Ageism is a bias or discrimination toward an individual or group based on their biologic age. I met Sally in August of 2019 when she was 95 years young. She was a new patient added on to my clinic with a chief complaint of “new bladder mass,” and I could not help but notice her age as I bustled into the procedure suite. I had been in practice for about 5 years at that time, and she was the oldest patient I could remember seeing in my clinic. I also remember thinking, please let this be a small tumor! Unfortunately, it was a large muscle invasive bladder cancer taking up the entire left side of her bladder and causing moderate amounts of blood in her urine. As she hopped off the cystoscopy table we began to talk, and I quickly learned what a remarkable woman she was.

Sally had lived a good and fulfilling life managing to avoid any significant medical diseases like heart or lung disease. She was living independently and taking care of all her own instrumental activities of daily living. Sally was widowed but had a large support group of friends and family. She enjoyed teaching others how to play the card game bridge. Her case was presented at our genitourinary oncology tumor board, and she was deemed too old for any chemotherapy. She was not an ideal candidate for bladder preservation strategies for cure due to the tumor characteristics. As I pondered what best to do for Sally, I kept returning to the idea of radical cystectomy as her best path forward. She is now 4 years out from radical cystectomy and ileal conduit and living her best possible life (Figures 1 and 2).

Figure 1. The author with Sally. Shared with permission from the patient.

Figure 2. The author with Sally. Shared with permission from the patient.

As Sally and I discussed her treatment options, it was clear that she wanted to continue living and maintaining a good quality of life. Failure to treat her cancer would negatively impact both of those goals. Older patients may be victim to ageism from their health care providers, and I strongly believe it is critical to not withhold treatment (surgical or medical) based on age alone. While Sally was certainly older biologically, her physiology suggested she could tolerate cystectomy and we decided via shared decision-making to proceed without bias. There are calculators that may be useful to help predict life expectancy (actuarial, health care, and governmental) that are beyond the scope of this article, but all have flaws: they are all models! I believed Sally could live another 5 years when I met her with a good quality of life, but this would only be true if we could cure her cancer with cystectomy.

Despite a decline in physical- and mental health–related quality of life when compared to noncancer controls,¹ my personal experience is that patients undergoing cystectomy are remarkably able to adapt, still engage in enjoyable activities, and return to an acceptable quality of life. In addition, several studies have revealed that older patients with bladder cancer are less likely to receive curative intent treatment compared to their younger counterparts.^2-7 We recently looked at my series of 481 consecutive patients who underwent cystectomy since 2015, of whom 59 were older than 80. We found no difference in length of stay, readmissions, or perioperative complications in those older than 80. However, we did see a slight increase in 30-day (0.5% vs 3.0% P = .02) and 90-day (2% vs 7%, P = .02) mortality in the older patients (unpublished data). The slight increase in mortality is real and should be discussed with older patients undergoing major abdominal surgery. But with careful patient selection, outcomes following cystectomy in octogenarians (and some nonagenarians) can be quite good.

Optimizing surgical and medical outcomes in older patients requires a careful assessment of the patients’ medical comorbidities, social support, frailty, performance status, and goals of care. There are numerous ways to assess frailty, which are also beyond the scope of this article, but I prefer grip strength testing and the get up and go test. If someone cannot squeeze my hand or get up out of their chair easily, then I would think twice about moving forward with risky treatments. Once these discussions and assessments have been completed, one can tailor a treatment plan to meet these goals that then align with patient-centered care.

Sally told me recently that I saved her life. I said that while I may have helped extend it, she was an inspiration, and her story was truly one for the ages. I asked her what her pearls for longevity were, and she quipped:

• Eat well
• Exercise
• Have meaningful connections

I’d like to add: Be aware of your biases and don’t be an ageist!