In this comprehensive introduction to cancer care for older adults, Dr. Hyman Muss explains geriatric oncology and health assessments. He also gives advice for talking with your health care team and taking care of yourself during and after treatment.
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Cancer.Net®: Doctor-Approved Patient Information from ASCO®
Cancer Care for Older Adults: An Introduction
What is Geriatric Oncology?
Hyman Muss, MD; Member, American Society of Clinical Oncology: Geriatric oncology is what is emerging as a subspecialty of cancer care, really focused on older patients. And why it’s important is older patients are very variable as far as their healthcare status when they get cancer. And it’s really a challenge to know how to best care for them. So, our branch of oncology, geriatric oncology, is really focused on learning more about older people, what their goals of treatment are, how to best care for them, minimize toxicity, and what might be the most appropriate treatments – smaller doses, larger doses of medicine, etc. So, it’s a very new and emerging and extremely important area of cancer care.
What Does “Health Status” Mean?
Dr. Muss: One thing that’s different about older people is there’s great differences in health status as we get older among people of the same age group. So, you can have a 75-year-old woman or an 80-year-old woman who walks in. They’re going to the gym every day, doing guitar lessons, and are extremely functional. And on the other hand, you can have someone, identical age, maybe living in the same apartment complex, who is wheelchair-bound, on multiple medications, maybe have mild cognitive loss. And yet, they’re both the same age.
So, factoring in the comorbid illnesses, and then deciding is cancer a major illness? And if it’s a major illness, how do the background illnesses of that patient affect your management of the cancer?
Older Adults in Cancer Clinical Trials
Dr. Muss: Unfortunately, most of the clinical trials we’ve historically done in the United States had very few older patients, or worse yet, many years ago, used to exclude patients that were, let’s say, less than 65. So, what happened was, you got, let’s say, a large trial of new drugs, and you looked at it, and the average cancer patient in that trial was 50, as opposed to the average cancer patient in the United States, who’s now diagnosed at age 67. So, there’s a paucity of data. ASCO has been terrific in promoting the interests of geriatric oncology, is to do research that looks at how treatments affect functional status of older patients. Not just what’s the tumor shrinkage rate, what’s the survival rate.
What Is A “Geriatric Assessment”?
Dr. Muss: One of the key things that’s emerged is the use of geriatric assessment. And geriatric assessment is a way of looking at various functional domains of older people. Can you wash yourself? Do you get your groceries? Do you drive? Do you have a good circle of friends? Etc. So, the geriatric assessment kind of codifies this. It’s like a patient-reported outcome. And we learn about whether patients can care for themselves. Can they drive? Can they go to the grocery and buy food?
If you can’t do that, you can’t live by yourself. And if you can’t wash and bathe yourself, you can’t live anywhere unassisted. You have to be in some kind of assisted care. So, all those issues are extremely important in determining what type of treatment you want to give a patient. And just as important in older people are things that we rarely talk about, like social support. Does the older person have a good circle of friends or children, or people that kind of come in and take he or she out? If you look at older people and their illnesses are identical, and their other health is identical, and you look at the patients who have great social support, great family, friends, and you look at the other patient who maybe he or she is in a little apartment complex for the elderly, and no one comes to visit them, and you look at the survival, it’s much better for the social support.
It’s as good as some of the treatment-related variables. Likewise, things like falls, they have major implications in older people. And what’s important is that there are interventions that correct, that are able to help the patients with that. So, in our specialty, looking at the entire patient and how their lives are going, and all the other interplay, of their functional status, how many medicines they’re taking, are they getting enough food, are they losing weight, is all key. And getting to your point of view of things like nutrition, what’s very important, older people frequently lose weight. And when you look at some of the models that have been built to predict life expectancy in the community, weight is important.
Talking with the Cancer Care Team and Expressing Your Goals
Dr. Muss: I think all people should be urged to ask questions. I think that older people need to come in with a friend or a family member or another pair of ears. I think that’s true for all patients, because actually, older people do a little bit better. But on many first visits of cancer patients, they’re like a deer in the headlights. And you talk with the patient, you go over things. So, I think for all patients, but especially older patients, it’s good to have someone, another pair of ears.
I think it’s very, very important that older people get a comfort zone, kind of know what the treatments entail, the side effects, and have a say in helping to select their care.
Margaret Sedenquist, Patient Advocate: At all times, I was told exactly what would happen with the different kinds of medication and surgery that I was going to have. Is that – I mean, I think that’s the main thing, is that there weren’t any holes or any misconceptions or any frightening information.
Dr. Muss: And the goals of a patient are very important. It’s important to ask the patient, what are your expectations for this therapy? If we look at younger people, like in their 50s, they may want to see that daughter graduate high school or college, do some special things in their life. If you ask older people, what are their fears or their most important goals, they want to have good treatment for their cancer. But they’re most afraid of cognitive loss from treatment and of losing their independence. So, you frequently hear, oh, I don’t want my family to have to keep bringing me in here; or, I’m able to take care of myself now, but if I have bad side effects, I’ll have to move to assisted living or to a nursing home, etc. Those are their great fears. A lot of differences in goals.
Taking Care of Yourself During and After Treatment
Dr. Muss: There are studies now exploring simple interventions like walking. So, it’s great to recommend to some people, go to a gym and get a trainer, etc. But this doesn’t fit the lifestyle of many older people who don’t have those resources, or the ability to do that. So, things like a walk, 30 minutes a day, five times a week, to keep their muscles strong during chemotherapy. Other minor exercise. Tai chi, other things that they can do, is very helpful. It’s important to maintain a good quality diet. You don’t want to see people especially losing weight when they’re getting treated. And older people can play a great role in this, and so can their families.
And there are many community centers and other places that can maintain their quality of life and independence during cancer treatment, which is so important.
Margaret Sedenquist: Think of cancer as just another experience, and to find a very good oncologist, as I did, and follow the advice that you’re given, and then expect to live the life you expect to live.
Where to Get More Information
Dr. Muss: So, I would say that if people are interested in more information about caring for older people with cancer, a great source is cancer.net, which has some wonderful informatics pieces, questions, etc., and has really been edited by some top experts in the field.
[Closing and Credits]
Cancer.Net®: Doctor-Approved Patient Information from ASCO®
ASCO's patient education programs are supported by Conquer Cancer Foundation of the American Society of Clinical Oncology. ConquerCancerFoundation.org
University of Michigan Comprehensive Cancer Center
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University of Nebraska Medical Center
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