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

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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

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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

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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.

Comorbidities Functional status

Social support ONCOLOGY GERIATRICS

Challenges in caring for older cancer patients

Factors influencing chemotherapy administration Crit Rev Oncol Hematol. 2011 Apr;78(1):45-58. Epub 2010 Mar 23. 4

Challenges of in Geriatrician/Oncologist collaboration

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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.

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 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

Oncology and Aging Objectives

The Dr. Joseph Kaufmann Chair in Geriatric Medicine

La Chaire Dr Joseph Kaufmann en gériatrie

McGill University

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Oncology and Aging Objectives of the JHG/McGill Program

 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

The Dr. Joseph Kaufmann Chair in Geriatric Medicine

La Chaire Dr Joseph Kaufmann en gériatrie

McGill University

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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

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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%)

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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

Measurements used in the Clinic

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16%(n=8)

30% (n=15)

42% (n=21)

12% (n=6)

0

20

40

60

80

100

Without frailtymarkers or IADL /

ADL disability

With frailtymarkers but

without IADL /ADL disability

IADL disabledwithout ADL

disability

ADL disabled

%

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

Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy- preliminary findings

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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

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Prediction Is Very Hard

Especially about the future

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Frailty as a clinical predictive tool

department visits and visits to the general practitioner in older newly-76(2):142-51! 

J Am Coll Surg.diagnosed cancer patients? Results of a prospective pilot study 2010 Nov; Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-

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):

 Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Am J Surg.Frailty as a predictor of surgical outcomes in older patients. 2010 Jun;210(6):

Tan KY, Kawamura YJ, Tokomitsu A, Tang T. Assessment for frailty is useful for predicting morbidity in early patients undergoing colorectal cancer resection whose comorbidities are already optimized. 2012

 J Cardiothorac Surg.colorectal cancer resection whose comorbidities are already optimized. 2012

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.!

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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

Prediction utilizing a combination of markers

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

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Acknowledgements Frédérique Retornaz MD: Marseille

The Dr. Joseph Kaufmann Chair in Geriatric Medicine

La Chaire Dr Joseph Kaufmann en gériatrie

McGill University

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