychologists. This holistic approach is not always available in most health care settings in India. Geriatric oncology becomes more challenging due to lack of teaching programs and research studies with focus on issues important to older patients with cancer. The deficiency of enough data on spectrum and changing trends of cancer prevalence in specific populations is missing in India. There is an urgent need of pan India cancer registry for elderly patients but till then interinstitutional and intrainstitutional collaborative efforts can help in providing insights to cancer prevalence in this population. This study aims to explore the prevalence of various cancers in adults aged 60 and above, focusing on gender differences in a tertiary care hospital setting in Punjab, India.

Materials and Methods

This is a 1-year retrospective study, aimed at analyzing the prevalence of various types of cancer among the elderly population. Institutional Ethical Committee approval vide Ref: IEC No. 2024–962 was obtained prior to the commencement of data collection. The data for this study was obtained from the surgical pathology reports of patients aged 60 years and above who were diagnosed with cancer between January 1, 2021, and December 31, 2021, at Dayanand Medical College and Hospital, Ludhiana, Punjab, India. The “elderly” population is defined as individuals aged 60 years and above. Late elderly (75 years and older): This subgroup refers to individuals who are typically more frail, with higher rates of comorbidities and increased vulnerability to age-related diseases, including cancer.2 Patients aged 60 years and above with histologically confirmed cancer diagnosis and complete medical record including demographic details and information about the cancer type and tumor site were included in the study. Descriptive statistics were employed to summarize patient demographics and tumor characteristics. The prevalence of different cancer types in the elderly population was calculated by determining the proportion of each cancer type relative to the total number of cancer cases in the study group. Subgroup analyses were performed to explore variations in tumor prevalence based on age group, sex, and type of cancer.

Results

Of the 608 cases included, majority (n = 499; 82.1%) were in the elderly group, that is, 60 to 74 years and 109 (17.9%) cases were very elderly, that is, ≥ 75 years. In the elderly group (60–74 years), the most common cancers were hematolymphoid (n = 112, 22.4%), followed by breast cancer (n = 74, 14.8%) and gastrointestinal cancers (n = 59, 11.8%). In the very elderly age group (≥ 75 years), hematolymphoid cancers remained prominent (n = 31, 28.4%), but male genital tract cancers increased significantly (n = 22, 20.1%). Other notable cancers in the very elderly age group included gastrointestinal (n = 14, 12.8%) and lung and pleura (n = 6, 5.5%). There were fewer cases of soft tissue and bone cancers (n = 2, 1.8%) and central nervous system (CNS) cancers (n = 0, 0.0%) in the very elderly age group compared with the elderly group (Table 1).

Out of the 608 cases, males were more affected (n = 326, 53.6%), and the most common cancers were in the hematolymphoid system (n = 97, 29.7%) followed by male genital tract (n = 58, 17.8%). Gastrointestinal cancers (n = 42, 12.9%) and urinary system cancers (n = 30, 9.2%) were also prominent. In females (n = 282, 46.4%), breast cancer was the most prevalent (n = 85, 30.1%), followed by hematolymphoid (n = 46, 16.3%) and cancers of the female genital tract (n = 43, 15.2%). Other notable cancers in females included gastrointestinal cancers (n = 31, 11%) and pancreatobiliary cancers (n = 22, 7.8%) (Table 2).

Among the hematolymphoid cancers (n = 143, 23.5%), multiple myeloma (n = 26, 4.3%) was the most frequently identified malignancy, followed by chronic lymphocytic leukemia (CLL; n = 12, 2.0%) and chronic myeloid leukemia (CML; n = 11, 1.8%). Metastatic carcinoma to the bone marrow was rare, found in only two patients (0.3%), both of whom had known breast cancers. Breast cancer represented 14.5% (n = 88) cases majorly in the form of invasive ductal carcinoma (IDC). Gastrointestinal cancers accounted for 12.0% (n = 73), with large intestine cancers being the most frequent (n = 37, 6.1%) and adenocarcinoma being the primary subtype. Esophageal and gastric cancers together accounted for 4.7% (n = 29) with squamous cell carcinoma predominating among esophageal cases and adenocarcinoma in gastric cases. The pancreatobiliary system was involved in 8.1% (n = 49). Male genital system cancers accounted for 9.5% (n = 58), the most common being prostate cancer (n = 55, 9.0%), primarily identified as acinar adenocarcinoma. Female genital tract cancers were encountered in 7.1% of patients (n = 43), primarily affecting the adnexa (n = 18, 2.9%) and uterus (n = 19, 3.1%), with high-grade serous carcinoma being the most common in ovaries and endometrioid adenocarcinoma being the most common in uterus. Cervix involvement by cancer in this age group was seen in only six patients (0.9%) and all were diagnosed as human papillomavirus-related squamous cell carcinoma. Soft tissue and bone cancers were seen in 7.1% (n = 43) of the patients. Urinary system cancers made up 6.7% (n = 41) cases, with the majority being urinary bladder cancer (n = 22, 3.6%) with infiltrating urothelial carcinoma as the predominant diagnosis and kidney cancer (n = 17, 2.8%) where clear cell renal cell carcinoma was most frequently reported. Head and neck cancers comprised 5.4% (n = 33), with oral and nasal cavity cancers making up the largest portion (n = 28, 4.6%). Lung and pleura cancers accounted for 3.8% (n = 23) cases. Skin cancers accounted for 1.3% (n = 8) cases, while CNS cancers were seen in 1.0% (n = 6) of patients (Table 3).

Discussion

Although geriatric oncology in India is still in its early stages, ample amount of work is already being done in this field. The Asian Geriatric Oncology Society (AGOS) is one such example. It is a professional organization dedicated to promoting and advancing the field of geriatric oncology in Asia. The AGOS Vision 25 by 25 initiative aims to have 25% of cancer care professionals in the region trained in geriatric oncology by the year 2025. This initiative is designed to enhance the understanding and management of cancer in older adults, addressing the unique needs of this demographic and promoting specialized care. The vision focuses on improving geriatric oncology to make sure elderly patients get the right and personalized treatment.

This study provides a comprehensive analysis of cancer cases in individuals aged 60 years and above, revealing distinct patterns in the types and prevalence of malignancies in this demographic. The incidence of most solid cancers increases with age, but typically shows a decline after the age of 75 to 85, likely to be due to less frequent screening practices. A similar pattern was observed in this study, where cancer cases were fewer in the late elderly group.

Report from the Indian Population Based Cancer Registries showed higher prevalence of hematolymphoid malignancies and male genital cancers consistent with this study.3 Age-related immune changes and environmental exposures contribute to the higher rates of lymphoma and leukemia in older adults. Although breast cancer risk peaks after 70, this study observed a lower incidence in those over 75 years, likely due to less frequent or aggressive screening, resulting in underdiagnosis.4 The Surveillance, Epidemiology, and End Results (SEER) study done by Priyadarshini et al found a lower incidence of female genital cancers in women aged 75 and above, in line with findings of this study.5 No case of CNS cancers was observed in the ≥ 75-year age group, contrary to reports suggesting higher brain tumor incidence in the elderly.6 This may be due to selection bias, where CNS cancers were underreported or missed due to early mortality from other causes.

Cancer statistics for the year 2020 highlights gender differences in cancer distribution. Breast cancer was predominantly found in females and prostate cancer in males, consistent with this study.7 In addition to this, males exhibited higher incidence rates for a range of other cancers. These include kidney cancer, urinary bladder cancer, gastrointestinal cancers (such as colorectal cancer), liver cancer, and head and neck cancers. The higher rates of these cancers in men are often linked to lifestyle factors such as diet, tobacco use, and excessive alcohol consumption. Smoking, for example, is a major risk factor for cancers of the lung, head and neck, and bladder, while alcohol consumption is strongly associated with liver and gastrointestinal cancers.8910 These results are similar to the studies done by various authors who have highlighted the importance of gender-specific approaches to cancer prevention, diagnosis, and treatment, considering the varying risk factors and prevalence of different cancers in men and women.

Various studies being done on geriatric cancers in India suggested that multiple myeloma is the most common hematolymphoid malignancy in the elderly, which is comparable to this study. This is followed by CLL and CML, further consistent with the SEER cancer registry.11 Prostatic acinar adenocarcinoma predominated in men over 60 in this cohort, which is in line with the global prostate cancer histology data.3 A 2020 study by Ferlay et al noted that breast cancer constitutes 25% of cancer diagnoses in women worldwide, with rising incidence in older women, especially in Western populations. IDC, observed in both men and women, is the most common type and results of this study are similar.12 Colorectal adenocarcinoma was the leading gastrointestinal malignancy (35.6%) in this study, differing from studies where esophageal squamous cell carcinoma is more common and more so in regions with high tobacco and alcohol use.313 Gupta et al noted high-grade serous carcinoma as the most aggressive form of ovarian cancer in postmenopausal women, and endometrioid adenocarcinoma as the most frequent uterine cancer subtype in older women.14 Female genital tract cancers in this study made up 7.1% of cases, with high-grade serous ovarian carcinoma and uterine endometrioid adenocarcinoma being the most common, aligning with broader trends. This study found no cases of salivary gland cancer in the over-60 cohort, differing from some studies that report salivary gland malignancies as relatively frequent in older adults. This could be due to regional differences or study demographics. However, significant oncogenesis was observed in other head and neck areas, particularly squamous cell carcinoma, consistent with findings by Marur and Forastiere linking squamous cell carcinoma of the head and neck to smoking and alcohol consumption in older adults.15

Several unique challenges exist in the treatment of elderly cancer patients such as comorbidities, frailty, poly pharmacy, psychosocial issues, and economic constraints.16 Screening tools in the geriatric and cancer population are essential for identifying health conditions, managing risks, and improving outcomes. These tools help assess and address various aspects of health such as elderly's medical, psychological, social, and functional capabilities. Each tool has its unique role in improving outcomes in the elderly population. There are some commonly used screening tools such as Vulnerable Elders Survey-13 (VES-13), Geriatric 8 (G8), Comprehensive Geriatric Assessment (CGA) and Onco Geriatric Screen (OGS).17 Some centers in India are starting to implement these tools to guide treatment decisions; however, more targeted initiatives focusing on elderly cancer care are needed.

Recently, the SCOPE-C (Screening for Cognitive Impairment in Older Adults) Version 1 screening tool is being used in India in the geriatric care setting to identify cognitive impairments early and to assess fitness of geriatric oncology patients to receive anticancer therapy. It allows clinicians to intervene and refer patients for further evaluation or management, potentially improving outcomes for older adults.18

Technological advancements have greatly impacted health care, providing opportunities to improve care for older adults with cancer. While research from high-income countries shows an increase in technology use among older adults, there is limited information about how health-seeking older adults in India use technology. This lack of data highlights the need for further studies to understand how technology can enhance cancer care for the elderly in India. Specifically, empowering them with the knowledge and skills to use digital tools such as telemedicine, health tracking apps, and online educational resources can help them manage their health more effectively.19

Limitations

This study is limited by its small sample size, retrospective design, and inclusion of institutional-based data only, thus might not reflect the prevalence in the entire population.

Conclusion

The patterns of cancer incidence observed in this study highlight the complexity of malignancies in individuals aged 60 and above. Though small, this study is a significant step in analyzing the cancer prevalence in the elderly population of Punjab. While there are efforts underway to address the needs of elderly cancer patients, more comprehensive approaches are needed, including training health care professionals, improving access to care, and focusing on multidisciplinary treatment strategies individualized to the unique needs of older adults. Expanding geriatric oncology will improve the overall care of this vulnerable population, enhancing both survival rates and quality of life.