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November/December 2012
Critical Aspects of Cancer Diagnosis and TreatmentBy David Yeager Broad variations in elders’ health status make cancer diagnosis and treatment more challenging. A lack of data from elder-specific clinical trials compounds the problem. As the number of older adults has grown, increased attention to medical conditions associated with aging has led to many improvements in geriatric care. But although medical advances have lengthened the lives of millions of older adults, new challenges are on the horizon. In the coming years, cancer treatment looms as a significant challenge. “As we make improvements in other diseases like cardiovascular disease, cancer is going to be the leading cause of death in this population,” says Supriya Mohile, MD, MS, director of the Wilmot Cancer Center Geriatric Oncology Clinic at the University of Rochester Medical Center in New York. “And people are living longer, so the cancer diagnosis is happening for many patients later in life, in their 70s and 80s.” Because people’s health status varies to a greater degree as they age, diagnosing and treating cancer is often more difficult with older adults than younger people. The challenge is compounded by a lack of data about how older adults will respond to standard treatments and whether they can be effectively treated with lower doses of chemotherapy. Most studies examining treatment response have been conducted with younger, healthier people. For this reason, physicians often don’t have as much information as they would like when considering treatment options. “Older people are very much underrepresented participants in our important clinical trials so we know how to treat these people only by extrapolation,” says Barry Lembersky, MD, an oncologist at the University of Pittsburgh Cancer Institute. Patient Assessment While some 60-year-olds may have multiple comorbid conditions, there are many 85-year-olds with few health problems and who lead active lives. Patients are often undertreated or overtreated based strictly on their age. This can result in less efficient patient care and more long-term expense due to preventable cancer progression in more healthy patients or chemotherapy toxicity in less healthy patients. A thorough patient evaluation will provide a more detailed understanding of how a patient will tolerate treatment. Mohile says a patient evaluation is important because a patient’s medical history doesn’t always provide a complete picture. Sometimes a patient has no significant conditions in his or her medical history but may come to the appointment in a wheelchair. Others may have several comorbidities but continue to walk three miles per day. Determining functional status before treatment helps doctors make adjustments during treatment to allow patients to maintain the best possible quality of life. There are other factors that need to be considered as well. One is cognitive function. Researchers are still learning how chemotherapy affects the brain, but a patient with mild memory impairment who undergoes chemotherapy is at risk of significant memory decline. A patient’s physical condition and associated risk of falling also warrant investigation. Chemotherapy can exacerbate weakness, and some chemotherapy drugs can cause peripheral neuropathy, increasing fall risk. When prescribing a treatment protocol, Mohile says the goal is to preserve cognitive function and minimize fall risk to the greatest possible extent. This is especially important because deficits in these areas can reduce patients’ level of independence, making them more reliant on social support, which creates a significant hurdle if they need help remembering to take medication or have limited access to transportation. “I think [functional status, cognitive function, and fall risk] are the three big things that we can get better at evaluating and intervening on so that patients have good quality of life. And it’s a challenge,” Mohile says. “You want to treat the cancer because the cancer is life limiting, but we know that some of these things will happen, and this causes a big stress on families and caregivers and daughters and sons who may not live in the area, who are trying to help from afar.” To fully understand health status, the Wilmot Clinic performs a comprehensive geriatric assessment using validated tools that help doctors measure several important factors, such as functional status, comorbidities, social support, psychological status, nutrition, polypharmacy, and fall risk. Although the assessment takes about 1 1/2 hours and it can be difficult to obtain insurance company approval, Mohile says doing this up front leads to better outcomes and less expense down the line because it helps identify who will benefit from aggressive treatment and who may have difficulty tolerating it. Opting for six months of chemotherapy for a patient with a two- or three-year life expectancy outside of cancer provides little benefit. Talking with patients can provide additional information, especially regarding what the patient hopes to gain from treatment. “I think older people have a little different perspective than younger people on the degrees of treatment that they’re wanting to pursue,” Lembersky says. Effective Evaluation “It wouldn’t be practical to do a really comprehensive assessment on every person who’s over 65 or even 70 or maybe even 75 and older,” Holmes says. “This is very time consuming, even for a geriatric oncologist who is trained in both fields. But I think where we have to move to in the future is to find briefer ways to screen for the people who then need more comprehensive assessments.” Some assessments, such as testing grip strength with a handheld dynamometer to get a sense of a patient’s overall strength, may not be practical for primary care physicians, but Holmes says there are several evaluation tools that can be used without adding significant time to patient visits. She says gait speed is a helpful test that can be performed quickly and easily. To assess gait speed, a patient can either perform a 10-ft (3 m) walk or a timed up-and-go, in which the patient gets up from a chair, walks across the room, and then walks back and sits down. Holmes notes that a time greater than 13 seconds to walk 10 feet indicates a higher risk of falls, which is a predictor of chemotherapy toxicity. In addition, items such as nutrition screening, cognitive and depression screening, a list of comorbidities, social supports, financial need, and activities of daily living can be logged by the patient or a caregiver while a patient is waiting to see the doctor. Toward Better Treatment “The overwhelming demographic imperative of older people who are going to have cancer in the coming years and the incredible shortage of geriatricians that we’re going to have, [coupled with a shortage of] oncologists, just means that we have to start thinking very creatively about how to get a dialogue going,” Holmes says. One aspect of care that would benefit from a collaborative approach is reducing polypharmacy. Because older patients tend to take more medications, they are more likely to have adverse drug interactions. And many chemotherapy drugs are excreted renally, so kidney function is a particular concern for older adults. Lembersky says even patients with normal creatinine levels are likely to have some renal decrement. Collaboration among oncologists, geriatricians, and primary care physicians can ensure that important information is not missed and help to determine which medications can be reduced or discontinued prior to chemotherapy, as patients should receive only essential medications during treatment. Additionally, a pharmacist should review a complete list of a patient’s medications to identify potential adverse interactions. Some blood pressure and diabetes drugs can react negatively with chemotherapy drugs, and some chemotherapy drugs can cause or exacerbate peripheral neuropathy in patients with diabetes. Some chemotherapy drugs can affect memory as well, and some newer agents carry a higher risk of coronary artery disease or high blood pressure. Physicians may need to determine whether higher-than-normal blood sugar or blood pressure is more damaging than the cancer treatment. In addition, some of the antinausea medications prescribed for chemotherapy can be difficult for older patients to tolerate. Special Concerns “We should really treat these older people not by chronologic age but by physiologic age and, when possible, treat with the standard regimens,” Lembersky says. “But we may have to dose adjust because of the comorbidities and drug-drug interactions to decrease renal insufficiency and other potential serious toxicities.” Another way that collaboration may be helpful is in continuity of care. Typically, a primary care physician who may be a geriatrician handles cancer screening and diagnosis. When a patient is referred to an oncologist, the primary care physician and the oncologist may never speak to each other, even though the primary care physician has valuable insights about the patient’s health status, medical history, medications, and treatment goals. The primary care physician then doesn’t see the patient again until the treatment is completed, which can be stressful for the patient. When he or she returns to the primary care physician, the doctor may not receive all of the necessary information about how to proceed with the patient’s follow-up care. Often the patient bears the responsibility of communicating the necessary information. “I think that it will really help in the future if we increase the communication amongst all the groups that are caring for the patient,” Holmes says. “Right now the patient is the main owner of all their information, and it’s just so overwhelming when you’re treated for cancer.” Holmes says more collaboration would minimize gaps in care. To smooth the transition, MD Anderson enrolls patients in a survivorship program after treatment. Patients then return to primary care physicians with a list of all the treatments that were received and everything that requires follow-up. Collaboration also allows physicians to be more proactive when assessing patients, which may be the most important factor in treatment success. For example, determining whether exercise is appropriate and if so, to what extent it can be tolerated also provides treatment benefits. This is information that a primary care physician is able to share with an oncologist. Mohile, who participates in several studies designed to keep older patients active and measure the effects of exercise, says exercise is beneficial for patients receiving cancer treatment and can improve treatment response. Unfortunately, insurance companies are reluctant to provide reimbursement for comprehensive exercise programs outside of physical therapy. However, whether the patient is exercising or not, time spent understanding the patient’s health status before treatment is likely to improve outcomes and save money. “If we can prevent [complications], we’re going to be able to save money so we need to put the money up front into the evaluation time, into the assessment time, rather than into [paying a certain] amount of money for this drug or [a certain] amount of money for this hospitalization, and [not allocating] money for interventions,” Mohile says. “You need to do that up-front part of it.” — David Yeager is a freelance writer based in Royersford, Pennsylvania.
Cancer Diagnosis and Treatment • Focus on physiologic age rather than chronologic age. Some 80- and 90-year-olds may lead active lives with few medical problems, while some 60- and 70-year-olds may have multiple ailments that put them at risk of treatment complications. Treatment should be based on physical function. • Consider the risks and benefits of treatment options. Chemotherapy can exacerbate comorbidities, memory problems, and fall risks. Even slight deficits can be adversely affected by chemotherapy. • Social supports are important. Patients may need help getting to appointments, caring for themselves, or even remembering to take medications. Physicians need to know about these issues. • Be aware of medications. The older the patient, the more likely he or she is taking at least one medication. A thorough review of medication usage before beginning chemotherapy can help reduce adverse drug-drug interactions. All nonessential medications should be discontinued prior to treatment. • Collaboration among primary care physicians, geriatricians, and oncologists can improve care. Each clinician has important information that can benefit the patient throughout the continuum of care and promote more efficient treatment. • Spend time evaluating patients up front to prevent later complications. The time spent evaluating a patient at the beginning of treatment can translate to better outcomes and less cost down the road. — DY
Patients Prefer Peace of Mind Over Aggressive Treatment Chemotherapy, feeding tube positioning, and high degrees of anxiety and depression contributed to negative feelings, which can sometimes be modified by healthcare workers, researchers said. Caregivers and physicians who remain engaged and “present” with dying patients “by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings have the capacity to improve a dying patient’s [quality of life],” says researcher Holly G. Prigerson, PhD. — Source: Archives of Internal Medicine
References 2. Muss HB, Berry DA, Cirrincione CT, et al. Adjuvant chemotherapy in older women with early-stage breast cancer. N Engl J Med. 2009;360(20):2055-2065. 3. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol. 2011;29(25):3457-3465.
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