A Beautiful Mind
Nursing professor accepts MacArthur award for her work in geriatric anthology

By Glen Fest
February 26, 2004

‘That’s so sad.” People meeting Sarah Kagan, Ph.D., RN, often get the wrong idea when she tells them she works with elderly patients with cancer. They react with sorrow as they imagine Kagan struggling through the daily despair of ailing seniors losing time and hope.

“My work isn’t at all sad,” Kagan counters. As both a practicing nurse and a researcher, she has found that the bleak outlook stems from ageist attitudes and a dearth of scientific knowledge about older people and cancer. Instead of believing that the elderly are “supposed to get sick,” Kagan has devoted her career to learning the paths to recovery for patients with cancer who are 65 and older, she said.

“It’s really about living, and living as well as you can,” said Kagan, an associate professor of gerontological nursing at the University of Pennsylvania. “As a result, I’m commonly in the situation of explaining to people what’s really rewarding and what’s really hopeful about working with older adults who have cancer.”

Thanks to the 41-year-old Kagan, there may be much more optimism to share in the years to come. Kagan was honored in the fall as one of 24 recipients of a 2003 MacArthur Foundation Fellowship, the “no strings attached” $500,000 annual award that goes to trailblazers in the fields of science, medicine and the arts.

Kagan is only the second nurse to win the prestigious “genius” grant, whose recipients in past years have included writer Thomas Pynchon, paleontologist Stephen Jay Gould, filmmaker Errol Morris, pioneering geneticist Barbara McClintock, magician and pseudoscience debunker James Randi and children’s activist Marian Wright Edelman.

The John D. and Catherine T. MacArthur Foundation cited Kagan’s efforts to meld research and clinical care to substantiate how elderly cancer patients respond differently than younger patients to treatment, in both physiological and psychological factors.

The foundation applauded Kagan’s 1997 book, Older Adults Coping With Cancer, for challenging “ingrained preconceptions about the treatment of older patients, [and] providing a framework for understanding their heterogeneity of responses to cancer.”

Like all MacArthur fellows, Kagan received the honor through an anonymous nomination process. She was notified by phone by the foundation, giving her “a bit of a shock,” she said, laughing.

Leading expert

The foundation noted Kagan is fast becoming one of the nation’s leading experts on older people with cancer—particularly head and neck cancers—while bridging the surprisingly nontethered sciences of oncology and gerontology. She is scheduled to publish her second book, Cancer in the Context of Lives Mostly Lived, next year.

“We are surrounded by a culture that views aging in a particular way,” Kagan said. “I think that older adults may even often self-stereotype themselves and believe that they might not benefit from cancer therapy. Or because they are old, they are supposed to be ill.”
Kagan’s interest in geriatric oncology began early in her career in the mid-1980s, when she arrived in San Francisco with dual bachelors degrees in behavioral sciences and nursing, and was offered a position at Children’s Hospital (now California Pacific Medical Center) under the wing of the medical/surgical oncology nurse manager. She accepted the job when she realized the effect nursing has in cancer treatment.

“That was when it really came together,” Kagan said. “Much of what older adults require to successfully complete cancer treatment is, in fact, delivered by nurses. Nurses really are the ones who make or break cancer treatment and the central experience of what we consider to be the medical model of cancer experience.”

Once she began treating adults, she “branched out” to study the psychosocial effect that cancer—and cancer treatments—had on older patients. “I began to understand that older adults are influenced 85 by ageist attitudes on the part of others,” Kagan said. “We’re almost paternalistic in an effort to protect older people whom we think are vulnerable.”

The idea that cancer was inevitable or expected in older populations perhaps fed the notion that the elderly would not benefit—or could not tolerate—conventional cancer treatments.

The elderly were less frequently enrolled in clinical studies than younger patients, due to insufficient family support or commuting difficulties, and because Medicare did not cover the costs of clinical trial participants older than 65 until 2000.

Oncology professionals also lacked studies on how elderly cancer patients with comorbidities—heart disease, diabetes, etc.—would respond to common therapies.

Edward Trimble, MD, a leading cancer researcher at the National Institutes of Health in Bethesda, Md., said among studies comparing treatments in clinical trials, “older patients tend to fare about as well as younger patients” when no comorbidities exist.

“But there is a perception 85 that they are frail and less likely to tolerate aggressive treatment for cancer, for they tend to get treated less aggressively.”

Collaborative gap

Even with the Medicare change, a large collaborative gap between gerontology and oncology remains, Trimble said. “We are looking at a number of cancer centers 85 that are active in gerontology, but we just don’t have that now,” Trimble said. “We need to come up with an effective form or scale 85 to help the busy oncologist figure out how somebody who is older and has morbidities is going to tolerate his cancer treatment.”

Kagan, Trimble said, has “been one of the people fighting the good fight to bring the oncologist together with the gerontologist.”

The prejudice that results in fewer care options for the elderly has spurred much of Kagan’s research, which includes collaborative articles in nursing and medical journals such as the American Journal of Epidemiology, Critical Care Nurse, American Journal of Nursing and Head and Neck.

Kagan teaches at Penn’s nursing and medical schools, and conducts research through Penn’s Hartford Center of Geriatric Nursing Excellence (one of only five geriatric nursing centers in the United States funded by the New York-based John A. Hartford Foundation).

She also holds a clinical post as a gerontology clinical nurse specialist at the Hospital of the University of Pennsylvania. In addition, Kagan holds numerous visiting academic posts in Hong Kong, Sweden and at Harvard University.

“One of the privileges I have is being able to see the success that advances in biomedical technology have generated, and also the needs that advancing therapies have created,” Kagan said, “which give nurses who are interested in building science and evidence-based practice a lot of room to take leadership. And that’s one of the things I really enjoy doing, and helping people see where we should go next.”

Contact Glen Fest at glenf@nurseweek.com.