Older patients will have different care goals, preferences, geriatric oncologist says

By 2030 the entire Baby Boomer generation — now estimated by the U.S. Census Bureau to number over 73 million people — will be older than 65.

“This is really important for us who care for individuals with cancer because the peak incidence of cancer diagnosis is in the eighth decade of life,” explained Tullika Garg, MD, MPH, a specialist in geriatric oncology at Penn State Health in Hershey, Pennsylvania, during a session at the Society of Urologic Oncology annual meeting. “It is also the second leading cause of death in people who are 85 and older.”

Urologic oncologists are not going to be immune from the demographic trends, she noted, adding that the incidence of genitourinary cancers is going to increase precipitously in older adults in the next few years.

Garg emphasized that oncologists should realize that older cancer patients are going to be different from their younger counterparts — particularly in terms of age-related conditions, as well as treatment goals and preferences — pointing to results from the GOSAFE (Geriatric Oncology Surgical Assessment and functional rEcovery) study, which assessed 977 geriatric patients prior to undergoing cancer surgery, and found that:

• 20% had difficulty walking
• 10% had a history of one or more falls
• 37% were taking more than five medications
• 31% had decreased food intake prior to surgery
• 66% screened positive for frailty

These conditions actually inform why geriatric cancer patients have different goals and preferences, Garg said. “They’re worried how cancer treatment will impact their current geriatric conditions.”

For example, she added, results from a survey of 226 patients ages 60 and older who had a limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease showed that if the outcome from treatment was survival, but with severe functional impairment or cognitive impairment, 74.4% and 88.8% of these patients, respectively, would not choose treatment.

Quoting the late geriatric oncologist Arti Hurria, MD — “Our patients want to know if they are treated, just how sick they are going to get, they want to know if they will be able to continue to function, and if their memory will be intact” — Garg noted that “ultimately between the combination of geriatric conditions and goals and healthcare preferences, our goal is to balance under- and overtreatment in this population.”

However, older adults are a heterogenous group, she said. “And we don’t have great data on how to make these decisions, and our clinical trial data are largely based on younger, healthier patients. We have to find ways to evaluate our patients — figure out who is fit, and then tailor care to what their needs are.”

Furthermore, she pointed out that traditional pre-treatment evaluations focus on chronological age, “which we know is not a great marker of fitness.”

Garg suggested that oncologists should consider adopting the concept of the Geriatric 5 Ms — representing mind, mobility, medications, multicomplexity, and matters to me — to help determine a patient’s fitness for treatment.

“One thing I would really like to do more in my own practice — and I think something which is really important for all of us — is to do cognitive screening,” she said. “Cognitive impairment really impacts the ability to provide good informed consent for surgery, and also impacts a patient’s risk of delirium in the postoperative period.”

Finally, Garg suggested that oncologists use frailty screening tools such as the Geriatric 8 questionnaire and the TUG (Timed Up & Go) test, assess patients’ risks of chemotherapy toxicity with tools such as the Cancer and Aging Research Group’s chemotoxicity calculator, and cultivate relationships with geriatricians.

She also advised oncologists to be mindful of ageism, and their own individual biases regarding age.

“My patients have taught me a lot about what is important to them, and they do worry about their cancer,” Garg said. “Certainly they care about the other non-traditional outcomes I talked about — but they do worry about their cancer, and our goal is to get them whatever treatment we can provide that is tailored to all of their goals and preferences.”

source: Medscape