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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
WCC version 24.8.12 1
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
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
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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
11
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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