OLDER ADULTS AND THE EFFECTS OF CO-MORBIDITIES ON CANCER TREATMENT

Cheryl Lillegraven MSN, ARNP, ACNS-BCGeriatric Clinical Nurse Specialist

DISCLOSURE AND ACKNOWLEDGMENTS I have nothing to disclose Thank you

Patti Berger and her ONS colleagues Conference Planning Committee

CURRENT STATE

Cancer is a disease associated with aging – the majority of cancer diagnoses and deaths occur in people older than 65 years – and the United States population is rapidly aging, with a projected doubling in the number of individuals age ≥ 65 from the year 2000 to 2030.

A dramatic increase in the number of new cancer diagnoses is projected for the next 20 years. It is anticipated that patients age ≥ 65 will account for 70% of all cancer diagnoses by the year 2030.

(Tinetti, 2012)

CURRENT STATE

Due to the overall increase in life expectancy coupled with more therapeutic management, elderly cancer patients are expected to live longer and in better conditions. More curative treatments Adjuvant chemo after surgery and age is no longer a

limiting factor Treatments of advanced disease, like palliative chemo,

are more frequently proposed to the elderly. Unfortunately, older adults are poorly represented in most oncology clinical trials and only a few studies have focused on advanced biological age, so results are extrapolated to the elderly.

THE FUTURE

Instead of only focusing on the cancer diagnosis, older persons are in need of a more holistic approach that focuses on a combination of medical, social, functional, cognitive, mental and nutritional needs.

COMORBIDITY

With increasing age, the number of comorbid illnesses increases.

A study of 7,600 patients older than 55 years with cancer, those age 55 to 64 had an average of 2.9 comorbid conditions compared with patients ≥ 75, who had an average of 4.2 comorbid conditions.

(Tinetti, 2012)

MULTIMORBIDITY

Patients with CAD, it is the sole condition in only 17% cases

Almost 3 in 4 individuals aged 65 years and older have multiple chronic conditions, as do 1 in 4 adults younger than 65 who receive care

(Tinetti, 2012)

RISK

Important to consider the physiologic age of the patient, as opposed to the chronologic age alone. Evaluation tools can be helpfulComprehensive Geriatric Assessment (CGA)

Allows for identification of older patients with higher risk of morbidity and mortality

Also identifies who is higher functioning and perhaps can tolerate a more aggressive approach

Risks and benefits of anticancer therapy must be assessed

Tools to risk-stratify an older patient population for frailty has enormous prognostic value

FRAILTY

Clinical SyndromeIncludes the presence of 3 or more of the following components Unintentional weight loss of 10 pounds or more in the past year Self-reported exhaustion (lack of vigor, or the presence of

fatigue and tiredness Strength – weakness (grip strength, loss of physical robustness) Slowness – slow walking speed, lethargic, unsteady and

unbalanced gait Low physical activity – inactivity or sedentariness

Scoring: 0 = robust, 1-2 = intermediate or pre-frail, 3 = frail

(consultgerirn.org)

FRAILTY

Epigenetic phenomenon Declining functional reserve Unclear, controversial etiology Functional immune alterations Associated clinical syndromes Potentiated normal aging changes

(Kagen, 2015)

FRAILTY

FRAILTY (CLEGG, 2011)

CGAThe CGA is an interdisciplinary patient evaluation that leads to the identification of the general health status including medical, functional, cognitive, social, nutritional and psychological parameters. Designed by geriatricians as a multidimensional assessment of general health status based on validated geriatric scales and tests that produce an inventory of health problems, allowing for the development of an individualized geriatric intervention programAt least 4 good reasons for an oncologist to obtain a CGA1. Has important prognostic information that can be helpful in

estimating life expectancy2. Can predict toxicity or decrease in QoL3. Can reveal previously unknown geriatric problems4. Allows targeted interventions, which can improve QoL and

compliance to therapyIt is recommended by the National Cancer Center Network (NCCN) and the International Society of Geriatric Oncology (SIOG).

(Kenis et al., 2013 & Caillet et al., 2014)

CGA CHALLENGES

1. Time consuming for busy clinicians2. Lack of trained staff3. Poor financial reward for performing the CGA by

insurance

There are shorter screening tools to detect older persons with a geriatric profile who would then benefit from the CGA4. Flemish Triage Risk Screening Tool (TRST)5. Vulnerable Elders Survey -13 (VES-13)6. Groningen Frailty Indicator (GFI)7. G8

(Kenis et al., 2013)

CGAStudy in Belgium (2013). Multi-center, non-interventional study Purpose – to evaluate the large-scale feasibility and usefulness of

geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions

1,796 patients who had a malignant tumor and were ≥ 70 years old and a treatment decision needed to be made. Limited to 6 tumor types: breast, colorectal, ovarian, lung, prostate cancer and hematological malignancies

The G8 risk tool was used to screen. If the G8 (range: 0-17) demonstrated a score of ≤ 14, a CGA was carried out. 70.7% of patients had abnormal G8 scores, warranting a CGA

The CGA detected unknown geriatric problems in 51.2% of these patients Geriatric interventions were planned in 286 patients (25.7%). Included

referral to a geriatrician, geriatric liaison team, SW, OT, PT, geriatric day care, fall prevention clinic, gero-psych, dietician

(Kenis et al., 2013)

CGA

Study in France (2014). Comprehensive Review Medline search for articles published between January 1, 2000

and April 14, 2014 Patients aged ≥ 65 years with solid malignancies Looked at studies with at least 100 participants, a multivariate analysis and

assessments of at least five the following CGA domains: nutrition, cognition, mood, functional status, mobility and falls, polypharmacy, comorbidities and social environment.

Results – All types of CGA identified a large number of unrecognized health problems capable of interfering with cancer treatment. CGA influenced 21-49% of treatment decisions. All CGA domains were associated with chemo toxicity or survival in at least one study. The abnormalities that most often predicted mortality and chemo toxity were functional impairment, malnutrition and co-morbidities

(Caillet et al., 2014)

CGA

For each patient the decision whether or not to have cytotoxic chemo and/or radiation and/or surgery for cancer is a balance between potential benefits and adverse effects. The CGA is useful and helpful in decision making. The outlook of older patients may differ from that of younger patients. Short-term QoL and the ability to manage their daily activities may be more important than a modest survival advantage when deciding whether or not to accept treatment (Chaibi, et al., 2011)

GERIATRIC SYNDROMES

Falls Sleep Pain Eating problems Confusion (dementia/delirium/depression) Incontinence Anxiety Living abilities (ADLs, IADLs) Skin integrity issues Elimination issues

GERIATRIC SYNDROMES – INOUYE AND COLLEAGUES (2007)

LONG WAY TO GO…..

GERIATRIC COMPETENCE

The healthcare needs of older adults require a healthcare workforce knowledgeable about the aging process, skilled in assessment and management of chronic illness, and with the ability to practice in interdisciplinary milieu

(Mezey et al., 2008)

Reframing healthcare as age-friendly supports geriatric competence

https://extranet.who.int/agefriendlyworld/

GERIATRIC COMPETENCY

Hospital staff lack education in caring for older patients

Lack of a shared philosophy of care within diverse care settings

Health care professionals paternalistic Little recognition of gero-oncology Decisions made on basis of chronological age

rather than supporting patients’ unmet needs

RESOURCES

1. www.consultgerirn.org2. www.nccn.org3. www.siog.org4. www.uptodate.com

Cheryl.lillegraven@unitypoint.org