Older Adults with Cancer and Multimorbidity: Exploring the Interface - - PowerPoint PPT Presentation

Older Adults with Cancer and Multimorbidity: Exploring the Interface between Geriatric Oncology and Palliative Care

Ron Maggiore, M.D. Assistant Professor of Medicine Division of Hematology University of Rochester October 18, 2019

Review of Pre-Talk Survey Results

• TBD

Review of Pre-Talk Survey Results

• TBD

Drawing from Real-Life Experience

• 74-year-old woman with stage IV (M1a) NSCLC on pembrolizumab therapy

>1 year, stable disease; dermatitis, well managed on topical therapies

• Severe COPD, oxygen-dependent, sees pulmonology and family medicine

for medical management

• Hospitalized in 2018 x2, recommended nocturnal BiPAP; patient does not

use consistently at home

• Re-hospitalized May 2019, June 2019 x2, July 2019, August 2019, and Sept

2019 for hypercapneic respiratory failure /COPD exacerbations

• Saw patient in early August before next hospitalization and broached

hospice and advance-care planning; already had a MOLST on file indicating DNR/DNI preference

Overview

• By 2030, approximately 2/3 of all cancer patients diagnosed in the

U.S. will be >=65 years

• More than half of these patients will have at least 1 other health

issue (comorbidity) that could affect cancer treatment decision- making and ultimately prognosis and advanced-care planning

• At least 2/3 of these patients will have 2 or more competing health

conditions

• Sometimes cancer is not the predominant issue in terms of what is

impacting the patient’s health status or health-related quality of life at present

Williams GR et al. JGO 2016

What is Multimorbidity?

• Multiple coexisting health conditions beyond an index

condition (i.e., cancer)

• Severity of These Illnesses?
• Functional Limitations?
• Geriatric Syndromes?

Williams GR et al. JGO 2016

Multimorbidity: More than just number and severity of concurrent illnesses?

• Perhaps!
• Does adding functional impairments and geriatric syndromes

impact health outcomes in older adults the same as or more so than number of medical conditions?

Importance of Multimorbidity

• Impacts mortality, which has strongest implications for cancer

screening and treatments, particularly in the early-stage setting

• Impacts chemo-related toxicity risk but may be more so via

functional impairment

• May bias physician referral patterns for specific cancers and

their treatments

• Creates barriers to clinical trial eligibility, enrollment, and

retention

Williams GR et al. JGO 2016

Multimorbidity: Incorporating Functional Limitations and Geriatric Syndromes

• Functional Limitations: Limited strength, limited upper body

mobility, limited lower body mobility, IADL impairment, BADL impairment

• Geriatric Syndromes:

– visual impairment, hearing impairment, depression, cognitive impairment, persistent lightheadedness/dizziness, severe pain

Koroukian SM et al. JGIM 2016

Multimorbidity: Incorporating Functional Limitations and Geriatric Syndromes

• In looking at 10 medical conditions, the combinations of age,

functional limitations, and geriatric syndromes were better at stratifying those with worse self-rated health and mortality at 2 years in those age ≥50 years from study start

– Worse self-reported health @ 2 years: age ≥68.5 years, difficulty walking several blocks, reporting fair/poor health – Worse mortality @ 2 years: age ≥80.5 years, impairments in both BADLs and IADLs

Koroukian SM et al. JGIM 2016

Health Care Costs and Multimorbidity: Veteran Affairs Health Care Study

• Large cross-sectional study of medical expenditures per patient
• ver 1 year (2009-2010), including rx drug costs
• Almost half (47%) of all VA costs were attributable to “high

cost” patients (top 5%). Inpatient care =50%

• These patients had 3+ comorbidities (77%); 5+ (41%)

Zulman DM et al BMJ Open 2015

Health Care Costs and Multimorbidity: Veteran Affairs Health Care Study

• Certain conditions alone drove costs: cancer, schizophrenia
• High burden of MH issues and run with cardiovascular,

endocrine (DM), and musculoskeletal conditions

• More conditions, more visits to: hospital, primary care, ER,

specialty care

Zulman DM et al BMJ Open 2015

A Different Approach to Care Models?

• Patient Health Value (PHV) model for high-cost/high-risk groups of

patients

• 3 identified at UCLA: dementia, CKD, and cancer
• Multidisciplinary teams created to address spending and care

pathways to improve evidence-based care and minimize hospital and other service utilization

• Was able to show thus far decrease in LOS and hospitalizations for

dementia and CKD patient subgroups

• Expand to other chronic serious illnesses?

Gupta R et al. Acad Med 2019

Importance of Interactions among Age, Cancer Symptoms, and Hospitalization

• An unplanned hospitalization for patients with advanced

cancer can signal a worse prognosis and may be an entrée to palliative care discussions/consultations (but very few are)

– Usually for cancer-related symptoms such as pain (66% in the Univ. of Wisconsin study; 58% in the Dana-Farber/BWH study).

• Age ≥70 years in addition to documentation of prior oncologist

recommending hospice, and 3rd line or beyond cancer treatment were risk factors for potentially avoidable hospitalizations in patients with GI cancers (mostly pancreatic)

Rocque GB et al. JOP 2013; Brooks GA et al. JCO 2014; Daly B et al. JOP 2016; Rocque GB et al J Pain Symptom Manage 2015; DiMartino LD et al HealthC (Amst) 2019

Importance of Interactions among Age, Cancer Symptoms, and Hospitalization

• Comorbidity increases risk for ICU death in patients with

advanced cancer, especially those with prior hospitalizations.

• May bias physician referral patterns for specific cancers and

their treatments

• Triggered (inpatient) palliative care consultations (TPCC) may

be difficult to implement and may not increase hospice enrollment (Wisconsin and UNC studies)

Rocque GB et al. JOP 2013; Brooks GA et al. JCO 2014; Daly B et al. JOP 2016; Rocque GB et al J Pain Symptom Manage 2015; DiMartino LD et al HealthC (Amst) 2019

Hospitalization for Patients with Cancer: A Missed Opportunity for Palliative Care?

• Two cross-sections of patients hospitalized at a university
• ncology unit (2000 & 2010; Wisconsin)
• Mean age=60 years (range, 27-88)
• 89% had advanced-stage disease
• GI>lung>breast cancers
• 66% admitted for cancer-related symptoms:

Rocque GB et al. JOP 2013

Hospitalization for Patients with Cancer: A Missed Opportunity for Palliative Care?

• Two cross-sections of patients hospitalized at a university
• ncology unit (2000 & 2010; Wisconsin)
• Mean age=60 years (range, 27-88)
• 89% had advanced-stage disease
• GI>lung>breast cancers
• 66% admitted for cancer-related symptoms:

Rocque GB et al. JOP 2013

Hospitalization for Patients with Cancer: A Missed Opportunity for Palliative Care?

• https://www.surveymonkey.com/r/DV9NS29

Rocque GB et al. JOP 2013

Hospitalization for Patients with Cancer: A Missed Opportunity for Palliative Care?

• Median survival after discharge date:
• 2000 cohort: 4.7 months
• 2010 cohort: 3.4 months

Rocque GB et al. JOP 2013

Median OS: 4.7 months Median OS: 3.4 months

Going One Step Further: Assessing Risks for Re-Hospitalization

• A study at MGH targeted adults with advanced cancer

receiving palliative-intent chemotherapy over an approx. 3- month period and followed for re-hospitalization for up to 1 year

• Patients were given a symptom burden questionnaire during

the index hospitalization (Edmonton Symptom Assessment System Revised; ESAS-r)

• N=200

Johnson PC et al. JOP 2019

Going One Step Further: Assessing Risks for Re-Hospitalization

• Over half had a re-admission during follow-up (58.5%)
• Mean time to first re-hospitalization was 1.93 months (SD +/-

2.07 months)

• Mean age: 64 years
• Most common cancer site: GI (43%); followed by lung and GU
• Mean Charlson CI score: 0.85
• Impaired mobility: 31%
• Reason for re-hospitalization:

– infectious (26%); cancer symptoms (19%)

Johnson PC et al. JOP 2019

Going One Step Further: Assessing Risks for Re-Hospitalization

• Characterizing the Potentially Avoidable Re-admissions (PARs)

identified by the study team:

– Lack of timely outpatient follow-up – Premature discharge from prior hospitalization

• Both speak to: What systems are in place regarding oncology-
• riented transitions of care?
• Predictors of PARs: Lack of spouse (=proxy for lack of social

support?), higher symptom burden scores during index hospitalization

Johnson PC et al. JOP 2019

Terminal ICU Admissions for Oncology Patients

• 1-year study at university hospital (University of Chicago)
• N=72 (mean age: 62 years; range, 58-74)
• Only 25% had advance directives documented
• 50% classified as potentially avoidable
• Predictors:

– Poorer Performance Status – Non-Independent Living Situation Prior to Terminal Admission – Relatively More Recent Cancer Diagnosis – Cancer Symptoms as Reason for Hospitalization – Multimorbidity (CCI) – Prior Hospitalizations in past year

Daly B et al. JOP 2016

Cancer Diagnosis and Geriatric Syndromes

Mohile SG et al JCO 2011

Cancer Diagnosis and Geriatric Syndromes ctn’d.

Mohile SG et al. JCO 2011

Palliative Care, Cancer, and Multimorbidity

• Large prospective trial across 6 cancer centers in the U.S.
• Randomly assigned to palliative care consultation vs. usual care

at time of first hospitalization

• N=906 patients with advanced cancer

– Most common conditions: HTN, COPD, “weight loss,” “fluid- electrolyte imbalance,” depression, arrhythmias

• Treatment effect for cost savings $2321 for those with 2-3

concurrent conditions (22% of patients): 4+, $3515 (32% of patients)

May P et al. Health Aff (Milwood) 2016

Issues Raised

• Workforce shortages and gaps in care provision longitudinally
• Access to palliative care resources and/or services
• Hospitalization: Inpatient screening and/or triggers for the

most vulnerable = most likely to benefit from palliative care consultation?

• Policy-making and advocacy at institutional and broader levels

May P et al. Health Aff (Milwood) 2016

Multimorbidity: Impact on End-of-Life Care for Older Adults with Cancer

• A linked data-set from Medicare and Health & Retirement Study and

National Death Index

• N=835 patients age >=66 years
• In-hospital and ER deaths were highest among those with hematologic

cancers

• Hospice enrollment highest among breast cancer, lowest with hematologic

cancers

• Number of comorbid conditions were not associated with 3 of the 4 study
• utcomes (receipt of cancer treatment, hospice enrollment, death in

hospital) and borderline for hospitalization

– However, # of geriatric syndromes were associated with lower likelihood of receipt cancer therapy

Koroukian SM et al. JGO 2017

Tele-Palliative Care

• May allow greater access and overcome geographic and

functional limitation issues

• Technology familiarity and logistics
• Feedback and input serially from providers, patients and

caregivers

• Needs assessments prior to implementation
• Stakeholders, reimbursement, other funding sources
• Patient-Reported Symptoms/Outcomes and Apps?

Calton BA et al. J Pall Med 2019

Integrating Geriatric Oncology and Palliative Care: Some recommendations from experts

• Advancing age increases risk of other competing life-limiting

health issues, lack of singular health or related interventions, less evidence base, increased frailty and physiologic reserve, differing goals/preferences with increasing emphasis on functional independence and intact cognition

• Recognizing heterogeneity in illness (and by extension)

functional trajectories

• Moving away from dichotomous roles of palliative care and

hospice

Fried TR et al. NEJM 2002; Cheng and Nicholson JGO 2018

Integrating Geriatric Oncology and Palliative Care: Questions to Consider

• Earlier palliative care referral for ANY frail older patient with

cancer?

– How best to capture these more at-risk patients? GA screening? Timing?

• Benefits that may be more for caregivers for older adults with

multiple health issues?

• Are trajectories (even from palliative care intervention, caregiver

symptom, or patient-reported symptom/QOL viewpoints) unique based on older age and/or different coexisting health issues?

Cheng and Nicholson JGO 2018

Identifying Palliative Care Champions

• Competing issues that potentially de-stabilize the sustainable

specialty-only model

– New approaches/systems, patient/healthcare system needs, competition, workforce shortages, existing systems expand scope of practice

• Establish new workforce framework?

– Basic→Champion→Specialist as time intensity/clinical complexity commensurately increases

Kamal AH et al. JAGS 2019

Questions? Comments?