The Role that Geriatricians Can Playin the Care of Older Patients withCancer Across the Care Continuum
Holly M. Holmes, MD, MS
Associate Professor and Division Director
Geriatric and Palliative Medicine

Disclosures: Holly M. Holmes, MD
No relevant financial relationship withcommercial interests
Will not reference unlabeled/unapproved usesof drugs or products in their presentation.
Acknowledgement for use of slides: Tanya Wildes, MD, MSCI,
Washington University School of Medicine

Objectives
1. Understand the potential role of primaryand consultative geriatrics relating to thecontinuum of care of an older adult who
has received a cancer diagnosis.
2. Understand and use geriatric medicine
centered principles and cancer focusedgeriatric assessment to enhance thedelivery of comprehensive supportive
cancer care for older adults.

Aging of the global population

From Health in 2015: from MDGs to SDGs. World Health Organization

New cancers
are increasing,because the numbersof older people areincreasing.

Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. J Clin Oncol 27:2758-2765.

Common themes across oncology,
supportive care, and geriatric medicine• Workforce shortages• Specialty identity• Shifting to a chronic disease model• Need to integrate care earlier• Multidisciplinary focus

There are 3.6 geriatricians
for every 10,000 people>75 years in the US.

Source: He, Wan, et al. U.S. Census Bureau,Current Population Reports, P23-209,65+ in the United States: 2005,U.S. Government Printing
Office,Washington, DC,2005.

Significant heterogeneity in survival

Upper, Middle, and Lower
Quartiles of Life Expectancy
for Women and Men at
Selected Ages from the2008 Life Tables of theUnited States

Walter LC and Schonberg MA. JAMA.
2014;311(13):1336-1347.

Treating Older Adults with Cancer• Estimating Prognosis (with and withoutcancer)• “Staging the Aging” (along with the cancer)• Shared Decision Making and Communication

Models of shared cancer care

Cohen HJ. J Am Geriatr Soc 57:S300–S302, 2009.

Chemotherapy in older adults:
Undertreatment or tailored treatment?
• Breast cancer1-4• Ovarian cancer4,5• Colorectal cancer6-8• Prostate cancer9,10• Sarcoma11
1Weiss Ann Surg Oncol 2013

16Hamlin Oncologist 2014

2Malik J Cancer Epidemiol 201317Balch Ann Surg Oncol 2015

3van de Water Br J Surg 2012

18Monroe Ann Surg Oncol 2013

4Bouchardy JCO 2007

19Hardy Cancer 2009

5Fourcadier BMC Cancer 2015

20Ramsey JCO 2004

6Ko Clin Colorectal Cancer 2015

21Enewold J Gastrointest Cancer 2015

• Acute myeloid leukemia12-14• Diffuse large B-cell
lymphoma15,16• Melanoma17,18• Nonsmall cell lung cancer19,20• Pancreatic cancer21

7Quipourt JAGS 2011
8Wildes J Geriatr Oncol 2010
9Bratt Eur Urol 201510Chen Int J Radia Oncol Biol Phys 201411Al-Refaie Ann Surg Oncol 2010
12Finn Curr Opin Hematol 2016
13Master Anticancer Res 201614Medeiros

Ann Hematol 201515Ha Cancer Res Treat 2016

Slide courtesy of Tanya Wildes

Chemotherapy in the noncurative
setting: Overtreatment• Aggressive care in the end-of-life is common– 4.5% of Medicare beneficiaries receive chemotherapy within
14 days of death1– Chemotherapy use in last 30 days similar across age
spectrum2• Chemotherapy use in the end-of-life:– No difference in survival3– Quality of death poorer3– Less likely to die in their preferred place4
1Wang J Geriatr Oncol 2016
2Mack Cancer 2015
3Prigerson JAMA Oncol 20154Wright JAMA 2016

Slide courtesy of Tanya Wildes

Older people are at greater risk oftoxicities• Decline in renal function with age• Similar benefits from adjuvant chemotherapy
for breast cancer, but higher side effects andTRM with age.
• Similar benefit in DFS or OS with 5-FU basedtx but greater risk of heme toxicities.
• Greater risk of death with induction therapy
and SCT for leukemias.
NCCN Guidelines Senior Adult Oncology 2014.

The Oncologist’s Focus

Hanahan and Weinberg. Cell 2011.

The Gerontologist’s Focus

Lopez-Otin C,The Hallmarksof Aging. Cell2013.

My bias: the Geriatrician’s Focus
SocialResources

Functional
StatusMedicalConditions

Patient
Physical
Function

Medications

Nutritional
StatusPsychologicalReserveCases: With and Without Geriatric
Assessment (GA)
Case 1• 78 year old woman withbreast cancer
recurrence• Referred to Geriatrics
because she thinks
she’s “too old fortreatment”• Had left breast cancer
in 1998• Now presents with rightbreast cancer

Case 2• 73 year old man
diagnosed withpancreatic cancer• Seems “older than hisage” and his surgeon isconcerned about his
likelihood of recoveringfrom surgery• His daughter moved inwith him after his wife
died one year ago

Cases: without GA
Case 1• Patient refuses
treatment and is lost tofollow up (?)
Or• Patient completespartial treatment andstops AI after 8 months

Case 2• Receives FOLFIRINOX
and is admitted to theICU; dies of sepsis (?)

Cases: with GA
Case 1• GA: FIT, no issues
except tremor andspinal stenosis• Encourage to pursue“the same therapy a 50year old woman in yoursituation would receive”• Completes standardtherapy but unable tocomplete AI

Case 2• GA: FRAIL, due tomoderate dementia andsevere comorbidity >>safe home carearranged• Hospitalized fordehydration after 1st
dose gemcitabine• Enrolls in hospice andlives 11 months

NCCN Senior Adult Oncology Guidelines
Is the patient at moderate or high risk of dying or
suffering from cancer given his/her overall life
expectancy?
Does the patient have decision-making capacity?
Are goals and values consistent with treating
cancer?
Are there risk factors for adverse outcomes fromcancer treatment?
NCCN Guidelines Senior Adult Oncology 2016.

Geriatric Assessment (GA)• Test multiple domains that are associated with badoutcomes.
• Use of validated tools to measure common geriatricproblems.
• Ability to diagnose
and intervene totreat reversible
problems.

Recommendations for Geriatric Assessment
Adults 75+:
GeriatricAssessment

Adults 65+ who failscreening

NormalAbnormal

Treat based on organfunction

Focus on treatableconditions

Dose
escalation
SIOG.org

Modifysupportive plan

Dosereduction

Primarily
palliative careIncorporating GA into cancer care•
•••
••••

Comorbid conditions: number andseverity
Medications: drug interactions,inappropriate meds
Cognitive: screening tools for cognitionand executive function
Affective: screening for depression andanxiety
Nutritional: weight loss, nutrition riskSocial: living situation, support at home,ability to get meds
Functional: activities/instrumental
activities of daily living
Physical: gait speed, timed-up-and-go,
short physical performance battery

Mohile and Rodin. JCO 2007;25:1936–1944.
Wildiers et al. JCO 2014.

Utility of Comprehensive Geriatric Assessment in Older
Adults with Cancer
RiskPrediction

Chemotherapy
Toxicity

Survival

Cancertreatment
modification

Modification oftreatment/
chemotherapy

Modification of
supportive careIntervention

GeneralGeriatrics vs.
Cancer-focused

Goals

Slide courtesy of Tanya Wildes

CRASH Score to Predict Toxicity
Predictors
0Points
12

Hematologic score
Diastolic BP
IADL
LDH

≤7226-29
0-459

>72
10-25

Chemotox

0-0.440.45-0.57>0.57

ECOG PS
Cognition
Nutrition
Chemotox

0MMSE 30
MNA 28-30
0-0.44

1-2

3-4
<30
MNA<28>0.57>459

Nonhematologicscore

Extermann, et al. Cancer 2012;118:3377-86.

0.45-0.57CRASH Score to Predict Toxicity

Extermann, et al. Cancer 2012;118:3377-86.

The CARG Score

Hurria, et al. JCO 2011;29:3457-3465

CARG Score Validation
A Development
andB Validation
cohorts

Hurria A et al. JCO 2016.

GA in Surgical Oncology
CATEGORIZATION BASED ON CGA DOMAINSFITFRAIL

All of:Any of:Function

ADL >18 and
IADL>43

ADL <19

Comorbidity

None >grade 2 OR Any grade 4<3 grade 2>2 grade 3

Polypharmacy<5 daily meds

> 7 daily meds

Nutrition

MNA ≥24

MNA <17Cognition

MMSE >26

MMSE <24Depression

GDS >13

Kristjansson SR, et al. Crit Rev Oncol Hematol. 2010;76:208-17.

Prediction of toxicity:
3.13 (1.65–5.92) times theodds of severe toxicity forfrail vs. nonfrail based on
CGA in 178 patients 70+
years with colorectal
cancerIADLs associated withperioperativecomplications

GA: Predicting toxicity in myeloma
Non-hematologic Adverse Events

Discontinuation of Therapy

Palumbo Blood 2015
Slide courtesy of Tanya Wildes

CGA: Predicting Early Mortality

Soubeyran J Clin Oncol 2012
Slide courtesy of Tanya Wildes

Utility of Comprehensive Geriatric Assessment in Older
Adults with Cancer
Risk
Prediction

Chemotherapy
Toxicity

Survival

Cancertreatment
modification

Modification oftreatment/
chemotherapy

Modification ofsupportive careIntervention

GeneralGeriatrics vs.
Cancer-focusedGoals

Slide courtesy of Tanya Wildes

A conceptual model of decision-making
Tumor Biology/
Treatment
Effectiveness

Personalized
Decisionmaking
PatientPreferences

Toxicity

Slide courtesy of Tanya Wildes

Patient Preferences

Fried T. N Engl J Med. 2002;346:1061-6.

CGA to Guide Treatment Planning• 161 patients age 73-97• Colorectal & GI > Breast > Lung > Other• CGA: severe comorbidity in 75, ADL
impaired in 52, decreased cognition in 42,malnutrition in 104, depression in 39 people• Results:– Same dose – 82 (53 required geriatric intervention)– Lower dose – 34
– Higher dose – 45
Chaibi P et al. Crit Rev Oncol/Hem 2011;79: 302–307

Treatment Modifications Based on CGA
Oncologist
assessment:
Initial treatment
plan•
•
•
•

CGA

Oncologist andgeriatrician: Finaltreatment plan

French ASRO study
N=217, mean age 83 years
40% treatment recommendation modifications
On multivariate analysis: ADL dependence and Fried’s frailty
markers associated with treatment modifications

Farcet PLOS One 2016

Slide courtesy of Tanya Wildes

CGA for treatment allocation

Corre JCO 2016

OutcomeComparisonTFFS

No different

Toxicity

11.8% vs 4.8%PFS

No different

OSNo different

Slide courtesy of Tanya Wildes

Utility of Comprehensive Geriatric Assessment in Older
Adults with Cancer
Risk
Prediction

Chemotherapy
Toxicity

Survival

Cancertreatment
modification

Modification oftreatment/
chemotherapy

Modification ofsupportive careIntervention

GeneralGeriatrics vs.
Cancer-focusedGoals

Slide courtesy of Tanya Wildes

CGA intervention associated with improved
chemotherapy tolerance••••

Pre-post study design
N=135, age 70+ undergoing chemotherapy
Participants completed self-report CGA
In intervention arm, high-risk patients referred togeriatrician• Outcomes:– Intervention group were more likely to complete treatment asplanned (33.8% vs 11.4%, p=0.006) and required fewer treatment
modifications (43.1 vs 68.8%, p=0.006)– Rate of grade 3+ toxicity similar (43.8% vs 52.9%, p=0.29)
Kalsi Br J Cancer 2015
Slide courtesy of Tanya WildesGap 70+ Study

ASCO Annual Meeting 2016, Abstract #10055.

Slide courtesy of PI Supriya MohileGA-driven recommendations
How can GA drive
non-oncologic
intervention andcancer treatment
decision making?
• Panel of 30 experts• 3 rounds of survey• 67% agreement =consensus
Mohile. JNCCN 2015;13:1120-30.

Mohile. JNCCN 2015;13:1120-30.

Models of shared cancer care

Cohen HJ. J Am Geriatr Soc 57:S300–S302, 2009.

Care of older survivors• Adverse event management• Short- and long-term toxicity assessment• Ongoing surveillance and screening• End of life careCancer Increases the Odds of Frailty
and Vulnerability in Older Persons
Vulnerability
ADL Limitations
IADL Limitations
Geriatric Syndromes
Frailty
Fair/Poor Health Status

0.8

1.0

1.2

1.4

Mohile S, et al. J Natl Cancer Inst 2009;101:1206–1215

1.6

1.8

Increased Prevalence of GeriatricSyndromes in Cancer Survivors• Vision loss
• Hearing loss
• Eating
problems• Memory
loss/dementia• Incontinence• Osteoporosis• Depression• Falls

Mohile S, et al. J Clin Oncol 29:1458-1464.

The importance of shared care atthe end of life
• Older people less likely to receive high quality
palliative care: less informed, not assessed,
undertreated• Older patients more likely to value quality oflife and function• Oncologists and older patients want primarycare involved
Lindskog et al Eur J Cancer 2015
Owusu, J Amer Geriatr Soc 2009.

Competing goals in older patientswith cancer?

CancerCare
PatientCentered
Care
Geriatrics
Care

Palliative
Care
Slide courtesy of Tanya Wildes

Summary• Incorporating geriatricians or geriatrics careprinciples into cancer care can provide value
information on prognostication andmodification to treatment plans with a goal
toward more patient-centered care.
• Shared care models between oncology,
palliative care, and geriatrics may represent
best supportive care.

Thank you
Holly.M.Holmes@uth.tmc.edu@DrHollyHolmes