Introduction

The cases of cancer in old people have significantly increased because of the overall aging of the population and the fact that cancer incidence and mortality rise exponentially in the 65 and above age groups [1,2,3]. The increasing caseload of older patients with cancer will present great challenges to all components of the healthcare system. As a result, there is a great need for clinical research to identify and implement evidence-based, best practices to eliminate pain and suffering from cancer in older patients, enhance their quality of life, and extend their survival. Clinical presentation-based investigation has become more imperative in elderly cancer patients due to limited financial resources available for diagnosis as well as treatment. Older cancer patients with locally advanced or metastatic disease might benefit from chemotherapy/hormonal therapy or combined with radiotherapy [4, 5]. Immunity of old cancer patients is comparatively less, as a result, the pattern of cancer is completely different during immunotherapy. The efficacy of immunotherapy is comparatively lower in the elderly patient’s bone marrow compared to chemotherapy and the former is very expensive. Geriatric cancer patients have 6 complex issues frailty, comorbidity, discrimination, tolerance, insurance, and transportation. These result in a presentation at an advanced stage of cancer, difficulty in lying down without motion for various radiological investigations, and suboptimal feasibility in the execution of radiotherapy, chemotherapy, hormonal therapy, and surgical treatment. Worrisome toxicities of these treatments in aging patients may require dose reduction but that may result in potential loss of efficacy [6, 7]. With lifestyle changes and other advancements along with the increase in cancer incidence especially among the elderly, due to reasons like ignorance and reluctance towards their health and sometimes lack caregivers at home as some children work away from their families, subsequently, there is a delay in diagnosis & treatment [8, 9]. So, to assess the present scenario, this prospective observational study has been conducted to know the mean time taken to make a diagnosis & start treatment in elderly cancer patients further to assess the quality of life and survival analysis.

Primary Objective

  • To determine the clinical presentation of geriatric patients with various cancers attending the Outpatient department of Swaroop Rani Nehru Hospital and Kamla Nehru Memorial Hospital (Regional Cancer Center) Prayagraj.

Secondary Objectives

  • To determine the time taken to make a diagnosis and the start of treatment from the time the patient first presents to any health facility.

  • To assess the quality of life and calculate three months of survival among these patients.

Patients and Method

This study was approved by the institutional ethics committee. A signed informed consent was obtained from each participant/legal guardian. This multicenter, historical patient records were analyzed for a period of 6 months (March 2022 to August 2022) on geriatric cancer patients ≥ 65 years of age who consented to provide the information and visited Swaroop Rani Nehru Hospital and Kamla Nehru Memorial Hospital & Regional Cancer Center, Prayagraj during the study period. Patient records and the World Health Organization Quality of Life Brief Version (WHOQOL-BREF) were used as study tools [10, 11]. All patients with a diagnosed malignancy attending during the first three months between 01/03/2022 to 31/08/2022 according to the first visit date to the above health facilities and who met the inclusion and exclusion criteria were enumerated for participation in this study. The patients were further followed up monthly to ensure follow-up of all patients till 6 months for calculating survival outcomes by performing survival analysis and Kaplan–Meier curves [12, 13] were constructed. The data collected was tabulated and analyzed using the statistical package of SPSS 23.0 trial version. Appropriate statistical tests were applied to analyze the data.

Case Report Form

For data collection case report forms were prepared which comprised the following sub-headings viz. were patient particulars, initial clinical presentation, type of cancer, investigations done, diagnosis & treatment so far, and follow-up (Visit 1, Visit 2 and Visit 3).

Inclusion Criteria

  1. 1.

    Male or female patient ≥ 65 years of age according to the legal identity card of the local constitution.

  2. 2.

    Patients with a diagnosis of malignancy with solid cancer irrespective of the stage as evidenced by one or more clinical features either confirmed by biopsy or any other tests.

Exclusion Criteria

  1. 1.

    Presence of a condition or abnormality that in the opinion of the investigator would compromise the safety of the patient or the quality of the data will be excluded.

  2. 2.

    Patients unable to give informed consent were excluded.

Results

A total of 80 participants with histologically confirmed cancers were included in this study. The majority of patients belonged to the 65–75 years age group (n = 62, 77.5%). Only 18 (22.5%) were in the age group of 76–85 years. Among total patients, the disease was confined to the primary site in 45 (56.2%) and it had nodal spread or metastasized in 35 (43.7%) at the time of first diagnosis.

Clinical Presentation, Time Taken in Diagnosis and Treatment

In patients of the age group of 65–75 years, 36 (45%) had carcinoma confined to loco-regional and 4 (5%) exhibiting lymph node spread. The majority of 22 patients (27.5%) had distant metastasized spread at the time of initial diagnosis. In the age group of 76–85 years, 9 patients (11.25%) had carcinoma confined to the primary region while 4 (5%) and 5 (6.25%) exhibited lymph node spread and metastasized spread respectively.The distribution of patients according to spread and site of cancer are summarized in Tables 1 and 2.

Table 1 Distribution of patients according to the spread of cancer
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Table 2 Distribution of patients according to site of cancer
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Out of 80 patients, a total number of head & neck cancer cases were 19 (23.7%), out of which 14 (17.5%) of cases were in the age group of 65–75 years, while 5 (6.2%) of cases were in the age group of 76–85 years. the total number of gastrointestinal cancer cases was 14 (17.5%), among which 11 (13.7%) and 3 (3.7%) cases were in the age groups of 65–75 years and 76–85 years, respectively. Third number of patients presenting with genitourinary cancer was 24 (30%), among them 16 (20%) were in the 65–75 years age group while 8 (10%) patients were in the age group of 76–85 years. There were 23 (28.7%) other cancer patients which includes unknown primary.

Overall data on the time taken to make a diagnosis, from the very first visit of patients to being diagnosed with various cancers, has been tabulated in Table 3 and analyzed. The mean time taken to diagnose patients with head & neck cancers was 11 days (12 days in the 65–75 years age group and 6 days in the 76–85 years age group); the maximum time taken was 106 days. The mean time taken for gastrointestinal cancers was 6 days (5 days in the 65–75 years age group and 8 days in the 76–85 years age group); the maximum time was 22 days. In genitourinary cancer, the mean time taken was 8 days (9 days in the 65–75 years age group and 6 days in the 76–85 years of age group), and the maximum was 35 days while in other cancers, it was 9 days (9 days in 65–75 years of age group and 7 days in 76–85 years of age group); the maximum delay was 66 days.

Table 3 Average time taken in diagnosis (in days)
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All of the patient's data, attributing to average time taken (9in days) to start treatment from the diagnosis date with various cancers was tabulated in Table 4 and analyzed. The mean time to start the treatment of head and neck cancer patients was 14 days (14 days in the 65–75 years age group and 15 days in the 76–85 years age group); the maximum delay was 61 days and one patient was not responding to treatment. However, in gastrointestinal cancers, the mean time to start the treatment was 8 days (6 days in the 65–75 years of age group and 24 days in the 76–85 years of age group); the maximum delay was 39 days and three patients were not responding to their treatment. In genitourinary cancers, the mean time taken was 11 days (13 days in the 65–75 years of age group and 3 days in the 76–85 years of age group); the maximum delay was 42 days and five patients were not responding to treatment. in other cancers, anthem the average time to start the treatment was 5 days (6 days in the 65–75 years age group and 2 days in the 76–85 years of age group); the maximum delay was 26 days and eight patients were not responding to treatment. Table 5 summarizes five major reasons for the delay in starting treatment in the present study.

Table 4 Average time taken to start treatment (in days)
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Table 5 Reasons for delay in starting treatment
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Quality of Life

All of the 80 participants completed their quality of life standard questionnaire (WHOQOL–BREF) for head & neck, gastrointestinal, genitourinary, and other cancers. Table 5 represents reasons for delay in starting the treatment.

Table 6, represent Quality of Life (QoL) score where D1 indicates as a Domain 1, D2 as a Domain 2, D3 as a Domain 3, and D4 as a Domain 4. In head and neck cancer treatment, a total of seven patients received radiotherapy, six were on chemotherapy, two were on combined treatment (concurrent chemo-radiotherapy), two patients received neo-adjuvant chemotherapy, one had surgery, and one was not responding to treatment. The highest score for the neo-adjuvant chemotherapy modality of treatment for this cancer was 66 in D1, showing a good quality of life. In gastrointestinal cancer treatment, a total of seven patients received chemotherapy; four were on supportive treatment, and three were not responding to treatment. The highest score was 66.8 in D4 for radiation therapy, and the lowest scores were in D3, i.e., 25, 39.1, and 39.1 for neo-adjuvant chemotherapy, surgery, and chemotherapy, respectively. In genitourinary cancer treatment, seven patients received chemotherapy, six were on radiotherapy, four were on combined treatment (concurrent chemoradiotherapy), one patient received neo-adjuvant chemotherapy, one had surgery followed by chemotherapy and five were not responding to treatment. The highest score for this cancer was 61.8 in D4, showing good quality of life in patients who received chemotherapy. In other cancer treatments, a total of ten patients were on chemotherapy, three had received radiotherapy, one had surgery and concurrent chemo-radiotherapy and eight were not responding to treatment. Among those with a combined modality of treatment in all cancers, the highest and lowest QOL scores were observed in D4 and D3 i.e., 81 and 31, respectively. The highest for surgery and lowest for radiation therapy scores are 81 and 25, in D4 and in D3, respectively.

Table 6 Quality of life Score of study participants on a 0–100 Scale
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Survival Analysis

It was observed that of the total number of enumerated study participants, 28 patients (35%) died during the study period, of which two (10.5%) were of head and neck cancer, 11 (78.5%) were of gastrointestinal cancer, 7 (29.1%) were of genitourinary cancer and 8 (34.7%) patients were suffering from other types of cancers. During the first month of follow-up, two cases of gastrointestinal cancer, one from genitourinary and one of other cancers died from their disease. During the second month of follow-up, three cases of gastrointestinal cancer, four cases of genitourinary cancer, and two cases of other cancers died from their disease. During the third month of follow-up, two cases of head and neck and genitourinary cancer, as well as five cases of gastrointestinal and other cancers, died from their disease.

Figure 1 shows cumulative survival [14] concerning the duration of follow-up (days) of geriatric cancer. The response was recorded during follow-up while patients were receiving their treatment. The four lines show survival KM curves for four different groups represented by G (gastrointestinal cancer), H (head and neck cancer), O (other cancers), and U (genitourinary cancer). A vertical drop in the curve is indicating an event (death of a patient). The short vertical lines on the curves mean that a patient was censored at this time. At time zero, the survival probability was 1 which showed a 100% of the participants were alive.

Fig. 1
figure 1

Cumulative survival in respect to duration of follow up (days) of geriatric cancer. The various colours indicates four different sites

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Follow-Up

The response of patients after their treatment started was seen during follow-up till three months to ensure follow-up of every participant summarized in Table 7.

Table 7 Response to treatment as seen during follow-up
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Table 7 shows response to treatment during follow-up and it was found that during the first month of follow-up, out of 19 patients in the head and neck group, five showed complete response, and 14 showed partial response. In the gastrointestinal group, out of 14, only one showed complete response, three showed partial response 8 survived with disease and 2 died. In the genitourinary group, out of 24 patients, 2 showed complete response, fourteen showed partial response, 7 survived with disease and one patient died. In other groups, out of 23 patients, three showed complete response, eight showed partial response, three were lost to follow-up, while 8 were surviving with disease and one patient died. During the second month's follow-up, head & neck cancer patients showed 5 complete responses and 14 partial responses. In gastrointestinal, out of 14 patients, only one patient showed complete response, two showed partial response, while 8 were living with the disease and three patients died. In genitourinary, out of 24 patients, 2 showed complete response, fifteen patients showed partial response, 3 survived with disease and 4 died. In others, out of 23 patients, 2 showed complete response, 9 showed partial response, 3 were lost to follow-up, 7 were surviving with disease and 2 died. During the third month follow-up of head and neck cancer patients, 5 showed complete response, 10 with partial response, 2 showed progression and 2 patients died. In gastrointestinal, out of 14 patients, only 1 showed complete response, 2 showed partial response 6 were surviving with disease and 5 died with disease. In genitourinary, out of 24 patients, 2 showed complete response, 14 showed partial response, 6 survived with disease and 2 died with disease. In others, out of 23 patients, 2 showed complete response, 7 showed partial response, 3 were lost to follow-up, 6 showed progression and 5 died of the disease.

Conclusion

Mostly geriatric cancer [15, 16] patients are often diagnosed later and the treatment process is typically delayed, resulting in a significantly reduced quality of life and an increased rate of mortality among them [9, 17]. The most prevalent cancers in the target populations were genitourinary (n = 24, 30%), head & neck (n = 19, 23.7%), and gastrointestinal (n = 14, 17.5%) while commonly experienced symptoms in the studied population were pain (77.5%), but different symptoms were observed for different types of cancers [18, 19]. A total of 28 (35%) patients died, while 17 (21.25%) of them were not responding to their treatments. A few studies on the Indian population elaborating on clinical characteristics, delays in diagnosis, and the start of treatment in the geriatric cancer population have been reported. However global efforts should be implemented to increase awareness about government policies to get cancer treatment free or at low cost which will further increase the quality of life and survival rate among these patients [20,21,22,23,24]. Massage of this paper is there is low suspicion of malignancy among doctors and patients in eastern Uttar Pradesh resulting in delayed and advance presentation with poor quality of life and poor outcome.