DR. ANDREW CHAPMAN AND DR. KRISTINE SWARTZ
Several weeks ago, Mrs. Smith, an 80-year-old widow, was diagnosed with breast cancer after she felt something in the shower. Her husband of 50 years died seven years earlier and she has lived alone since. She is scared about what the disease means and how to face it. After all, she is 80. People her age don’t get chemotherapy.
Mrs. Smith sees her family doctor every couple of months and takes medication for low thyroid. Having enjoyed good health throughout her life, she has only been in the hospital for children’s births. A couple of people she’s known have had cancer—her best friend’s husband died a year ago from colon cancer and her neighbor was diagnosed with prostate cancer this year. But what does her cancer mean for her?
Mrs. Jones is also 80 years old. Several months ago when her dementia worsened, she moved into a nursing home and has difficulty remembering the name of her husband of 50 years who visits daily. She needs help to get dressed, eat her meals and use the bathroom. With an aide and walker by her side, she can walk small distances.
She has had diabetes and heart disease for 15 years and takes multiple medications. Mrs. Jones was also hospitalized last year after she fell and fractured her hip. Several weeks ago, she was diagnosed with breast cancer after an aide felt something while bathing her. Her husband has many questions. What does this cancer mean for her?
These are two very different 80-year-old women with breast cancer who represent the diverse and unique challenges that come with older cancer patients—the ever-growing group that makes up the bulk of those diagnosed with the disease.
Currently, the median age of cancer patients at the time of diagnosis is 66. Geriatric patients make up 60 percent of new cancer diagnoses and 70 percent of all cancer deaths and those numbers are expected to increase as the geriatric population doubles in size by 2030. What’s more, there’s currently a shortage of geriatric oncology physicians to treat them.
As these challenges become increasingly more evident, a paradigm shift in cancer care will most likely have to occur if we want to better serve the geriatric patient population.
Age is Just a Number
As illustrated above, age is a poor predictor of a person’s overall health status. Chronological age is less important than “functional” age. A 90-year-old patient living independently with no chronic medical problems may do better with cancer treatment than a 70-year-old that lives in a nursing home and has multiple medical problems. Functional age can be a much more accurate predictor of outcomes for geriatric cancer patients. 3,4,5. The complexity of the geriatric patient is what makes functional age so much more important.
Due to normal changes to the body as we age, older adults respond and process chemotherapy drugs differently than their younger counterparts, making side effects and toxicities more severe. Older patients often have other medical problems, including high blood pressure and diabetes, as well as common geriatric problems such as frequent falls, depression, memory problems, poor nutrition, and lack of social support. These can all make cancer treatment much more difficult.
A multidisciplinary program is necessary to manage these unique aspects of cancer in the elderly. The Kimmel Cancer Center at Thomas Jefferson University Hospital has taken this sort of novel approach to geriatric oncology with a program that features a medical oncologist, a geriatrician, a nurse navigator, a pharmacist specially trained in oncology and geriatrics, a registered dietician, and a social worker. A joint effort between the Departments of Medical Oncology and Family and Community Medicine, Division of Geriatrics, the Senior Adult Oncology Center provides a comprehensive assessment, usually during a single visit, to identify problems related to aging and cancer.
A developed personalized treatment plan for a 85-year-old women with lung cancer who is hard of hearing and suffers from diabetes, for example, takes into consideration her risks, potential for complications, and personal preferences to help ensure autonomy, dignity, and quality of life.
Navigating Complex Cancer Care
That first, and perhaps the most important, interaction the patient has is with the nurse navigator, who serves as the patients’ primary contact person throughout the experience. She schedules the initial visit for the patient, assists with gathering any records that may be crucial to obtain prior to the appointment, and helps coordinate the multiple specialists evaluating the patient during the encounter.
Once the visit is complete she schedules any additional imaging or lab testing that may be needed and follow up appointments or referrals.
Older patients’ other medical problems, such as high blood pressure and diabetes, often necessitate multiple medications, which can interact with anti-cancer therapies. This is where a pharmacist comes in. Patients need the opportunity to review their medications, how to take them, and what each is prescribed for with the pharmacist—identifying potential issues with drug-drug interactions and appropriateness of medications.
Cancer patients are also often at risk for malnutrition. According to the National Cancer Institute, about 20 to 40 percent of cancer patients die from causes related to malnutrition, while 80 percent develop some form of clinical malnutrition. Elderly men and women often experience weight loss, decreased appetite, and may also have problems with nausea, vomiting or swallowing. To address this, each patient meets with a registered dietician specializing in oncology to review strategies to improve their nutritional status prior to cancer treatment.
Social workers are also on hand to assist families with obtaining more support in the home, arranging transportation for treatments, and applying for assistance programs to help offset costs of treatment.
Older patients may also have difficulty hearing instructions during the doctor’s visit or trouble reading the directions on the medication bottle. Memory problems can make understanding and signing consents for treatment impossible. Assistance may be needed to get to and from the treatment center. Closely monitoring and reporting side effects from treatment may be tough for many, leading to delays in care and more significant consequences. In general, significantly more social support is needed when compared to someone younger.
Furthermore, the biology of cancer is different in the elderly. For example, some cancers are more resistant to the usual treatment options when present in older adults, whiles others are less aggressive and easier to treat. Historically, geriatric patients have been woefully under-represented in clinical trials, meaning most of the data available for treatment outcomes and potential side effects is based on younger patients. This can lead to over and under treatment of geriatric patients further showing why geriatric centered cancer care is so important.
More Patients, Less Doctors
Adding to the challenge, there is a national shortage of physicians adequately trained to care for the geriatric population. To cope with the aging of the U.S. population, it is estimated nearly 36,000 geriatricians will be needed by 2030. Currently there are about 7,100 physicians certified in geriatric medicine. Workforce shortage is even more staggering problem in the field of geriatric oncology. While older patients make up the majority of new cancer patients, few oncologists have ever received formal training in managing geriatric issues. There are only 10 geriatric oncology training programs nationwide, with less than 100 graduates annually6.
While multidisciplinary, patient-centered care is the norm in the field of geriatric medicine, most oncologists have not received formal training in multidisciplinary teamwork. Studies have shown multidisciplinary teamwork can reduce re-hospitalization rates and healthcare costs, while improving patient outcomes and quality of life7,8. In fact, across the country, few other geriatric oncology programs offer these services in a centralized clinic. Traditionally, a patient’s “functional” status is evaluated via brief subjective screening tools commonly used in medical oncology. These tools have not been validated in the geriatric population, often leading to a poor estimate of a person’s true functional status.
Each patient seen in the Senior Adult Oncology Center receives a Comprehensive Geriatric Assessment (CGA), which is considered the gold standard in geriatric evaluation. Patients undergo a variety of validated tools to assess functional status, co-existing medical conditions, memory problems, psychological well-being, social support, nutritional status, and medication use. CGA, combined with other treatment measures, has been shown to reduce the decline in function, fall risk, early re-hospitalization, health care costs, and nursing home admission rates9,10,11. Evidence for CGA’s use specifically in cancer care is also striking, with studies demonstrating improved prediction of survival, chemotherapy toxicity, and rates of complications and death following surgery12,13.
Mrs. Smith and Mrs. Jones may be the same age, but they represent very different clinical situations. Mrs. Smith has maintained a reasonable functional status and has limited medical problems. She can anticipate an average life expectancy of 10 years. It is likely that her cancer will become a major health issue for her in her lifetime. The goals of her treatment plan should be developed in context of this consideration.
Mrs. Jones has had a sharp decline in her abilities and is now requiring considerable assistance just to do daily activities. Her other medical conditions, including her dementia, will limit her life expectancy. It is important to understand what she can anticipate from the cancer and if treatment may further worsen her other medical conditions. Her husband has concerns about putting her through extensive tests and treatments. The goals of her treatment plan will likely be very different from Mrs. Smith’s plan.
Both women, despite being the same chronological age and having the same cancer, have very different treatment plans. They deserve complete individualized assessments that focus on maintaining quality of life.
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