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 over 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 3 rd 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 oncology 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 oncology 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: Median OS: 4.7 months • 2000 cohort: 4.7 months • 2010 cohort: 3.4 months Median OS: 3.4 months Rocque GB et al. JOP 2013
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- oriented 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
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