Geriatric Oncology: Improving the care of older adults with cancer

Transcription

1 Geriatric Oncology: Improving the care of older adults with cancer Doreen Wan-Chow-Wah, MD, FRCPC Assistant Professor, Division of Geriatric Medicine, Department of Medicine Associate member, Department of Oncology McGill University Medical Director, Geriatric Oncology Clinic, Segal Cancer Centre 2017 CAGPO Annual Meeting Hotel OMNI Mont-Royal September 29, 2017

2 Disclosure I have no disclosure statements.

3 We ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way. Atul Gawande Being Mortal: Medicine and What Matters in the End

4 Objectives: Identify the role of the geriatrician in Oncology care Explain how a geriatric assessment affects treatment decision-making Determine which patients will benefit from a geriatric assessment Learn what to do when there is no geriatric oncology clinic in your center

5 What is the # 1 risk factor for developing cancer? A) Strong family history B) Obesity C) Exposure to sun/radiation D) Tobacco E) Aging F) Viruses and bacteria

6 What % of breast cancers is diagnosed in women < 50 and 70? A) 36 % and 16 % B) 17% and 32% C) 21% and 23% D) 52% and 10%

7 Mrs. P 100 year old woman Living at home with 105 yr old sister Private caregiver for some ADLs and all IADLs. Left breast cancer age 85 Lumpectomy, Hormonal therapy PMHx: bilat hip surgery Hypothyroidism, osteoporosis Locally advanced breast cancer with ulcerated skin nodules

8 Case from the clinic: Mr. F 84 year old man post-op surgery for Stage III CRC Referred for: Geriatric evaluation for further treatment PMHx: Hypertension, anxiety Meds: Diovan, Clonazepam Lost 40 lbs over 1 year, less energy, tires easily Social/Functional hx: Lives with 2 sons, independent in ADLs and IADLs Wife died of metastatic CRC last year

9 Age pyramids (in number) of the Canadian population, 2009, 2036 and 2061 Source(s): Statistics Canada, Demography Division.

10 Canadian Cancer Society - Canadian cancer statistics 2016

11 Oncology and Aging In Canada, adults 70 years+ 10.5% of population 43% of new cancer cases 61% of cancer deaths Canadian Cancer Statistics, 2014 Number of older adults expected to more than double by 2056

12 Canadian cancer statistics 2016

13 Canadian cancer statistics 2016

14 Oncology and Aging Risk of developing cancer increases with AGE Growth and aging of population = cancer burden 44% of new cancer cases in 70, 62 % of deaths due to cancer in 70 Half of all newly diagnosed lung and colorectal cancer cases will occur in 70 More deaths from breast cancer in 80 than any other age group Canadian Cancer Statistics 2016

15 Particularities of older adults with cancer Heterogeneous population Good 80 year old? Physiological aspects of aging that impact cancer & its treatment Age-based disparities in cancer care Understaged Undertreated Suboptimal care

16 Particularities of older adults with cancer Shifting goals of care Quality of life / Independence & Autonomy morbidity, alleviate symptoms survival, cure disease Communication affected by sensory & cognitive changes Lack of research Underrepresented in clinical trials Lacking quality of life outcomes

17 Good 80 year old?

18 Spectrum of health in older patients Vulnerable Healthy Disabled

19 The Clinical Challenge: Appropriate Treatment OLDER PATIENT CANCER Type, stage, prognosis Comorbidities, Medications Functional status (ADL, IADLs) Frailty markers Cognition Social support Mobility Nutritional status Patient wishes Life expectancy CANCER THERAPY (or NOT): Surgery, Chemotherapy, Radiotherapy ( Curative, Palliative ) TOXICITY PHYSICIAN: Knowledge, attitudes, time, preferences, resources

20 A systematic review of factors influencing older adults' decision to accept or decline cancer treatment. Puts MT 1, Tapscott B 2, Fitch M 2, Howell D 3, Monette J 4, Wan-Chow-Wah D 4, Krzyzanowska M 5, Leighl NB 5, Springall E 6, Alibhai SM 7. Accepting treatment: Convenience Success rate of treatment Seeing the necessity for treatment Trust in physician Following physician s recommendations Declining treatment: Discomfort of treatment Fear of side effects Transportation difficulties

21 IMPORTANT QUESTIONS Will the patient die WITH or FROM the cancer? Will the patient SUFFER from the cancer? Will the patient TOLERATE the cancer treatment? Are there factors which may INTERFERE with the cancer treatment and which are potentially REVERSIBLE? Medical Functional Social

22 General approach to treatment planning in an older cancer patient Extermann et al, Current Treatment Options in Oncology 2011: 12;

23 VES-13 Predicts risk of functional decline or death over 2 years Score 3 : vulnerable

24 G8 Soubeyran et al. JCO 2011, abstract 9001 Score 14: + Geriatric risk profile

25 Comprehensive Geriatric Assessment (CGA) Functional status Comorbidities Cognition Psychological evaluation Social support Nutritional status Polypharmacy Geriatric syndromes (dementia, delirium, depression, falls, incontinence)

26 The Geriatrics 5M's: A New Way of Communicating What We Do. Tinetti, Huang and Molnar. J Am Geriatr Soc Sep;65(9):2115. doi: /jgs Epub 2017 Jun 6.

27 Functional status Activities of Daily Living (ADL)

28 Functional status Instrumental Activities of Daily Living (IADL)

29 Cognitive Evaluation

30 However Patients seen in oncology seem to be in better health and to be more functional than traditional geriatric patients Usual geriatric measurement tools would have a ceiling effect (Hurria, 2006) There is a need to use more sensitive tools in order to identify functional older cancer patients who may be vulnerable to complications in response to aggressive treatments.

31 Gait Speed and Survival in Older Adults. Studenski et al. JAMA. 2011;305(1):50-58

32 Grip strength : Dynamometer

33 Montreal Cognitive Assessment test (MoCA): Screening tool for Mild Cognitive Impairment

34 Why do a CGA? Provide an estimate of life expectancy to determine treatment plan Identify reversible conditions Uncover new problems Anticipate toxicities, prevent complications Determine patient wishes and decision-making capacity Clarify social support system Improves survival, decrease institutionalization, improve/maintain functional status and QoL

35 Usefulness of CGA in Oncology detection of impairment not identified in routine history or physical examination ability to predict severe treatment-related toxicity ability to predict OS in a variety of tumors and treatment settings ability to influence treatment choice and intensity Wildiers et al. JCO 2014; 32 (24)

36 Geriatric assessment predicts survival and toxicities in elderly myeloma patients: an International Myeloma Working Group report by Antonio Palumbo, Sara Bringhen, Maria-Victoria Mateos, Alessandra Larocca, Thierry Facon, Shaji K. Kumar, Massimo Offidani, Philip McCarthy, Andrea Evangelista, Sagar Lonial, Sonja Zweegman, Pellegrino Musto, Evangelos Terpos, Andrew Belch, Roman Hajek, Heinz Ludwig, A. Keith Stewart, Philippe Moreau, Kenneth Anderson, Hermann Einsele, Brian G. M. Durie, Meletios A. Dimopoulos, Ola Landgren, Jesus F. San Miguel, Paul Richardson, Pieter Sonneveld, and S. Vincent Rajkumar Blood Volume 125(13): March 26, by American Society of Hematology

37 Long-term outcomes by American Society of Hematology Antonio Palumbo et al. Blood 2015;125:

38 Life Expectancy Possible to estimate if a person is likely to live substantially longer or shorter than average Number/severity of comorbid conditions and functional impairments stronger predictors than age Life expectancy substantially below average CHF (Class III, IV), ESRD, Severe COPD (home O2), Severe dementia (MMSE < 10), Dependency in many ADL Life expectancy substantially above average No comorbid conditions or functional impairments Courtesy of Dr. Louise C. Walter

39 Upper, Middle, and Lower Quartiles of Life Expectancy for Women and Men at Selected Ages Copyright restrictions may apply. Walter, L. C. et al. JAMA 2001;285:

40 eprognosis Lee S. et al. Geriatric prognostic indices based on Prognostic indices for older adults: A systematic review. Yourman et al. JAMA 2012;307(2): Designed for older adults without a dominant terminal illness Rough guide for clinicians about possible mortality outcomes

41 eprognosis Lee S. et al.

42 Lee S. et al.

43 eprognosis test subject 82 F BMI 25 Very good health No significant cardiac, pulmonary disease No diabetes Never smoked No difficulty walking ¼ mile No hospitalizations in last 12 months No dependency in ADLs and IADLs

44 Lee S. et al.

45 Lee S. et al.

46 Polypharmacy

47 85 year-old patient stage IV colorectal cancer Patient had 2 falls in past month. According to his wifedecreased appetite in past 6 months- lost 15 kg. History of hypertension, atrial fibrillation, gout, constipation. Medications : Ramipril 10 mg qd -Pantoloc 40 mg qd Furosemide 40 mg qd -Citalopram 20 mg qd Digoxin 0,125 mg qd -Allopurinol 300 mg qd Metoprolol 25 mg bid -Lactulose Coumadin 3 mg qd -Atorvastatin 40 mg qhs Lorazepam 1 mg qd Calcium 500 mg + Vit D 400 U bid Cl Cr = 20 ml /min INR = 2.5 B.P. 120/60 pulse 50/min

48 Polypharmacy About 1/3 of community dwelling older adults take 5 prescription drugs (Qato et coll. JAMA 2008;300(24): ) Aging has an impact on pharmacokinetics( GFR, changes in body composition, changes in hepatic metabolism) Drug-drug interactions and drug-disease interactions Inappropriate drug use in the elderly (2015 updated Beers criteria by the AGS) Need to frequently re-evaluate medications all along their cancer care trajectory (dehydration orthostatic hypotension falls) Chemotherapy toxicity Side effects of supportive therapies (antiemetics, steroids)

49 Evaluation of a Pharmacist-Led Medication Assessment Used to Identify Prevalence of and Associations With Polypharmacy and Potentially Inappropriate Medication Use Among Ambulatory Senior Adults With Cancer Nightingale et al. JCO Mar patients, mean age 80 Mean number of medications % polypharmacy (>5 meds) 43% excessive polypharmacy (> 10 meds) 51% potentially inappropriate medications

50 J Clin Oncol 2007;25:

51 Breast cancer hormonal therapy Tamoxifen and SSRIs Concomitant use of SSRIs can decrease efficacy of tamoxifen. Powerful inhibitor of CYP2D6 (eg. fluoxetine, paroxetine) and moderate inhibitor of CYP2D6 (eg. sertraline) that interferes with transformation to active metabolite endoxifen. Paroxetine: mortality risk from breast cancer Kelly et al. BMJ Feb 8;340:c693 Citalopram: Weak inhibitor of CYP2D6; has minimal effect on conversion to endoxifen (Jin et al., 2005; NCCN Breast Cancer Risk Reduction Guidelines v )

52 Xeloda (Capecitabine) Colorectal cancer (adjuvant, metastatic) Metastatic breast cancer Prodrug of 5-fluorouracil Converted to active metabolite in the liver and soft tissues Adherence ON BID for 2 weeks and OFF for 1 week

53 Xeloda (Capecitabine) side effects Hand-foot syndrome (54-60%) Deficiency in Dihydropyrimidine dehydrogenase (DPD) Diarrhea (47-57%) Nausea (34% to 53%) Vomiting (15% to 37%) Hematological toxicity Anemia, neutropenia, thrombocytopenia

54 Abiraterone (Zytiga) Metastatic prostate cancer, castration resistant Avoid in combination with CYP3A4 inducers that will decrease efficacy of Abiraterone Hepatic toxicity Adverse effects: Edema 25% Fatigue 39% Hypertriglyceridemia 63%, hyperglycemia 57% Constipation 23%

55 Hurria A et al. JCO 2011;29:

56 Ability of (A) risk score versus (B) physician-rated Karnofsky performance status (KPS) to predict chemotherapy toxicity. Hurria A et al. JCO 2011;29: by American Society of Clinical Oncology

57 Cancer survivors chemo brain Prevalence: 15 to 70% of patients who received chemo Symptoms: Disorganized Difficulty concentrating Word-finding difficulties Difficulty multitasking Difficulty learning Fatigue Mental fogginess Attention deficits Short-term memory deficits

58 Renaming chemo brain : Cancer or cancer-therapy associated cognitive change Complex phenomenon No clear definition Factors other than chemo may play a role: Impact of surgery and anesthesia Hormonal therapy Menopause Anxiety / depression Fatigue Supportive care medications (pain meds, antiemetics) Comorbidities Genetic predisposition Hurria et al. Cancer Investigation (2007) 25:

59 Cancer therapies/supportive care drugs and comorbidities Histamine-2 receptor blockers (Ranitidine, famotidine): Induce or worsen delirium First-generation antihistamines (diphenhydramine, hydroxyzine): Delirium, cognitive impairment, urinary retention Corticosteroids: Delirium, Diabetes, Osteoporosis, Insomnia Anthracyclines, Herceptin and cardiac toxicity Platinums (Carboplatin,Cisplatin,Oxaliplatin): neurotoxicity Taxanes : neurotoxicity Oral agents caution!

60 Geriatric Oncology clinic Segal Cancer Centre, Jewish General Hospital

61 Our Vision Promote a comprehensive approach to the care of older cancer patients and their families Collaborate with the treating teams to develop an individualized, integrated plan of care. Make recommendations based on a multidimensional assessment.

62 Cancer Care Teams TUMOR SITE TEAMS Breast Cancer Service Colorectal Cancer Program Hematologic Oncology Pulmonary Oncology Head & Neck Oncology Gynecologic Oncology Urologic Oncology Dermatologic Oncology SPECIALTY TEAMS Young Adult Oncology Program Oncology and Aging Program Palliative Care Radiation Oncology Clinical Research Unit Cancer Prevention & Genetics Cancer Nutrition-Rehabilitation Program Psychosocial Oncology Program Hope & Cope

63 The Geriatric Oncology Team Physicians (D. Wan-Chow-Wah, J. Monette, F. Gaba, N. Belkhous) Nurses (Nursing Clinical Consultants: Brandy Vanderbyl, F. Strohschein; Clinical Administrator: J. Bianco) Physical Therapist Occupational Therapist Social Worker Nutritionist Neuropsychologists Administrative Assistants

64 Geriatric Oncology Nurse Navigator: Model of Care Tebo et al., 2013

65 Who are referred? Age 65 Active cancer diagnosis Suspected vulnerability to adverse effects of cancer treatment Impaired functional status Impaired mobility (e.g. falls) Cognitive impairment Polypharmacy Multiple comorbidities

66 Reasons for referral Graphic from CCRC poster 2015, created by Fay Strohschein

67 Geriatric Oncology Assessment- JGH Items Comorbidities Medications Functional Status Social support Cognition Mood Mobility Nutritional status Physical activity/energy Strength Measurements Medical chart, history History, list from pharmacy ADL, IADL History MMSE, MoCA Geriatric depression scale Gait speed, Report of falls Weight, Body Mass Index, History of weight loss or appetite Self-Report questions Grip strength by dynamometer

68 Health and functional status Characteristics of Study Sample Total = 397 N= 397 (%); Mean (SD) Mean age (years) 81 (6.0) Gender Male Female Living Alone Presence of a Caregiver 129 (32.5) 268 (67.5) 170 (42.9) 359 (93) Type of cancer Endometrial Colorectal Lung Breast Other 79(19.9) 60(15.1) 47(11.8) 44(11.1) 167(42.1) Mean number of chronic diseases 4.93 (2.3) Mean Charlson Comorbidity Index score 4.12 (2.4) Mean number of medications 7.02 (4.0)

69 Health and functional status Characteristics of Study Sample Total = 397 N= 397 (%); Mean (SD) Functional Status ADL disability IADL disability ECOG (0-1) (>2) FRAILTY MARKERS 99 (25.7) 293 (76.5) 179 (76.5) 55 (23.5) Poor nutritional status 158 (85.4) Mobility Impairment gait speed <1 m/s 284 (82.8) Low grip strength 172 (50.4) Mood disturbance 69 (28.9) Low energy level 27 (11.3) Cognitive impairment MMSE <26/30 MoCA <26/ (55.9)

70 Health and functional status Characteristics of Study Sample Total = 397 N(%) Cognitive impairment MMSE <26/30 MoCA <26/ (55.9) Mild Cognitive Impairment (MCI) 101 (25.4) Dementia 78 (19.6) Cancer Therapy Related Chemotherapy related Radiation treatment related Hormone therapy related 33 (8.3) 20 (5.0) 8 (2.0) 5 (1.3)

71 Meeting the Needs of the Aging Population: The Canadian Network on Aging and Cancer (CNAC) M.T.E. Puts, T. Hsu, E. Szumacher, S. Sattar, S. Toubasi, C. Rosario, E. Brain, W. Duggleby, C. Mariano, S. Mohile, H. Muss, M. Trudeau, D. Wan-Chow-Wah, C. Wong, S. Alibhai. Current Oncology 2017 :24 (2) Clinical and cost-effectiveness of a comprehensive geriatric assessment in Canadian elders receiving chemotherapy: the 5C study Canadian Cancer Society Impact Grant

72 Mrs. P 100 year old woman Living at home with 105 yr old sister Private caregiver for some ADLs and all IADLs. Left breast cancer age 85 Lumpectomy, Hormonal therapy PMHx: bilat hip surgery Hypothyroidism, osteoporosis Locally advanced breast cancer with ulcerated skin nodules

73 Case from the clinic: Mr. F 84 year old man post-op surgery for Stage III CRC Referred for: Geriatric evaluation for further treatment PMHx: Hypertension, anxiety Meds: Diovan, Clonazepam Lost 40 lbs over 1 year, less energy, tires easily Social/Functional hx: Lives with 2 sons, independent in ADLs and IADLs Wife died of metastatic CRC last year What our CGA revealed : Not keen on adjuvant chemotherapy now. Still grieving loss of his wife, and witnessed side effects of chemo that she experienced. I am almost 90 yrs old, I don t want to get sicker. Cognitively intact 4 year mortality: 59% 10 year mortality: 83-91% ECOG 2 Grip strength:18 kg Gait speed: 0.6 m/sec CARG Risk score: 11 (High risk, 83%) Risk / Benefit of chemo?

74 Take home message Rise in cancer incidence and mortality with aging Elderly are a heterogeneous population Screening for patients 70 to detect potential vulnerability Individualization of care, with focus on health and functional status, rather than chronological age Life expectancy, harms and benefits of treatment

75 Take home message Patient preference, quality of life Geriatric 5M will help you become GPG Partnership between Geriatrics and Oncology is necessary to improve cancer care

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77 Geriatric Oncology: Improving the care of older adults with cancer