Towards an integrated oncology and geriatric approach Overcoming health system � s boundaries Howard Bergman MD, FCFP, FRCPC Chair, Department of Family Medicine Professor of Family Medicine, Medicine and Oncology The Dr. Joseph Kaufmann Professor of Geriatric Medicine, McGill University Ana Patricia NAVARRETE-REYES MD Fellow, McGill/JGH Geriatric Oncology program Médico revisor, Clínica de Geriatría Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Doreen Wan-Chow-Wah MD, FRCPC Assistant Professor Director, Geriatric Oncology Program Division of Geriatric Medicine and Department of Oncology McGill University and JGH 1 WCC version 24.8.12
Oncology and Aging: the clinical challenge Underdetection / undertreatment / overtreatment Difficulty for physicians lies in selection of appropriate older person – Those who appear too old or with “too many” co- morbidities may be appropriate – Those who appear fit may be more vulnerable than we think – Tailor treatment decisions on the basis of health and functional status rather than on the basis of age or impression – Anticipate/prevent complications 2
Oncology and Aging: the clinical challenge Factors influencing treatment decisions Patient related – Life expectancy – Health and functional status – Family/social support/organisation – Patient/family attitudes/preferences Cancer related – Type, stage, prognosis/treatment Physician related – knowledge/attitudes/preferences – Time/patience/organisation/infrastructure 3
Difficulties in decision making regarding chemotherapy for older cancer patients: A census of cancer physicians. Wan-Chow-Wah D, Monette J, Monette M, Sourial N, Retornaz F, Batist G, Puts MT, Bergman H. Challenges in caring for older cancer patients Comorbidities Functional status ONCOLOGY GERIATRICS Social support Factors influencing chemotherapy administration Crit Rev Oncol Hematol. 2011 Apr;78(1):45-58. 4 Epub 2010 Mar 23.
Challenges of in Geriatrician/Oncologist collaboration 5
Challenges of in Geriatrician/Oncologist collaboration Majority of older patients do not need referral to Geriatrics Referrals to Geriatrics mainly for cognitive evaluation and complications from chemotherapy Main barrier to consulting Geriatrics: wait time too long Presently little collaboration between cancer specialists and geriatricians, but willingness from both parties to collaborate more. Many thought optimal collaboration would be presence of geriatrician at Tumour board meetings, to identify potential problems and expedite a Geriatric evaluation. 6
Oncology and Aging McGill University The Dr. Joseph Kaufmann Chair in Geriatric Objectives Medicine La Chaire D r Joseph Kaufmann en gériatrie Develop a systematic clinical approach to the assessment and management of older persons with the appropriate instruments for oncologists, geriatricians, primary care physicians and other specialists and health care professionals – Develop an appropriate collaborative care model among oncology, geriatric medicine and primary care Promote informed attitudes and decision making for clinicians, patients and families based on evidence 7
Oncology and Aging McGill University The Dr. Joseph Kaufmann Chair in Geriatric Objectives of the JHG/McGill Program Medicine La Chaire D r Joseph Kaufmann en gériatrie Education/training for MD’s, nurses and other professionals • fellowship, international trainees Improve care of older persons with cancer by promoting increased population, biological, clinical research on older persons with cancer – A better understanding of the health and functional characteristics and the trajectories of older persons with cancer » Tailor treatment decisions on the basis of health and functional status rather than on the basis of age or impression » Anticipate/prevent complications 8
Senior Oncology Consultation Service– Geriatric Oncology Clinic The Vision ! To promote a comprehensive approach to the care of older patients with cancer and their families by collaborating with the treating teams to develop an individualized, integrated plan of care. " Make recommendations based on a multidimensional assessment. " Fellows, residents, other healthcare professionals 9
Reason for referral – Memory impairment : 113 (41.9%) – Opinion on treatment plan : 108 (40.0%) – Mood/Behavior: 35 (13.0%) – Comorbidity: 25 (9.3%) – Mobility: 23 (8.5%) 10
Measurements used in the Clinic Items Measurements Comorbidities Medical chart, history Medications History, list from pharmacy Functional Status ADL, IADL Social support History Cognition MMSE, MoCA Mood Geriatric depression scale Mobility Timed Up and Go, Gait speed, Report of falls Nutritional status Weight, Body Mass Index, History of weight loss or ↓ appetite Physical activity Questionnaire Strength Grip strength by dynamometer 11
Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy- preliminary findings 100 80 42% 60 30% (n=21) % (n=15) 16% 40 12% (n=8) (n=6) 20 0 Without frailty With frailty IADL disabled ADL disabled markers or IADL / markers but without ADL ADL disability without IADL / disability ADL disability Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H. Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for chemotherapy Journal of Gerontology; Medical Sciences 2008 12
Oncology and Aging Present proposed approach: geriatric assessment for all older persons presenting to oncology Core of geriatric assessment based on assessment of ADL/IADL and mental status (Folstein) Geriatric assessment not intended for independent patients affected by only one severe medical condition Older persons presenting to oncology are healthier and more independent than those presenting to geriatrics Ceiling effect if only traditional geriatric assessment is used. 13
Prediction Is Very Hard Especially about the future 14
Frailty as a clinical predictive tool department visits and visits to the general practitioner in older newly- 76(2):142-51 ! diagnosed cancer patients? Results of a prospective pilot study 2010 Nov; J Am Coll Surg. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen- Frailty as a predictor of surgical outcomes in older patients. 2010 Jun;210(6): Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. 2010 Jun;210(6): Am J Surg. Tan KY, Kawamura YJ, Tokomitsu A, Tang T. Assessment for colorectal cancer resection whose comorbidities are already optimized. 2012 frailty is useful for predicting morbidity in early patients undergoing colorectal cancer resection whose comorbidities are already optimized. 2012 J Cardiothorac Surg. Chen CH, Ho-Chang, Huang YZ, Hung TT. Hand-grip strength is a simple and effective outcome predictor in esophageal cancer following esophagectomy with reconstruction: a prospective study. 2011 Aug Chen CH, Ho-Chang, Huang YZ, Hung TT. Hand-grip strength is a simple and effective outcome predictor in esophageal cancer following esophagectomy with reconstruction: a prospective study. 2011 Aug 15;6:98. ! 15
Prediction utilizing a combination of markers be optimized by considering a combination of 5-meter gait speed for frailty, " Nagi items for higher-level disability " Parsonnet score for comorbidities and illness severity. " Afilalo et al. In Press 2011 Afilalo J, Eisenberg M, Bergman H et al. Gait Speed as an Incremental Predictor of Mortality and Major Morbidity in Elderly Patients Undergoing Cardiac Surgery. Journal of the American College of Cardiology. 2010 16
Conclusions Partnership between Geriatric Medicine and Oncology is necessary to improve cancer care with diverse forms of Collaboration on clinical activity, training, research and patient and public education Understand heterogeneity of older persons – Focus on health and functional status, rather than chronological age – Measurements and instruments need to reflect heterogeneity 17
McGill University Acknowledgements The Dr. Joseph Kaufmann Chair in Geriatric Medicine La Chaire D r Joseph Kaufmann en gériatrie Frédérique Retornaz MD: Marseille 18
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