Perspectives on the Intersection of Cancer and Older Age

Sarah H. Kagan has provided a significant exploration of what it means to grow old with cancer. This illuminating book weaves the narrative of Mrs. Eck, a cancer patient, in her 80s, together with the threads of the many people, places, and experiences related to her cancer journey. What emerges is a deeply insightful and multidimensional perspective in which the meaning of cancer in old age is explored and applied to life, living, and dying. Kagan's book compels the reader's consideration of multiple social dimensions and constructs often neglected or altogether invisible in previous explorations of what it means to be old and have cancer. In achieving her aim, Kagan provides a bold yet eloquent discussion that explores (a) living daily life in the face of impending future death; (b) the individual and larger social context that infuses our understandings and perspectives of the older cancer patient; (c) the dynamic paradoxical relationship between human aging, health, and biomedical science, and finally; (d) the embodiment of individual aesthetics as they relate to age, gender, and cancer. The book represents a small but no less significant contribution to the gerontological literature. In particular, the book serves as a much needed reminder that patients are people, and their lives, although enmeshed in illness and medical care, are their own. Furthermore, the book offers a salient and much needed jumping-off point for further critical examination of the relationships between the person/patient and the biomedical discourse that accompanies their diagnosis, treatment, and management. Medical practitioners, caregivers, and scholars will all find nuggets of wisdom and kernels of insight that may be directly applied in caring for and understanding older cancer patients. Biomedical professionals, however, may be somewhat less accustomed to the deeper sociological and experiential discussions. Likewise, although the voice of Mrs. Eck will resonate with patients and their families, Kagan's deep discussions of American social discourse in relation to the lived experience of older cancer patients favor the professional and academic audience. This book reflects an introspective and highly thoughtful exploration of cancer in the lives of older patients that can only be achieved through a career that exemplifies a passionate devotion to the topic. Kagan's long history of clinical work and academic inquiry provides her with a rich well of experience in which the themes of this book were drawn. At the outset, Kagan moves away from the commonplace generic discussion of the experience of aging and cancer couched within the context of medicine and science. In contrast, she shifts the focus to a person-centered perspective that recognizes older cancer patients as the sum of dynamic and fluid individual experiences understood within socially constructed domains. The book begins with an enjoyable discussion of the author's own journey toward a more intimate understanding of the poignant but less acknowledged aspects of being old and having cancer. For Kagan, chronological age is not a patient characteristic to be used as a primary determinant for a myriad of medical health outcomes but rather a pinnacle from which one's life—past, present, and future—and death can be viewed. Chapter 1 begins with the symptom story or narrative of a woman in her 80s living with pancreatic cancer. Her voice challenges the image of cancer as all encompassing and threatening of certain impending death. In refreshing contrast, cancer comes to be viewed as only one more facet of life in a play that is not quite over. This perspective is further elucidated in subsequent chapters. Chapter 2 challenges and examines the seemingly well-established stereotype that the experience of cancer in old age is marked by “enveloping debility, endless despair, and proximate death” (p. 26). Kagan provides convincing evidence that the reality of the older cancer patient is vastly different, often more reminiscent of personal triumph and hope than failure and gloom. The persistent lack of symmetry between lived reality and perception lies in our own social construction of disease. Societal beliefs and values equate increasing age with decreasing physical and mental prowess and perhaps even self worth. The perception of cancer in older adults is melded with societal perceptions of failure and success. The connotations of successful aging and historical puritanical mores that “link moral matters of behaviour and moral life” (p. 32) to disease and disability further erode the societal image and expectations imposed upon older adults living with cancer. In sharp contrast, Kagan suggests that age, as representative of a lifetime of accumulated life experience, offers a powerful tool for navigating cancer in meaningful personal ways. The book's third chapter reflects on the multiple paradoxical relationships that further muddy the landscape of cancer in older age. First, Kagan examines the relationship between medical science and social experience. Although science continues to look for the fountain of youth or at least increased longevity, such outcomes are rarely sought or desired by the very people believed to be at risk. Perhaps, suggests Kagan, “The relevance of life and the meanings of one's life might necessitate clearly drawing the point where aims are judged achieved or unachievable and accomplishment outweighs enthusiasm” (p. 43). In this light, the experience of aging, having cancer, and dying are uniquely individual and personal. In contrast, the diagnosis and treatment of diseases, including cancer, are unequivocally standardized. In the next chapter, Kagan continues her dissection of socially embedded understandings related to being old and having cancer. In particular, she illuminates how our societal views of age and aging manifest in physical embodiment as well as actions well grounded in ageist views. Bringing her discussion full circle, the chapter culminates with a discussion of “projected future constructions that may or may not fit a scientific continuum” (p. 49). While offering a rich and persuasive discussion of the detrimental outcomes of ageist views, the chapter affords little fodder for remediation or reconciliation on behalf of the researcher or care provider. Chapters 5 turns to the lived experience of the older cancer patient. Specifically, Kagan argues that three concepts: “integrating cancer into a life mostly lived,” “symptom stories,” and “quality of daily living,” (p. 65), “can be employed to frame an understanding and theoretically ground care of older adults who have cancer within parameters that then echo their own experiences” (p. 65). These three concepts, taken together, represent opposing ideas found manifest in clinical language. For example, a symptom story better captures and defines how older patients manage symptoms as part of their daily life. In contrast, symptom management, a term commonly used in health care, negates personal experience in favor of “ameliorating symptoms of cancer or of comorbid disease and side effects of biomedical treatment” (p. 69). The language used by patients, argues Kagan, reveals much about the ongoing relationships between a person and their life, their disease, and their health care provider. Ultimately, although the language of medical providers is dominated by age, the language of the older patient is person centered. Although Kagan hints at the many possible advantages of embracing patient-centered language in a care setting, the methods for doing so are more opaque. The final chapter brings much needed consideration of the aesthetics of being old and having cancer. Increasing age and the experiences it brings with it are evidenced in our physical body, often in public view. For older cancer patients, the physical presence of advanced age and poor health are often visually obvious, especially for patients with cancers of the head and neck. Kagan explores how aesthetics are bound to social constructions of health and age as well as how values regarding form and function affect medical decisions and expectations. Kagan's questions regarding surgical reconstruction reflect critical issues related to providing appropriate and meaningful care for older cancer patients. Cancer in the Lives of Older Americans is a valuable contribution to the gerontological literature. The book offers a provocative story, unlike most academic books, that beholds the often quiet voice of real patients with real lives and real cancers. Although the book may seem to read less like the clinically based cancer texts that have become commonplace, it has much to offer varying audiences.

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