Basics in Geriatric Oncology. Ravindran Kanesvaran Consultant Medical Oncologist and Course Director National Cancer Centre Singapore

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1 Basics in Geriatric Oncology Ravindran Kanesvaran Consultant Medical Oncologist and Course Director National Cancer Centre Singapore

2 How did it start? Ongoing geriatric oncology service at NCCS ( the only one in SEA) Idea to promote its principles to other health professionals in the community 3 workshops : GPs, Nurses, Allied Health Funding : SSO / MSD/ NCCS PGEU

3 The GAP Knowledge on elderly cancer patients Misconceptions about treatment ageism New assessment techniques Working as a team Key role of GPs in management of elderly patients ( where can you contribute)

4 Course Overview

5 Objectives Demographics of cancer in the elderly Introduction to Geriatric Oncology Geriatric Asssessment and Treatment Geriatric onco NCCS Summary

6 Population Ageing in Singapore by 2030

7 Aging and chronic disease The big 3 cardiovascular disease, cancer and stroke increase with age 4 out of 5 persons 65 years of age have one or more chronic conditions Once acquired, chronic conditions usually remain Disability associated with aging is often the result of chronic disease

8 Aging and chronic disease

9 Report on Registry of Birth and Death, Retrieved from:

10 Cancer and the elderly 60 % of all malignant tumors occur in the age group 65 years and older Incidence data shows that as one ages the potential for developing cancer increase Persons age 65 and older are eleven times more likely developing a cancer than persons under age 65

11 Cancer is a disease associated with aging 60% of cancer occurs in people >64 Rates per 100k population CDC, Morbidity & Mortality Wkly Rpt 2013 Age Groups

12 Top 5 Cancers in Singapore ASR- age standardised rate per 100,000 population, MOH Singapore website

13 Cancer Registry

14 Heterogeneity of Aging

15 Geriatric Oncology There is gross under representation of this group in clinical trials Talarico et al JCO 2004 A lack of data regarding their cancer treatment outcomes Geriatric Oncology is rapidly coming to the foreground of oncology practice

16 Current Practice of Oncologic Assessment We use functional status (ECOG or Karnofsky s scales) assessment It has been shown to poorly predict functional impairment in the elderly Repetto et al JCO 2002

17 What is a Comprehensive Geriatric Assessment (CGA)? Multidisciplinary evaluation of older persons in which their multiple problems are uncovered, described and explained CGA has been used by firstly by geriatricians and later oncologists to understand these group of patients better Multiple benefits to patients assessed using CGA

18 Components of CGA

19 Why Do CGA? Predictive value for chemotherapy toxicity, survival and treatment choices. Identify reversible conditions that may improve patient s fitness for treatment Determine patient decision making capacity Clarify patient s values and goals for treatment

20 The role of CGA Some components of the CGA have been shown to be prognostic in both Western and Asian populations independent of performance status alone Asmis et al JCO2008, Kanesvaran et al JCO 2011 CGA evaluation has been shown to impact treatment toxicity, survival and treatment decisions in elderly cancer patients Puts et al JNCI 2012

21 Why don t we use CGA for our patients at present? Time constraints (takes minutes to administer) Requires manpower Lack of functionalization of CGA data Specifically in Asia: Lack of data to support its use

22 CGA and Chemo Toxicity Prediction

23 Predictive Model for Chemotherapy Toxicity Risk Factors for Gr.3-5 Toxicity OR (95% CI) Score Age > ( ) 2 GI/GU cancer 2.2 ( ) 3 Standard dose 2.1 ( ) 3 Poly-chemotherapy 1.8 ( ) 2 Hemoglobin (male: <11, female: <10 ) Creatinine Clearance (Jelliffe-ideal wt) < ( ) ( ) 3 1 or more falls in last 6 months 2.3 ( ) 3 Hearing impairment (fair or worse) 1.6 ( ) 2 Limited in walking 1 block (MOS) 1.8 ( ) 2 Assistance required in medication intake 1.4 ( ) 1 Decreased social activity (MOS) 1.3 ( ) 1 Hurria et al. JCO 2011;

24 Model Performance: Prevalence of Toxicity by Score Grade 3-5 Toxicities High 83% (>11) Mid 53% (6-11) Low 27% (0-5) Hurria et al. JCO 2011;

25 CGA and survival

26 Patients and Methods Retrospective analysis of 249 consecutive cancers patients at NCCS aged 70 years and above Univariate and Multivariate analysis done using CPH method Simple nomogram developed using regression coefficients from multivariate model All cause mortality was captured from hospital database and national death registry Kanesvaran et al JCO 2011

27 CGA NOMOGRAM The scales of the nomogram reflected the coefficients from the Cox model rescaled to a user friendly (100 point) range Kanesvaran et al JCO 2011

28 Its too time consuming.. I have no time to do this in the clinic..

29 Screening tools Tool Components Data in community dwelling elderly Data in oncology patients VES-13 Age, self-rated health, functional capacity and physical performance Score predictive of increased risk of death or functional decline over 2 years Mixed results for identifying CGA impairment in different populations Groningen Fraility Indicator Mobility/physical fitness, vision/hearing, nutrition, comorbidity, cognition, psychosocial Correlation between the GI score and CGA Predicts mortality in older cancer patients receiving chemotherapy G8 Nutrition, mobility, cognitive defect, polypharmacy, age, self-perceived health status Derived from MNA Sensitive for predicting deficits on CGA

30 Geriatric Oncology Service NCCS Started in 2007 by Dr Donald Poon Took over in 2010 HMDP at Duke Centre for Aging and DCI in Restarted Geriatric Oncology service in July 2015

31 CGA workflow Patient (Criteria: 70 years old, newly diagnosed case) Consent Taking No Yes No action required Negative Comprehensive Geriatric Assessment (CGA) & 20ml Blood Taking Positive No action required Recommendations will be given to primary physician

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34 Recommendations to primary physician Recommendations: 1) Refer memory clinic 2) Refer dietitian 3) Control BP 4) Stop drug XXX, YYY CARG chemotox score: 7 G3-5 tox risk: 51%

35 The 3 important Questionnaires Pre workshop Post workshop 3 Months later

36 Conclusions Cancer is a common problem among the elderly The elderly should be treated as a unique group Once diagnosed, treatment will depend on the GA and patients goals/choice IT IS NOT THE END OF THE ROAD!

37 Acknowledgement PGEU staff and Prof Simon Ong All the invited speakers SSO MSD All the participants

38 THANK YOU Members of the SingHealth Group Changi General Hospital KK Women s and Children s Hospital Singapore General Hospital National Cancer Centre Singapore National Dental Centre Singapore National Heart Centre Singapore National Neuroscience Institute Singapore National Eye Centre SingHealth Polyclinics