Geriatricians Play an Increasingly Important Role in Cancer Care

By Kathryn L. Hale

Martha Anne Burrows, who has survived ovarian and breast cancers and is now being treated for a tumor near her spine, visits Dr. Holly Holmes for a geriatric assessment.

In the past, many elderly patients did not survive long after a cancer diagnosis. Even older patients who were healthy enough to undergo the standard treatment for their cancer often had a shorter life expectancy than younger people with the same cancer.

But as cancer treatments improve, many older patients are choosing more aggressive therapies, and they are surviving cancer in unprecedented numbers. To meet the special needs of these patients, some physicians have begun to focus their practice on providing primary care for older patients before, during, and after cancer treatment.

Geriatrics and cancer

Holly Holmes, M.D., an assistant professor in the Department of General Internal Medicine at The University of Texas MD Anderson Cancer Center, is one of only a handful of practicing geriatricians in major cancer centers around the country—and she’s busy. Nearly 7,000 new patients age 70 years or older register at MD Anderson every year.

To enable older patients to receive the most effective treatments possible, oncologic geriatricians focus on medical conditions typically associated with aging, such as chronic diseases and dementia, and on related health problems, such as motor disorders, polypharmacy, nutritional deficits, and geriatric syndromes. Geriatric syndromes is a term used to describe clinical conditions that affect older patients and do not fit into discrete disease categories—such as frailty, falls, weakness, memory loss, confusion, and mobility problems.

“Geriatric syndromes don’t go away just because a person has cancer,” Dr. Holmes said. “I care for patients who are facing treatment for their cancer, and I try to reverse or control the other conditions to help them get through the treatment better.”

Dr. Holmes and her peers at other institutions are working to fill a gap in what is known about how cancer and its treatment affect older people over both the short and long term. To that end, they participate in the Cancer and Aging Research Group, which designs and carries out trials that focus on clinical problems that are more common in older cancer patients than in younger patients. Dr. Holmes explained the need for such trials: “In the past, older people were underrepresented in the clinical trials that set the standards for cancer care. So we don’t have as much systematic information about how they will respond to cancer therapy.”

How old is “old”?

Dr. Holmes has been collaborating on a pilot study designed to predict how older patients with hematologic malignancies will tolerate and recover from allogeneic stem cell transplantation. At first, she resisted getting involved in the project because for the purposes of stem cell transplantation, “older” people are defined as those 60 years or older. In modern geriatrics, people are not considered old until they are in their 80s or 90s. Because people in their 80s and 90s are not candidates for stem cell transplants, Dr. Holmes at first did not see how this study had anything to do with her practice. But then she met a patient who changed her mind—a 55-year-old man who, in the weeks following his stem cell transplant, developed multiple geriatric syndromes such as frailty, frequent falls, difficulty walking, weight loss, and weakness. Before his transplant, he had been strong and robust except for his cancer, but he had suddenly become a “geriatric” patient. This kindled Dr. Holmes’s interest in developing a way to predict who, among older patients, would do well after a transplant and who would not.

The study is investigating whether a comprehensive geriatric assessment—a defined panel of parameters that includes the patient’s physiologic age, comorbid conditions, medications, functional abilities, competence in activities of daily living, nutrition adequacy, physical performance status, mental and cognitive abilities, and social support—can be used to predict how well a patient will do during and after transplantation.

“We’re looking at the people who develop what might be called a frailty syndrome after transplantation: excessive fatigue, exhaustion, weakness, and weight loss,” Dr. Holmes said. “We compare objective measures, such as grip strength, gait speed, weight loss, and self-reports of physical activity and energy level, with their pretransplant baseline assessments to find clues as to which parameters we could eventually use to make informed decisions about the risks and benefits of a transplant for an individual.”

Improving patient assessment

There is no standard for geriatric assessment in cancer care; most oncologists continue to rely on simple scales of performance status that have been in use for years: the Eastern Cooperative Oncology Group scale and the Karnofsky scale. Both are useful for assessing patient status, but the goal of the Cancer and Aging Research Group is to develop assessment tools that offer more predictive value while remaining easy for busy clinicians to use. “As geriatricians who work with older cancer patients,” Dr. Holmes said, “part of our job is to give the oncologists the information they need to improve their pretreatment assessment and selection of therapy for each patient.”

Dr. Holly Holmes demonstrates tests of balance and grip strength for patient Martha Anne Burrows.

The U.S. National Comprehensive Cancer Network (NCCN) has published guidelines on senior adult oncology, and Dr. Holmes was a member of the panel that developed the comprehensive geriatric assessment recommendations for those guidelines.

For the stem cell transplant study, Dr. Holmes modeled her comprehensive geriatric assessment on one tested in a recent multicenter prospective study of how well such an assessment predicts chemotherapy toxicity in older adults. The results of that study, which were reported in the Journal of Clinical Oncology in 2011, indicated that among adults older than 65 years undergoing chemotherapy for a solid tumor, the risk of severe toxicity or death was higher in those older than 72 years. The risk was also high in those who had a gastrointestinal or genitourinary cancer and in those who received multiple chemotherapy drugs at standard doses. Patients who had a low baseline hemoglobin level or creatinine clearance, reduced hearing acuity, a fall in the last 6 months, limited ability to walk one block, a need for assistance in taking medications, or reduced social activities also had a high risk of severe toxicity or death.

Dr. Holmes acknowledged that it is not realistic to expect oncologists to incorporate a comprehensive geriatric assessment into their pretreatment evaluation because of the time required to do so. “In its most recent guidelines for cancer care in older adults,” she said, “the NCCN recommends that the oncologist perform a briefer assessment that nevertheless addresses the important domains of older patient resilience: sensory acuity, physical abilities, nutrition, urinary continence, mental status, activities of daily living, home environment, and social support.”

It is often the patient’s responses to these simple assessments that determine whether Dr. Holmes is consulted. Even a single question can clearly indicate the likely presence of some comorbid conditions and geriatric syndromes. “It can be difficult to get a meaningful answer from a general question, but if there’s any red flag, the patient can be screened further or referred to a geriatrician,” she said.

Dr. Holmes may be called in when an oncologist has concerns about an older patient’s ability to undergo treatment. If the need is indicated, she can carry the assessment further, probing for the severity and underlying cause of conditions revealed by the initial assessment. She looks at both physical and mental status: “All older cancer patients should be screened for cognitive deficits because of the potential effect of chemotherapy on cognition. I use simple tests to measure their physical functions: the ‘sit-to-stand’ test, grip strength, and gait speed. Gait speed is a terrific test because it reveals several different functions at once: cardiac and respiratory fitness, muscle strength, joint mobility, fall risk, and balance. You can capture all sorts of qualitative data just by watching someone walk.” She also assesses the drugs and supplements the patient is taking, looking for side effects and interactions that might impair performance.

Dr. Holmes is sometimes consulted to offer an opinion on whether a patient should undergo standard therapy or an alternative. The NCCN recommends that oncologists approach these clinical decisions in terms of life expectancy. Dr. Holmes said this approach means considering a patient’s likelihood of dying from the cancer in his or her remaining lifetime (i.e., how long this person would live if he or she did not have the cancer) and whether the cancer is likely to degrade the patient’s quality of life.

Assessing the individual

Preliminary data from the stem cell transplant trial suggest that the more rigorous comprehensive geriatric assessment is not much better than the traditional performance scales alone at predicting which patients will develop posttransplant geriatric syndromes. Dr. Holmes believes this is partly because oncologists already understand, and incorporate into their pretreatment assessment, the effects of comorbid conditions and physical abilities on a patient’s response to treatment.

Dr. Holmes said, “In patients undergoing allogeneic transplant, a very aggressive therapy, the characteristics of the cancer itself and the events of the peri-transplant period—infections, graft-versus-host disease, number of hospitalizations, and complications and the medications needed to treat them—seem to be more meaningful than any baseline characteristics in predicting geriatric syndromes.”

While it is still not clear whether a comprehensive geriatric assessment should be incorporated into all older cancer patients’ pretreatment evaluations, the role of oncologic geriatricians continues to expand as physicians seek to balance effective treatments with quality of life for their patients. “Cancer care is not a ‘one size fits all’ matter for older patients any more than it is for younger patients,” Dr. Holmes said. “We need to look at each person and each cancer individually and decide what information is pertinent to the clinical decision-making for that person.”
 
For more information, contact Dr. Holly Holmes at 713-563-4485.

FURTHER READING

Other articles in OncoLog, July 2012 issue:

• Compass: Early-Stage Cervical Cancer
• House Call: Exercise and Cancer Prevention

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