For some reason, the paradigm for death in our society seems to be cancer, and it is this disease that many elderly fear the most. Yet statistics still show that cardiac disease is by far the most common cause of death in western societies, despite the recent (40 years) age-adjusted decline in mortality for cardiac disease. What this means is that even though a 75-year-old man is less likely to die in the next year of heart disease than a similarly aged man would have in 1960, it is still the most likely cause of death. The greatest misconception is probably among women, who often think that breast cancer is a more common cause of death than heart disease.
Why is this the case? Although it is true that breast cancer can affect very young women, advancing age is the biggest risk for the prevalence of both cancer and cardiac disease. I think the more likely reason for the societal fear of cancer is the belief that cancer is likely to cause a particularly difficult death. This popular conception is based on two factors: a lack of appreciation of the effectiveness (and often a lack of availability) of modern palliative care, and a mistaken belief that cardiac death results in sudden death, usually in the setting of an acute myocardial infarction (MI). However, in the elderly, this is not usually the case.
There has been a recent dramatic increase in the prevalence of congestive heart failure in the elderly, partially at least as a result of modern advances in treatment of acute MI that allows more patients to survive the acute incident. Patients with Grade IV ventricular function have a 50% annual mortality rate, worse than many cancers. Patients can be severely symptomatic and have very poor quality of life. Frequently in these patients, palliative care would seem to be appropriate, and yet it is not often 'prescribed.' Part of the reasoning is that for many of us the word 'palliative' is only associated with cancer. As well, our ability to predict survival in specific individuals with congestive heart failure is poor, thus making them inappropriate for some palliative care services that expect a very limited time frame per patient.
This topic was recently discussed in the British Medical Journal in an article entitled 'Cancer isn't the only malignant disease.1 The case described a man with incurable and severe peripheral vascular disease, and the reasons for lack of a palliative focus in his management. Fortunately, in this case the physicians eventually recognized the need for palliation, and the patient was able to die at home. The article is definitely worth reading and the BMJ (like Geriatrics & Aging!) is one of the few journals available on line (at bmj.com) in its entirety at no cost to the user.
This month's journal focuses on some of the key issues primary care doctors face in managing the cardiovascular problems of their patients. Current issues in heart failure management are discussed and there are articles on the management of multi-vessel coronary artery disease (stenting vs. bypass). The internationally renowned expert in geriatric cardiology, Dr. W.S. Aronow, has contributed an article on the controversies in treatment of low HDL cholesterol levels and elevated triglycerides.
The issue also contains articles on frontotemporal dementias, treatment of depression in the elderly, acute urinary retention and screening for urogenital cancers in elderly women. Dr. Madhuri Reddy has contributed an article on the difficulties inherent in making long term predictions of patients' needs, and Dr. Mark Clarfield has provided an entertaining article on the history of geriatrics. Enjoy this issue.
- Moulder E. Cancer isn't the only malignant disease. BMJ 2002;324:07.