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Treviso Geriatric Oncology Advanced Course

The management of cancer in the older

person

G.Colloca MD PhD

Università Cattolica del Sacro Cuore Roma

4

Changing Patients, Changing needs

HEALTH PROFESSIONALS NO GERIATRIC

TRAINING

PATIENTS OVER 80: OVER THE PAST 10 YEARS

The management of cancer in the older person

• GERIATRIC ASSESSMENT

The management of cancer in the older person

• GERIATRIC ASSESSMENT

DOES NOT EXIST…..

The management of cancer in the older person

• GERIATRIC ASSESSMENT is:

Methodology

Experience

Management

Involvement

The management of cancer in the older person

• GERIATRIC ASSESSMENT is:

DIFFERENT POINT OF VIEW

Think different

The management of cancer in the older person

• GERIATRIC ASSESSMENT

chronological age vs biological age

The management of cancer in the older person

• GERIATRIC ASSESSMENT

• LIFE EXPECTANCY (LONGEVITY)

All older cancer patients

Community Hospital Long Term Care

Facility Hospice

SCREENING (oncologist or geriatrician)

ONCOLOGIST

Interdisciplinary Team:

Oncologist, Geriatrician, Physical therapist,

Professional Nurse, Psycho-oncologist, Social Worker……….

Modified approach

FRAIL

PRE-FRAIL/FRAIL FIT

Usual Care

GERIATRICIAN (CGA)

Geriatric palliative care

Palliative Oncology

Balducci L, Colloca G et all. Surg Oncol. 2010 Sep;19(3):117-23

FRAILTY….

The management of cancer in the older person

Does it REALLY EXIST?

The management of cancer in the older person

82 yrs Women Ovarian Cancer

VES 13: 2 Fried criteria: >3 FRAIL ADL:4/6 IADL:5/8 SPPB:5/12 GDS: 6/15 MMSE: 28/30

NO FRAIL

Brown M, and coll. J Gerontol A Biol Sci Med Sci 2000;55:M350-

M355[17]

Physical frailty is due to a number of factors, including declines in strength,

loss in range of motion, slowness of movement, paucity of movement, poor

balance, and reduced muscular and cardiovascular endurance.

Carriere I, and coll. J Clin Epidemiol 2005;58:1180-1187[20] Frailty is a physiological precursor of disability. Frail subjects are those

who are at risk of becoming disabled (despite of the apparent good health),

and to whom can be recommended physical training programs designed to

postpone dependence

Chin A Paw MJ, and coll. J Clin Epidemiol 999;52:1015021[21] Frailty is a physical condition representing a large threat to older people’s

functioning and quality of life. It is different from functional dependence and

can be found in non-institutionalized subjects

Fried LP, and coll. J Gerontol. 2001;56A:M146-M156[9] Biological syndrome of decreased reserve and resistance to stressor,

resulting from cumulative declines across multiple physicologic systems,

and causing adverse outcomes. This concept distinguishes frailty from

disability.

Minitski A, and coll. J Am Geriatr Soc 2005;53:2184-2189[14]

Rockwood K, and coll. J Gerontol A Biol Sci Med Sci 2007;62:722

727[15]

Rockwood K, and coll. CMAJ 2005;173:489-495[16]

Frailty is a multifactorial and dynamic process determined by the

accumulation od deficits (symptoms, signs, functional impairments, and

laboratory analyses)

Rockwood K, and coll. CMAJ 2005;173:489-495[16] Frailty is a multidimensional syndrome characterized by loss of reserves

(energy, physical ability, cognition, health) and rising vulnerability

Powell C. J R Soc Med 1997;90:23-26[19] Frailty is identified by decreased reserves in multiple organ systems. It

may be initiated by disease, lack of activity, inadequate nutritional intake,

stress, and/or the physiologic changes of aging. Frailty develops slowly in

a stepwise process, with increments of decline precipitated by acute

events. Frail older persons present “homeostenosis”, a state of decreased

ability in the body physiologic response to maintain homeostasis in times

of acute stress. Frailty is a product of excess demand imposed upon

reduced capacity.

Puts MTE, and coll. J Am Geriatr Soc 2005;53:40-47[18] Frailty in older persons is an unstable condition due to a dynamic reduction

of physiological reserves, physical abilities, comorbidity, and multisystem

decline. It causes an increased risk for adverse outcomes, such as falls,

disability, institutionalization, and death. Frailty can be seen as a position

on a continuum from healthy through very frail.

Cesari M, Colloca G, Pahor M, Sarcopenia and Frailty in older woman.

“Increasingly, geriatricians define frailty as a

biological syndrome of decreased reserve and

resistance to stressors, resulting from

cumulative declines across multiple

physiologic systems, and causing adverse

outcomes. This concept distinguishes frailty

from disability”

Fried LP et al, Cardiovascular Health Study

A syndrome encountered in older persons that has

diverse predisposing, precipitating, enabling and

reinforcing factors. The key feature is a state of

vulnerability to adverse health outcomes. There is a

characteristic clustering of features that can lead to

its recognition. The balance between assets and

deficits will determine the consequences for an

individual. Adaptability, physical environment & social

environment are important determinants of the

impact of frailty.

Canadian Initiative on Frailty and Aging, 2003

The management of cancer in the older person

• GERIATRIC ASSESSMENT

• LIFE EXPECTANCY (LONGEVITY)

• FRAILTY

PHYSICAL

FUNCTIONAL

COGNITIVE

FRAILTY

Multidimensional

Unstable

Heterogeneous

AGING Increased vulnerability to

disease and accidents over time

DISABILITY Functional limitations

resulting from impairments

COMORBIDITY Disease processes

resulting from biology and exposures

Walston J, Ferrucci L,Fried L, J Am Geriatr Soc. 2006 Jun;54(6):991-1001

Molecular and Disease

Oxidative Stress Mitochondrial Deletion Shortened Telomeres DNA Damage Cell Senescence

Gene variation

Inflammatory disease

Inflammation

Neuroendocrine

Dysregulation

Interleukin 6

IGF-1

Dehydroepiandrosterone-

sulfate

Sex steroids

Anorexia

Sarcopenia, osteopenia

•Immune function

•Cognition

•Clotting

•Glucose Metabolism

Impaired Physiological Clinical

Slowness Weakness Weight Loss Low Activity Fatigue

Lang PO, Zekry D Gerontology. 2009;55(5):539-49.

• Frailty is most obvious under “stress”

acute illness

new medications

surgery

pain

change in environment or support

• Surgery and Illness - Frailty Stress Tests

FRAILTY AND STRESS

The management of cancer in the older person

• GERIATRIC ASSESSMENT

• LIFE EXPECTANCY (LONGEVITY)

• FRAILTY

The management of cancer in the older person

• GERIATRIC ASSESSMENT

• LIFE EXPECTANCY (LONGEVITY)

• FRAILTY

• COMORBIDITY/MULTIMORBIDITY

Comorbidity: combination of additional diseases beyond an index disorder.

Multimorbidity:any co-occurrence of two or more chronic or acute diseases and

medical conditions within one person, whether coincidental or not, indicating a

shift of interest from a given index condition to individuals who suffer from

multiple disorders.

Disease based

perspective

Individual based

perspective

A. Marengoni J Am Geriatr Soc 57:225–230, 2009.

Patterns of Chronic Multimorbidity in the Elderly Population

The management of cancer in the older person

• GERIATRIC ASSESSMENT

• LIFE EXPECTANCY (LONGEVITY)

• FRAILTY

• COMORBIDITY/MULTIMORBIDITY

• COMPLIANCE/QUALITY OF LIFE

Quantitative and qualitative model of successful aging

SUCCESSFUL AGING

Optimal overall functioning Well-being

Physical

Functioning

Social

Functioning

Psychocognitive

Functioning

WELL-BEING = SUCCESSFUL AGING

Social Contacts

Physical and Cognitive

Functioning

Adaptation

Margaret Von Faber et al, Arch Internal Med 2001;161:2694-2700

“Health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”

WHO

If you do not ask the right questions, you do not get

the right answers.

A question asked in the right way often points to its

own answer. Asking questions is the A-B-C of

diagnosis. Only the inquiring mind solves problems

Edward Hodnett

The “Modern” Patient

Co/multimorbidity

Multiple drugs

Function deficits Cognitive deficit Physical deficit

Incontinence

Malnutrition Anemia

Osteoporosis

FRA

ILTY

Researchers have largely shied away

from the complexity of multiple chronic

conditions — avoidance that

results in expensive, potentially harmful

care of unclear benefit.

Tinetti M. NEJM 2011

Affective problems Social problems

Falls Sarcopenia

Specific Guidelines

RCTs

Observational Studies

Biological Evidences

Evidence Based Medicine (EBM)

52

A Missed Target

Real World

RCTs Multim

orb

idity

Age

60 85

Guidelines for Older Adults

GU

IDEL

INES

Comorbidity: combination of additional diseases beyond an index disorder.

Multimorbidity:any co-occurrence of two or more chronic or acute diseases and

medical conditions within one person, whether coincidental or not, indicating a

shift of interest from a given index condition to individuals who suffer from

multiple disorders.

Disease based

perspective

Individual based

perspective

A. Marengoni J Am Geriatr Soc 57:225–230, 2009.

Patterns of Chronic Multimorbidity in the Elderly Population

COMPREHENSIVE GERIATRIC ASSESSMENT

DEFINITION

The CGA is “a multidisciplinary evaluation in which

the multiple problems of older persons are

uncovered, described, and explained, if possible, and

in which the resources and strengths of the person

are catalogued, need for services assessed, and a

coordinated care plan developed to focus

interventions on the person's problems”

Solomon D. J Am Geriatr Soc, 36 (1988), pp. 342–347

Second and third generation assessment instruments: the birth of standardization in geriatric care

The systematic adoption of "second-generation" comprehensive

geriatric assessment instruments, initiated with the Minimum Data Set

(MDS) implementation in U.S. nursing homes, and continued with the

uptake of related MDS instruments internationally, has contributed to

the creation of large patient-level data sets.

We argue that the harmonization by InterRAI of the MDS forms for

different health settings, referred to as "the third generation of

assessment," has produced the first scientific, standardized

methodology in the approach to effective geriatric care

Bernabei et al. J Gerontol A Biol Sci Med Sci 2008

Short Physical Performance Battery

• Delirium

• Falls & Immobility

• Acute Urinary Incontinence

• Dehydration or Acute Nutritional Crisis

• Functional Decompensation

Why might each frail older adult manifest the

same stressor with a unique disease presentation?

ATYPICAL DISEASE PRESENTATIONS

59 Follow up yrs

Pro

bab

ility

of

surv

ival

GAIT SPEED AS VITAL SIGN IN OLD AGE Arch Int Med 2012; 172: 1162-68

60

Short Physical Performance Battery (SPPB)

Guralnik JM J Gerontol. 1994

Is this patient going to die of cancer or with cancer ?

Is this patient going to live long enough to suffer the consequences

of cancer ?

Is my patient able to tolerate the treatment ?

Are some complications of cancer treatment more common in

older individuals?

Is the social network of my patient adequate to support him or her

during the treatment ?

THE GERIATRIC EVALUATION OF ELDERLY PATIENTS

WITH CANCER

Comorbidity Charlson comorbidity index

CIRS CIRS-G

NYHA

No. of comorbid conditions

Simplified comorbidity score

Summary of comorbidities

Hematopoietic cell transplantation comorbidity index

Functional

status ADLs (Katz index)

IADLs (Lawton scale)

PS index

Barthel index (any version)

Visual and/or hearing impairment, regardless of use of glasses or

hearing aids

MOS Physical Health

Mobility problem (requiring help or use of walking aid)

Timed Get Up and Go

Hand grip strength

Short Physical Performance Battery

One-leg standing balance test

ECOG PS

Karnofsky self-reported performance rating scale

Comorbidity: Charlson comorbidity index CIRS CIRS-G NYHA Simplified comorbidity score Hematopoietic cell transplantation comorbidity index Functional status: ADLs (Katz index) IADLs (Lawton scale) PS index Barthel index MOS Physical Health Mobility problem Timed Get Up and Go Hand grip strength Short Physical Performance Battery One-leg standing balance test Walking problems, gait assessment, and gait speed ECOG PS23,25,26 Karnofsky self-reported performance rating scale19–21

Cognition Mini Mental State Examination (any version)

Informant Questionnaire on Cognitive Decline in the

Elderly (any version)

Modified Mini Mental State Examination

Clock-drawing test

Blessed Orientation-Memory-Concentration Test

Depression Geriatric Depression Scale

Center for Epidemiologic Studies Depression Scale

Hospital Anxiety and Depression Scale

Mental health index

Presence of depression (as geriatric syndrome)

Distress thermometer

Nutrition Body-mass index (weight and height)

Weight loss (unintentional loss in 3 or 6 months)

Mini Nutritional Assessment (any version)

Short Nutritional Assessment Questionnaire

Polypharmacy Beers criteria

STOPP and START criteria

Geriatric syndromes Dementia

Delirium

Incontinence (fecal and/or urinary)

Osteoporosis or spontaneous fractures

Neglect or abuse

Failure to thrive

Self-reported No. of falls (within different time frames)

Constipation

Polypharmacy

Pressure ulcers

Sarcopenia

If you do not ask the right questions, you do not get

the right answers. A question asked in the right way

often points to its own answer. Asking questions is the

A-B-C of diagnosis. Only the inquiring mind solves

problems

Edward Hodnett

• Weight loss

• Slow walking speed

• Low levels of physical activity

• Subjective exhaustion

• Weakness (Low grip strength)

• 3-5 is “frail”

• 1-2 is “intermediate”

• 0 is “not frail”

“Frailty Phenotype”

Fried LP, Tangen, Walston et al. J Ger Med Sci 2001