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Assistant Professor of Medicine

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Presentation on theme: "Assistant Professor of Medicine"— Presentation transcript:

1 Assistant Professor of Medicine
Age is Just a Surrogate for Aging: Weaving the Principles of Geriatrics into Oncology Tanya M. Wildes, MD, MSCI Assistant Professor of Medicine April 1, 2017 Department of Medicine Division of Medical Oncology

2 Objectives Discuss the epidemiologic trends and outcome disparities that mandate filling in evidence gaps in the care of older adults with cancer Review the components of geriatric assessment Understand what is known about the utility of geriatric assessment in research and patient care in older adults with  cancer Explore future directions for expanding our knowledge base about cancer in older adults, focusing on current fall-prevention studies.

3 “It seems like old people do worse…” – Steve Devine, circa 2005
N=152 patients with NHL who underwent BEAM/Auto Only mucositis was statistically more common in older patients Age not associated with toxicity, length of stay, readmission or OS (after adjusting for comorbidities) Comorbidities were independently associated with OS …If it’s not just age, what else could it be? Wildes et al BBMT 2008

4 “The bonds that clients have developed with their older pets are especially strong and drive the increasing demand for more proficient and highly compassionate medical treatment of companion animals diagnosed with cancer.” “This book offers more than just a competent clinical approach to the most common tumors in dogs and cats. This book also offers a focus on the special needs of geriatric pets and their owners.” “Amply illustrated with dozens of case studies representative of those regularly encountered in practice, Canine and Feline Geriatric Oncology will provide readers with the tools needed to diagnose and treat aging pets with cancer, and to help clients make the best decisions for themselves and for the animals with whom they share their lives.”

5 Outcome disparities & gaps in knowledge
Poorer overall survival Across disease types1 Is OS always an appropriate endpoint? Reviewer: “This is comedy… of course older people will not live as long…” Other outcomes: relative survival, quality of survival Increased risk of toxicities of therapy2 Undertreatment Outcomes of importance to older adults3 Underenrollment in clinical trials Protocol: Restrictive eligibility criteria4 Provider: concerns about toxicity4 Patient: Treatment at tertiary care center, loss of continuity with primary oncologist5 1DeAngelis Lancet Oncol 2014 4Denson Cancer Control 2014 2Hurria JCO 2011 5Basche JOP 2008 3Fried NEJM 2002

6 Geriatrics 101 Who is geriatric? Comprehensive Geriatric Assessment
Why age ≥65? Retirement age set at 65 in Germany in 1916… Incidence of frailty increases over age 75 Varies by cancer type – factor in cancer biology and common comorbidities Acute leukemia studies consider age >55 or >60 Other studies use age >65, >70, >75 Comprehensive Geriatric Assessment What is frailty?

7 Comprehensive Geriatric Assessment
Function Activities of Daily Living Instrumental Activities of Daily Living Physical function Falls Comorbidities Many tools: CCI, CIRS-G, ACE-27 Medications Polypharmacy Inappropriate medications START/STOPP criteria Psychological status Depression/Anxiety Cognitive impairment Dementia Delirium Incontinence Social support Vision/hearing Goals of Care

8 “Frailty, thy name is…” - Shakespeare
Fried’s phenotypic frailty Slowness (gait speed) Weight loss Low physical activity Weakness (grip strength) Low energy/self-reported exhaustion Nonfrail/Prefrail/Frail Rockwood’s accumulation of deficits Of the things that could possibly be wrong, how many are? Index 0 to 1 Fried J Geron Med Sci 2001 Rockwood J Geron Med Sci 2007

9 The Impact of CGA in General Geriatric Populations
Reduced functional decline Reduced fatigue Better social functioning Better HRQOL Fewer emergency department visits Decreased nursing home admission Reduced mortality in some settings

10 Cancer and Aging Research Group Prospective Study
Designed to develop a model predictive of chemotherapy toxicity in older adults Sociodemographic characteristics Tumor characteristics Treatment characteristics Laboratory values Geriatric assessment parameters Inclusion: Age ≥65, cancer, to start new chemo regimen Models created using total score on geriatric assessments as well as individual items Hurria J Clin Oncol 2011, 2015

11 Cancer and Aging Research Group
500 patients enrolled from 7 institutions Average age 73 (range 65-91) 61% stage IV disease Outcome: 53% had grade III/IV toxicity Hurria J Clin Oncol 2011

12 Risk factor for Grade III-V Toxicity
OR (95% CI) Score Age ≥73 years 1.8 ( ) 2 GI/GU Cancers 2.1 ( ) 3 Standard dose chemotherapy 2.1 ( ) Polychemotherapy 1.7 ( ) Anemia (Male < 11, female <10) 2.3 ( ) Cr Cl <34 ml/min (using Jeliffe equation/IBW) 2.5 ( ) Falls in last 6 months 2.5 ( ) Hearing impairment 1.7 ( ) Limited ability to walk 1 block 1.7 ( ) Requires assistance with medications 1.5 ( ) 1 Decreased social activities 1.4 ( ) Possible score 0-25

13 CRASH Trial Chemotherapy Risk Assessment Scale for High Age Patients
Location: USF/Moffitt and 6 community centers Predictors: Age, sex, BMI, diastolic blood pressure, comorbidity (CIRS-G) CBC, LFTs, CrCl, albumin Self-reported health, ECOG PS, IADLs, GDS, MMS, MNA cancer stage, marrow invasion, prior chemotherapy, tumor response, toxicity of chemo regimen (MAX2) Extermann, Cancer 2012

14 CRASH Trial N=518 evaluable Median age 76 (range 70-92)
54.8% had stage IV cancer Toxicity: 31.8% grade IV hematologic toxicity 56% grade III/IV nonhematologic toxicity Combined: 67.8% Extermann, Cancer 2012

15 CGA in Predicting Early Death
Soubeyran J Clin Oncol 2012

16 How does CGA impact decision-making in older adults with cancer?
Validation of tools ongoing Online calculators available PCORI-funded COACH study - Improving Communication in Older Cancer Patients and their Caregivers (NCT )

17 Cancer Treatment Modifications Based on CGA
Oncologist assessment: Initial treatment plan CGA Oncologist and geriatrician: Final treatment 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

18 How does Geriatric Assessment inform Decision-making in Hematologic Malignancies?
N=157 with hematologic malignancies underwent GA at Innsbruck University Hospital Clinician determined treatment, blinded to GA Categorized as: Standard treatment Attenuated treatment No treatment despite being required No treatment required Hamaker Leuk Lymph 2016

19 Modifying Supportive Care Based on CGA See NCCN OAO-H for full details at nccn.org *credit to Dr. Holly Holmes* Therapeutic class (Examples) Conditions adversely affected Modification Corticosteroids Delirium Diabetes Consider dose and duration Use lowest possible dose Benzodiazepines Falls Cognitive Impairment Avoid for insomnia, agitation, delirium Consider alternatives First-generation antihistamines Urinary retention Use only when convincing benefit exists Don’t use for sleep! Phenothiazine antiemetics (prochlorperazine) Parkinson Disease Avoid

20 Delphi Consensus of Geriatric Oncology Experts
3 rounds of consensus Selecting patients for geriatric 93% consensus using criteria “Age ≥ 75 or younger with age-related issues or concerns” 89% consensus using evidence-based screening tools such as VES-13, impaired objective physical performance, CARG and CRASH tools Mohile et al JNCCN 2015

21 Functional Status Physical Therapy Occupational therapy
Home safety evaluation Refer to social work Evaluate fall risk Exercise Adapted from Mohile et al JNCCN 2015

22 Cognition Involve caregiver Assess/minimize medications
Delirium prevention Refer to social work Assess capacity and ability to consent to treatment Identify health care proxy Cognitive testing/neuropsychology referral Adapted from Mohile et al JNCCN 2015

23 Social Support Refer to social work Transportation assistance
Nursing/home health Caregiver management Home safety evaluation Support groups Refer to psychiatry/psychology Spiritual care Adapted from Mohile et al JNCCN 2015

24 Objective Physical Performance
Physical Therapy Exercise Occupational therapy Home safety evaluation Rehabilitation Nursing/home health Adapted from Mohile et al JNCCN 2015

25 Psychological status: anxiety/depression
Refer to social work Counseling refer to psychiatry/psychology Start medications Support programs Spiritual care Adapted from Mohile et al JNCCN 2015

26 Nutrition Nutrition consult Make specific dietary recommendations
Oral care Supplements Refer to social work Physical/occupational therapy Adapted from Mohile et al JNCCN 2015

27 Medication Management: “Addition by subtraction"
Polypharmacy Beers Criteria for Medications Considered Inappropriate in the Elderly, 2015 update START:Screening Tool to Alert Doctors to the Right Treatment STOPP:Screening Tool of Older Person’s Prescriptions Drug-Drug Interactions Nccn.org – Older Adult Oncology Guidelines 2016 (OAO-C)

28 Fall prevention in older adults with cancer
Older adults with cancer are at greater risk for falls than noncancer controls: 20-50% over 6 months (33% over a year in noncancer population) Falls are preventable How to identify older adults at greater risk?

29 Optimizing fall risk prediction in older adults with cancer
Aim: To establish the optimal strategy of fall-risk assessment to predict falls in older adults receiving cancer therapy. Hypothesis 1: Older adults with cancer have unique risk factors for falls Hypothesis 2: Fall-risk in older adults with cancer is dynamic and ongoing risk assessment is needed Methods: Prospective cohort study (N=200) Eligible patients: Age ≥70, receiving systemic cancer treatment Baseline geriatric assessment Ongoing assessment with clinical visits Monthly falls ascertainment

30 Falls are preventable: Stepping On
Community-based, small group interactive/education sessions Fall Stories PT – strength and balance exercises OT – home and community safety Pharmacist – medication safety 7-week program, with 3 month booster and home visit Aims to improve falls self-efficacy, encourage behavior change and reduce falls Results: In RCT – reduced falls by 31%1 In real-world (State of Wisconsin) – reduced fall injuries (ER visits and hospitalizations) by 9% on population level2 1Clemson JAGS 2004 2Guse Am J Public Health 2015

31 Stepping On: Cancer Edition
Currently ongoing at Wash U Adapting the Stepping On program for older adults with cancer through qualitative feedback from patients and caregivers Eligibility: Age ≥70 Have cancer/receiving systemic therapy Have fallen or are concerned about falling

32 Quick Overview of the Program
Session 1 Introduction, Overview, and Choosing What to Cover Guest expert introduces the balance and strength exercises. Session 2 The Exercises and Moving about Safely Review and practice exercises with guest expert, explore the barriers and benefits of exercise, moving about safely — chairs and steps, learning not to panic after a fall. Discuss signs of nerve damage from chemotherapy that may increase the risk of falls. Session 3 Advancing Exercises and Home Hazards: less emphasis on advancement Review and practice exercises, discuss when and how to upgrade your exercises, identify hazards in and about the home, and problem-solving solutions. Session 4 Vision and Falls, Community Safety, and Footwear Review and practice exercises. Guest experts discuss the influence of vision on risk of falling and talk about strategies to get around the local community and reduce the risk of falling. Learn about the features of a safe shoe and identify clothing hazards. Session 5 Medication Management, Bone Health, and Sleeping Better Identify the importance of Vitamin D and calcium to protect from fall injury. Guest expert talks about medications that increase falls risk. Strategies to sleep better are discussed. Premedications, dehydration. Session 6 Getting Out and About Discuss and give participants the opportunity to see and try hip protectors. Explore different weather conditions that could lead to a fall. Review exercises. With guest expert, practice safe mobility techniques learned during the program in a nearby outdoor location. Session 7 Review and Plan Ahead Review and practice exercises, review personal accomplishments from the past 7 weeks. Reflect on the scope of things learned. Review anything requested. Finish any segment not adequately completed. Time for farewells and closure. Follow-up home visit Support follow-through of preventive strategies and assist with modifications. 3-Month Booster Session: Review achievements and how to keep them going.

33 So far… 1st & 2ndwave complete, 3rd wave started, qualitative data analysis beginning, preliminary program modifications begun. Feedback and observations: The participants have absolutely loved it. Sometimes the caregivers were more frail than the patients. We’re helping the patients meet their goals! “I just want to be able to have 2 beers on my anniversary and not fall”

34 Let’s agree to stop saying “But it’s time-consuming”!
Distinguish brief geriatric assessment from comprehensive geriatric assessment. Feasibility studies show that abbreviated geriatric assessment takes ~20-25 minutes, only ~4-6 minutes of care provider time! How long does it take to arrange a PET scan? How long does it take to order genomic testing? How long does it take to arrange hospitalization for toxicity of chemotherapy?

35 Conclusions Geriatric assessment is feasible in the oncology setting
Geriatric assessment has potential utility in: Predicting early mortality Predicting toxicity of therapy Informing decisions regarding modified treatment Possibly lowering toxicity of therapy Age alone is a surrogate for aging, which is better delineated through geriatric assessment Harriet Thompson, 92 yo Oldest woman to run a full marathon Completed marathon while receiving RT

36 Resources Journal of Geriatric Oncology ASCO Geriatric Oncology
Cancer and Aging Research Group Mycarg.org NCCN Older Adult Oncology Guidelines International Society of Geriatric Oncology (siog.org) Position papers Geriatric Assessment Tools Journal of Geriatric Oncology ASCO Geriatric Oncology

37 Information at: www.mycarg.org/r25
Application at Applications due April 30, 2017

38 Assistant Professor of Medicine
Tanya Wildes MD, MSCI Assistant Professor of Medicine Campus Box 8056 660 South Euclid Ave St. Louis, MO 63110 (314) ©2016


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