Geriatric oncology

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Geriatric oncology

  1. 1. MATURE ADULT HEALTH A Cancer Revolution From weekly tea parties after chemotherapy to more aggressive and tailored treaments, the emerging field of geriatric oncology is changing the way doctors fight cancer in elderly patients. by Christopher Johnston C hemotherapy doesn’t usually offer a patient much to look forward to. But Nancy Hull makes sure to schedule her treatments at the Cleveland Clinic for Wednesday afternoons, so she can partake of the weekly high tea held in the bistro on the first floor of the Taussig Cancer Center. On a recent Wednesday, as a pianist tickled the ivories of the lobby’s grand piano and the scent of apple cinna- mon tea wafted through the bistro, Hull relaxed in the sunlight from the floor-to-ceiling windows along Carn- egie Avenue. “It’s quiet,” sighs Hull, 66, of Cleveland, before pick- ing up her cream puff. “It also provides a nice break from the sterile hospital scene.” Hull enjoys selecting her favorite from the more than 150 fine china cups and saucers kept in two tall cabinets. Donated by Clinic employees, each set displays the name of the giver’s loved one who was a victim of cancer. The Clinic has treated nearly 2,000 cancer patients, their fam- ilies and friends and Clinic staff to tea since February. Most of the 120 tea tipplers on a recent afternoon were elderly. While the event is not on the same scale as the Boston Tea Party, it is symbolic of a gradually un- folding revolution in health care. Cancer patients 65 and older used to be treated the same as anyone else, even though they have a different physiology and different medical demands. But as peo- ple live longer, the medical profession is confronting the fact that Now, the emerging field of geriatric oncology is incorporating it has much more to learn about how to treat elderly cancer pa- elderly special needs into treatment. Geriatric oncologists are also tients. Nearly 60 percent of newly diagnosed malignant tumors conducting more clinical trials on elderly cancer patients, pursu- are found in people age 65 and older, according to the National ing more aggressive and more carefully tailored cancer treatments Cancer Institute, and these older patients account for 70 percent for them, and addressing the barriers that have kept many older of all cancer deaths. cancer patients from getting good care. “There is a growing population who could potentially have can- In July, University Hospitals Case Medical Center opened its cer and may be amenable to treatment,” says Dr. Elizabeth O’Toole, new geriatric oncology clinic in the Ireland Cancer Center. UH director of MetroHealth Medical Center’s division of geriatrics and was one of eight cancer research centers to receive grants from a palliative care. “But we’re not sure how best to treat them, because five-year, $25 million initiative of the National Cancer Institute of the changes that occur in their physiology and psychosocial is- and National Institute of Aging. sues, which make the decision-making process more difficult.” The program helps elderly patients with needs ranging from 104 AUGUST 2 0 0 7 | w w w . c l e v e l a n d m a g a z i n e . c o m
  2. 2. [Mature Adult Health] physical therapy to help with prescrip- pational therapists. Pharmacy services are vene in those problems,” says Dr. Cyn- tion management to psychological and included because many older patients suf- thia Owusu, director of UH’s new geriat- social challenges. Two geriatric oncolo- fer from over-prescribed, under-managed ric oncology center. “In the long term, we gists team up with a social worker and a drug therapies. expect that will translate into fewer recur- nurse practitioner trained in both geriat- “We’ll be able to identify problems that rences of cancer and prolonged survival.” rics and oncology and physical and occu- are peculiar to older patients and inter- Virginia and Leland Sholl, of Pickerington, enjoy tea and goodies after an G eriatric oncologists are also look- ing for ways to aggressively treat cancer patients in their 80s and 90s. appointment at the Taussig Cancer Center, which holds a weekly “high tea.” For many years, doctors advised can- cer patients at that age against the rig- ors of painful and sometimes debili- tating treatments. The doctors figured those patients probably didn’t have much longer to live anyway, so why make them suffer? “Twenty or 30 years ago, people would say, ‘Well, he’s 90. What are you going to do with cancer?’ ” says Dr. Derek Raghavan, director of the Taussig Cancer Center at the Cleveland Clinic and chair of the Clinic’s cancer division. “But now we’re looking at 90-year-olds who quite reason- ably might expect to live to 100.” An 85-year-old woman with a breast cancer lump that hasn’t spread could po- tentially have been written off in the past, Raghavan says. “If you don’t manage it correctly, that breast cancer could spread 106 AUGUST 2 0 0 7 | w w w . c l e v e l a n d m a g a z i n e . c o m photos courtesy of cleveland clinic
  3. 3. [Mature Adult Health] and kill her in two years,” he explains. “If you do manage it correctly, you have the potential for her to be alive 10 to 15 years without recurrence.” To help doctors treat elderly patients, geriatric oncologists are working to en- roll more elderly patients in clinical trials. “People are starting to realize that older pa- tients are different and should be treated differently,” says Owusu. “So, we need to design trials to address that.” Elderly patients are often deemed too frail to handle the side effects of many can- cer drugs, so they’re excluded from intense chemotherapy treatments and clinical trials of new drugs, Owusu says. Only 9 percent of patients in clinical trials completed over the past several years were 65 or older, she says. That means sufficient data doesn’t yet exist for elderly patients, so their physicians must extrapolate from data on younger pa- tients when they decide on chemotherapy or radiation treatments for elderly patients. “When you design clinical trials that way, you cannot conclude that the treat- ments are applicable to all patients,” Owu- su says. “So, we may be giving these elderly patients substandard therapy.” Some on- cologists even conclude that since a clin- ical trial didn’t include any 70-year-old patients, the drug may not be safe for the elderly, she adds. UH’s geriatric oncology clinic currently has three studies under way involving pa- tients age 65 and older. One is a clinical trial for a new biological agent with min- imal side effects for patients with breast cancer. Another study will evaluate the effectiveness and benefits of the geriat- ric oncology program itself, to determine whether its interventions better enable patients to complete their treatments in a cost-effective way with fewer complica- tions than treatments by oncologists only. The Cleveland Clinic is studying che- motherapy treatments, which sometimes suppress elderly immune systems. It’s looking for drugs that are not too toxic for the elderly but still effective. Ragha- van recently managed a multicenter study of single-agent chemotherapy for breast, bladder and colon cancer pa- tients. It incorporated detailed histories of the elderly patients, including their other medical conditions, from depres- sion to dementia, and what kind of so- cial support they have. The study also tested how well they could clear the drug from their blood system. “It is a very important study at a nation- al level,” Raghavan says, “because it will allow us to tailor chemotherapy schedules CLEVELAND | AUGUST 2007 107
  4. 4. [Mature Adult Health] specifically for an older age population.” may well do things that are quite differ- sion and dementia. However, doctors can Over the past five years, research has ent,” Raghavan says. adjust their treatments to take patients’ demonstrated that elderly patients can The studies revealed that while some other conditions into account. tolerate the same treatment regimens ad- elderly patients experience no problems ministered to younger patients, as long as physicians carefully evaluate the patient’s entire physical health, according to the with cancer treatment, others suffer se- verely from the side effects. The stud- ies concluded that patients are less likely D octors are also tackling some of the simplest reasons that the elderly of- ten do not get effective cancer treatment. National Cancer Institute. to tolerate treatments if they suffer from Raghavan identified three in a paper pub- “If their chronological age is not com- other medical conditions typically found lished last year. First, older generations’ mensurate with their physical age — so in the elderly, from heart or lung disease cultural perspective can lead them to view they are a ‘young’ 80-year-old, say — you and diabetes to poor nutrition to depres- cancer as an embarrassment to their fam- ilies, rather than a medical disorder that needs assessment and treatment. “For people who were born around World War II or earlier, the whole thought of having cancer was seen as a socially unaccept- able condition,” Raghavan says. “You just didn’t talk about it.” A second factor is “medical protection- ism,” when doctors are overly protective of elderly patients. Some doctors who are not experts in cancer care for the elderly believe subjecting them to the rigors of chemother- apy, radiation or clinical trials will result in unnecessary suffering or experimentation. Doctors may keep patients from receiving care that will ultimately help them. Raghavan’s third factor was the all- too-typical situation of older people not possessing the resources to access proper medical care. For instance, they may live alone and have no means of transport. D espite recent improved and enlight- ened approaches to cancer care for the elderly in some quarters, Raghavan be- lieves a tremendous effort is still required to educate primary care physicians and oncologists about the geriatric oncology revolution. “The elderly need to be looked at as a multitiered system,” he says. “Just looking at age isn’t the way to go.” Owusu, who joined the first class of ge- riatric oncology fellows at Boston Univer- sity’s medical school in 2002, is focused on developing an abbreviated geriatric assessment that can be administered in the short time most physicians have with their patients during regular office visits. She says she would like to see every oncol- ogist receive training in how to adminis- ter geriatric assessment tools. She is also optimistic that geriatric oncology training programs will continue to emerge at ma- jor medical centers throughout the U.S. to meet the growing need as the baby boom- er generation ages. “We in medicine realized that we had better start planning now and training people to cope with this issue,” Owusu concludes. “Because it’s going to be a huge problem a few years down the road.” n 108 AUGUST 2 0 0 7 | w w w . c l e v e l a n d m a g a z i n e . c o m

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