Focusing on Older Cancer Patients: A Clinical Need and a Research Necessity
People age 65 and older represent approximately 60 percent of cancer patients and account for 70 percent of annual cancer deaths. As the U.S. population continues to age, these percentages will only continue to grow in the coming decades.
“We really need to ask ourselves, if the majority of cancer patients are 65 and older, why have we structured oncology science and care to be a set of systems that is focused on younger patients and views the majority as a minority?” asked Dr. Sarah Kagan, a clinical nurse specialist and geriatric oncology researcher at the University of Pennsylvania Abramson Cancer Center. For instance, she continued, cancer clinical trials typically include few older patients and mostly those without other significant illnesses. “That’s not real life in an aging society,” Dr. Kagan said.
Recognition of these issues has improved greatly, said Dr. Harvey J. Cohen, director of the Center for the Study of Aging and Human Development at Duke University Medical Center. “But there is still a long way to go to have the broader [oncology] community understand and generate more specific evidence of what to do about them,” he said.
The “Older” Patient
How to most effectively treat and manage older patients is one of the greatest challenges in contemporary cancer care, said Deborah Boyle, an oncology nurse from Banner Good Samaritan Medical Center in Phoenix, and an advocate for geriatric cancer patients for more than 2 decades. In 2008, Ms. Boyle led a Geriatrics Task Force assembled by the Oncology Nursing Society to focus greater attention on the needs of older patients and the role of nurses in their care.
The challenge, Ms. Boyle said, begins with defining just what constitutes an older patient. “Chronologic age is not a good marker of appropriateness for therapy,” she explained. “Rather, what we should address is a patient’s physiologic age.”
For example, an oncologist may see two 70-year-old women diagnosed with breast cancer. The first could be quite fit with good mobility, strong mental acuity, and no other significant medical conditions. The other patient could be a widow with little in the way of a support system at home, suffering from osteoporosis and heart disease, taking six or seven different medications, and have early signs of dementia. The needs and treatment approaches of these two patients are likely quite different.
And that’s the problem, argued Dr. Kagan. “Oncology has yet to find effective, comprehensive ways to understand the integration not just of biological aging, but also the psychological and sociological implications of what it means to be old in our society.”
Making clinical trial participants more representative of the types of patients seen in everyday practice, particularly older patients, has been a significant challenge, said Dr. Ted Trimble of NCI’s Division of Cancer Treatment and Diagnosis (DCTD). Comorbidities and clinician and patient reluctance are among the factors that limit older patient participation. In addition, Dr. Trimble explained, older patients are less likely to be referred for treatment to NCI-designated cancer centers, and they are more likely to be treated at sites that don’t offer clinical trials.
NCI is working at multiple levels to improve the situation, he said. “We’re working with the clinical trials cooperative groups to develop more trials that target older patients, particularly those with comorbidities,” he explained. “We want to be able to figure out if the results coming out of trials with healthier patients can safely be used in older patients and those with comorbidities.” The available evidence, Dr. Trimble added, indicates that older patients are often undertreated because of a lack of such information.
DCTD also has a program to test newly identified chemotherapy agents in patients with issues such as organ dysfunction. “As new agents come to be used in clinical trials or become standard therapy, we’ll have information on how to dose patients with comorbidities,” said Dr. Trimble.
The Nurses’ Role
When seeing older patients, oncologists may be aware of issues apart from the cancer itself, such as the patients’ mental state and the kind of care assistance they have at home, said Dr. Cohen, who works with NCI-funded clinical trials cooperative groups. “But they don’t necessarily call it to mind when occupied with a patient,” he said. “They’re preoccupied with how to best treat the tumor itself, which is understandable.”
That’s why oncology nurses can play such an important role in helping to manage older patients, said Mary Kate Eanniello, an oncology nurse educator from Hartford Hospital, a large community hospital in Hartford, CT.
“We are knowledgeable about the diversity of patients, that elderly patients are different from the average younger patient,” she said. Nurses can be more focused, she continued, on “the idea of age competency; that different patients at different times in their lives will need to be handled differently.”
Ms. Eanniello’s hospital is one of more than 300 across the country that have implemented the Nurses Improving Care for Healthsystem Elders (NICHE) program. Developed by the Hartford Institute for Geriatric Nursing at the New York University College of Nursing, the NICHE program provides programs and tools nurses can use to improve the care of elderly patients.
At Hartford Hospital (which is not affiliated with the Hartford Institute), Ms. Eanniello is the primary NICHE educator for the facility’s oncology nurses. The training that nurses receive through the NICHE program, she said, allows them to anticipate whether patients are likely to tolerate certain treatments or if they require more vigilant post-treatment monitoring. According to Chris Waszynski, a nurse who oversees the NICHE program for the entire hospital, the results of the training speak for themselves: a significant decrease in patient falls, increased detection of delirium, and decreased length of hospital stays.
“I tell our staff on the inpatient unit that you can’t not like geriatrics and be an oncology nurse,” Ms. Eanniello said. “The opportunities we have to make an impact on the quality of life for older patients are only limited by the time we can stay awake.”
Oncology nurses play a central role in the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center in Tampa, FL, said Dr. Lodovico Balducci, the program’s chief. “The nurses are in the best position to identify age-related problems, because the nurses, by both training and vocation, are better attuned to the kinds of issues older patients face,” he said.
Getting Cancer Specific
Currently, few hospitals, academic cancer centers, and community oncology practices have specialized or standardized methods for managing older patients, Dr. Cohen noted. One potentially valuable tool is the comprehensive geriatric assessment (CGA), which provides an in-depth analysis of medical, psychological, or social issues that can affect patient treatment and overall management. The assessments can be clinically important, added Dr. Ted Trimble of NCI’s Division of Cancer Treatment and Diagnosis. “We’ve learned that those initial assessments can be more predictive of how a patient will do with their cancer than their [Eastern Oncology Cooperative Group] performance status.”
In addition to a lack of training on how to conduct such assessments, there is also a shortage of evidence on their use in an oncology setting, Dr. Cohen noted, including whether they measurably improve outcomes and overall care. But that may soon change.
At Moffitt, for instance, patients who are age 70 or older routinely undergo a two-part screening process, Dr. Balducci explained. The initial screening, performed by a nurse, identifies patients who may need a more in-depth geriatric assessment because of signs of depression or lack of an adequate caregiver. Patients will also undergo an assessment by one of the program’s oncologists with a tool called CRASH, developed by Dr. Balducci’s colleague Dr. Martine Extermann, which identifies older patients at increased risk of severe chemotherapy complications. Results from a study done at Moffitt involving the CRASH assessment were presented at the American Society of Clinical Oncology annual meeting in June 2010.
The NCI cooperative clinical trials group Cancer and Leukemia Group B, meanwhile, is incorporating a CGA into several clinical trials for use with older participants. The CGA that will be used, Dr. Cohen explained, is less extensive than similar tools used at other elder care facilities, and can be completed by patients in the waiting room. The trials will determine whether the assessment results correlate with outcomes such as survival and toxicities, which “could allow oncology staff to make better decisions about which drug regimens to use and the intensity of those regimens,” he said.
Such assessments, Ms. Boyle said, address a critical need for older patients. “We need to identify issues that could influence their outcomes before treatment begins, not during the course of therapy,” she stressed.
The cancer patient population is changing, Dr. Balducci said, and oncology professionals must not only acknowledge that shift, but begin to alter how they approach older patients. “It’s a general principle that physicians and nurses need to become experienced in the assessment of the older person,” he said, “because that is going to be the medicine of the future.”
The Oncology Nursing Society is developing a new training program on older patients for oncology nurses, according to the society’s director of education, Michelle Galioto. The training program is being developed by a team of gero-oncology and geriatric nursing specialists from across the country, Ms. Galioto explained, and will be reviewed by other specialists and enhanced as needed.
The program is expected to be launched later in 2010 on a regional level and will cover:
- Normal and pathologic changes in the older adult
- The different side effects of cancer and cancer treatment in older adults
- Strategies for managing symptoms and treatment side effects
- Psychosocial considerations
- Patient and family education