Assessing and Managing Care for Older Adults, with Arti Hurria, MD, and William Dale, MD, PhD

May 21, 2018
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Approximately 70% of people diagnosed with cancer are 65 or older, and often older adults with cancer have different needs and concerns than young adults or children. In this podcast, we will discuss new recommendations from ASCO about how doctors can assess older adults in order to ensure they get the care they need.



ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses.

Approximately 70% of people diagnosed with cancer are 65 or older, and often older adults with cancer have different needs and concerns than young adults or children. In this podcast, we will discuss new recommendations from ASCO about how doctors can assess older adults in order to ensure they get the care they need.

This podcast will be led by Dr. Arti Hurria and Dr. William Dale, two co-chairs of the expert panel that produced these recommendations. Dr. Hurria is the Director of the Center for Cancer and Aging and Professor in the Department of Medical Oncology & Therapeutics Research at City of Hope. Dr. Dale is the Arthur M. Coppola Family Chair in Supportive Care Medicine and Clinical Professor in the Department of Supportive Care Medicine at City of Hope.

ASCO would like to thank Dr. Hurria and Dr. Dale for discussing this topic.

Dr. Hurria: Hi. This is Arti Hurria. I'm a geriatric oncologist from City of Hope.

Dr. Dale: This is William Dale. I'm a geriatrician and palliative care physician, also at the City of Hope.

Dr. Hurria: And it's our honor to be with you today to talk about this topic that is dear to both of our hearts, which is really caring for older adults with cancer and some of the unique considerations that we need to think about as care providers as we're providing care for these individuals. And so as part of an effort to really clarify guidelines as to how to care for older adults with cancer, Dr. Dale, Dr. Mohile, and I led an effort that looked at developing guidelines for clinicians on some key things that they should consider as they're taking care of older adults with cancer. And one of those is something called a geriatric assessment. A geriatric assessment really is a fancy way of saying, "Get to know your patients as a whole individual beyond their chronological age." So in addition to the patient's age, understanding how active are they in their daily life. What other medical problems do they have? What's their social support? Are they feeling anxious and depressed? What's their nutritional status, and what's their memory like? And all of those things together, the fancy term for it is geriatric assessment, but it really is getting to know your patient as a whole person, all about them, and taking that into consideration when you're making a cancer treatment decision.

And although it is important no matter what to get to know your patient, one of the key things that we tried to address within these guidelines was should this assessment be used in older adults to predict the risk of who might have a harder or an easier time with chemotherapy? And the recommendation was yes, that this assessment should be done in all patients over the age of 65 who are going to be undergoing chemotherapy treatment. And that was because we were really able to review the medical literature and show that understanding each of these different elements of who an individual is can really help us to 1, identify some areas of vulnerability, areas where perhaps we can help and intervene. And 2, it can help to guide our treatment and that we can identify patients who might have a harder or an easier time with chemotherapy.

So just deconstructing the first part about what does a geriatric assessment tell us about an older individual, and just to give you some examples. The assessment might pick up things like an individual is falling, and if they are, we should consider a physical therapy assessment. If they have been losing weight, we should have a nutritionist involved. If they don't have family support, we would think about getting our social worker involved and providing additional support for the patient during treatment. If they have other medical problems, we would think about how that might influence the treatment and the types of drugs that we get. So there's so much value that we can get from this assessment that might tell us about who this individual is, and also what are certain interventions that we can do to help them through their cancer therapy?

The second question we asked was, "Okay. If you do this assessment, can it be utilized by the doctor to be able to understand who might have a harder or easier time with chemotherapy?" In other words, can it predict who might have severe side effects from the treatment? And the answer there again is yes. There have been some tools that have been developed that are called chemotherapy toxicity calculators. They can help a doctor understand how risky is the treatment for this individual, and they utilize elements of the geriatric assessment when making that assessment. And they're relatively simple to perform, certainly less than 5 minutes, but even less than that on average to complete this assessment and to get the assessment of what the risk is. And then this can really be utilized in 2 ways: 1, again, to think about, "Well, what things can we do to help that patient if they are at high risk?" And then secondly, it can really be used as part of the decision-making process so that a patient can look at that information with their doctor and help choose a course that would be best for them. And with that, I will turn it over to my colleague, Dr. Dale, to continue with our guidelines and the questions that we asked.

Dr. Dale: Thank you, Dr. Hurria. Along with assessing for chemotherapy toxicity and other appropriate interventions for patients identified through geriatric assessment, another important area is overall prognosis based on people's overall health. And another part of the recommendation is to establish life expectancy or prognosis for patients, and it's something that everybody would like to know. Often the best information we have is about prognosis related to the cancer. But from a geriatric assessment perspective, knowing prognosis for all of the other conditions that someone has, all of those things identified by geriatric assessment, as Dr. Hurria described, whether you've fallen down, whether you have other medical conditions, whether your nutritional status is good, can be used to accurately predict what people's other risks are and what their prognosis is from things separate from the cancer. And in fact, there are online tools at a place called ePrognosis that your physician can use to give accurate information.

What's most important about this is it allows people to establish appropriate goals of care so that they can maximize the quality of life that they have, both in making decisions about cancer-directed interventions like chemotherapy, but also other interventions that might be done that are just as risky, like functional loss that would prevent you from doing things you need to do at home, your loss of social mobility and the ability to interact with friends that could be related to your diagnosis, or the interaction of your cancer and its treatments with your other conditions. So it's important to initiate those conversations with your physician and ask them, and even mention the possibility of using ePrognosis as that's now part of the guideline recommendations to use one of two established prognostic indices or guides that are available on the website.

In addition to that, a fourth recommendation is what should be done with those deficits or problems that might be identified with a geriatric-assessment-guided check of a patient? So if it's identified that someone's having functional impairments, what's the appropriate intervention that should be recommended? In this case, it might be physical therapy, or as mentioned earlier, if people are having difficulties getting to their appointments, that they need transportation to be arranged. If they've had a fall, they could have interventions in the house, like a safety evaluation, to help prevent falls and prevent them from having other difficulties. So overall, the geriatric assessment, in addition to identifying needs related to cancer, it can help predict your life expectancy or prognosis, and it can guide you in the interventions that are most appropriate found on the geriatric assessments. And that is the fourth of our 4 recommendations that overall should become part of the usual discussion and conversation between a patient, and their physicians, and the rest of the multidisciplinary care team.

Dr. Hurria: Thanks so much, Dr. Dale. That was a wonderful overview. Can you give me a sense, sort of practically, when you're with a patient, how do you incorporate these different assessment tools, at what part in the visit, and what might a patient expect?

Dr. Dale: Thanks, Dr. Hurria. What I would try to do is first, make sure a patient has a clear understanding of what their care plan is from their oncologist. But then to turn quickly to their geriatric assessments and to talk about them about what's most important to them in their lives, to establish what their goals are personally, and how we can use this discussion and the formal assessments to help them achieve those goals, whether that's to supplement their cancer-directed therapy with other kinds of therapies, or whether it's to have them have a more detailed conversation with their oncologist about what to do about their chemotherapy choices.

And I would turn the question back to you and your role as an oncologist for an older patient about how to make choices about their chemotherapy in light of their overall assessment including the geriatric assessment.

Dr. Hurria: Thanks so much, Dr. Dale. I think that's a really wonderful question. It really comes down to— as you're making this chemotherapy treatment decision, the chemotherapy in some ways or the ability to prescribe it is almost the easy part. The really hard part is to make sure you're doing the right thing for the right individual at the right time, and that it’s what the patient really wants. And so what I find is that as I go through the assessment findings and really get to know this individual, and then look at the chemotherapy toxicity tool with them, I get a sense of, "Do they feel that this treatment is worth it? Is this in line with what their goals are?"

And it really is something that is not only practical, meaning that it leads to specific things I might be able to do to help the patient, but it also really is a springboard for getting to know each other better and to starting to talk about, "Here are the treatment options, and how does that fit within your goals? And here are the risks that we might have if we decide to embark on this chemotherapy regimen together. And how can we help to decrease that risk?" So it becomes a very integral part of my conversation with an older adult.

Dr. Dale, have you found that this process can be done in a relatively time-efficient way in practice? Is it the type of thing that you are able to really pretty smoothly incorporate within your daily care? Or is it something that the patient should anticipate quite a bit of extra time for?

Dr. Dale: Thank you, Dr. Hurria. That's a great question. The tools, at first, may appear like they're very time-consuming, especially since they may be unfamiliar to patients and even some community oncologists. But the truth is, a significant amount of work has been done, including by Dr. Hurria, to show that the geriatric assessments, for example, the CARG chemotherapy toxicity tool, take about 20 minutes to complete in total. And in many ways, each of these pieces of the assessment can be done individually. Asking people about falls is only 1 or 2 questions to have to ask. To open the discussion about depression is another question. Comorbidities and many other information that's clinical can be gotten out of the medical record, which doesn't take time away from the encounter with the patient. And even a number of these things can be done outside of the clinic time completely answered by patients before the visit or collected by somebody in the clinic whether it's a nurse in the clinic or a medical assistant. And there's a lot of evidence that all of this information, which is so valuable for decision-making, is much less time-costly, certainly, a lot less money-costly than many tests that we currently do. So finding a way to fit in most or all of it should fit into a normal daily practice with some thoughtful integration.

From the perspective of a busy oncologist, are there parts of this that you incorporate formally into your practice? Or is it mostly informal from your perspective, especially for someone in a busy community practice?

Dr. Hurria: I think, "Doing something is better than nothing" is the way I sort of tell my colleagues within the community. So even if there's some simple questions within the assessment that they can integrate into their daily practice, I think that can be helpful. But I also think that, as you had discussed, so much of this actually can be completed by the patient even before the oncology visit.

And so if a patient would like to do this assessment, they could actually go to the Cancer and Aging Research Group website. It's, And go to Geriatric Assessment Tools, and take the assessment themselves, print out the results, and allow that to be a springboard for their discussion with the oncologist. So, I agree with you. What we're trying to do is really make this time-efficient for both the patient and the doctor, and spend less time trying to complete the assessment within the clinic and more time discussing the results.

Dr. Dale: Dr. Hurria, I love the idea of the patient taking the initiative on this. I think the one fear patients have sometimes is not knowing what to bring up with the doctors. But I do think if the patients bring it up, including bringing the assessment or even just asking, "Gee, what do you think about my other problems, like my other medical conditions?" or, "What about my situation at home? How can I manage that?" it does both alert the practicing oncologist to have that conversation and tends to invite in the rest of the multidisciplinary team, which is so essential to delivering on a lot of these interventions that also might have appeared daunting. But there's a lot of expertise out there that we could draw on if we just open the conversation.

Dr. Hurria: Yeah. That is a fantastic point. Well, with that, Dr. Dale, I just want to say it's such an honor as always to have a chance to learn from you and hear about your expertise. And I thank you for doing this podcast together.

Dr. Dale: Thank you, Dr. Hurria. It's been a real pleasure.

ASCO: Thank you, Dr. Hurria and Dr. Dale. More information about cancer care for older adults can be found at If this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play.

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