Cancer in the Older Person:What is Different?

Arti Hurria, MD

Director, Cancer and Aging Research Program

City of Hope

Duarte, CA, USA

Disclosures

Company Role

Celgene PI

Novartis PI

GTx, Inc. Consultant

Boehringer Ingelheim

Pharmaceuticals

Consultant

Carevive (formerly On Q Health) Consultant

Sanofi Consultant

�Demographics of cancer and aging

�Aging and implications for cancer treatment

- What is different?

�Leveraging technology to meld geriatrics &

oncology

�Workforce and educational needs

Outline

The World-Wide Population is Aging2002

United Nations. Population Division. Department of Economic and Social Affairs. Population Ageing 2002

0–9

10–19

20–24

No data

>20% age 65+

0–9

10–19

20–24

No data

Vast Majority of Countries Age 65+

United Nations. Population Division. Department of Economic and Social Affairs. Population Ageing 2002

0–9

10–19

20–24

No data

Vast majority of countries:

>20% age 65+

The World-Wide Population is Aging2050

Projected Rise in Cancer Incidence from 2012 to 2035

0

2

4

6

8

10

12

14

16

2012 2035

Cancer

Incidence

(millions)

108% in patients ≥ 65

41% in patients <65

Globocan 2012 (IARC)

Take-Home Message #1: Cancer is a Disease of Aging

What is Different about Older adults?

� The world-wide population is aging

� Majority of cancer diagnosis and death occur

in older adults

� The number of older adults with cancer is

on the rise

The Aging Spectrum

Pediatrics Geriatrics

Population Requires Unique Skill Set:

� Age-related change in physiology

� Vulnerable to toxicity

� Dependent in daily activities

� Concern regarding long-term effects of therapy

Pediatrics: Chronological Age = Functional Age

www.cdc.gov/ActEarly

Chronological Age 80

Geriatrics: Chronological Age ≠ Functional Age

Linear Decline Of Organ Reserve With Increasing Age

Shock, The Biology of Aging: A Symposium 1960

AgeCreatinine

(mg/dL)

CrCl*

(ml/min)

40 1.4

50 1.4

60 1.4

70 1.4

80 1.4

90 1.4

100 1.4

AgeCreatinine

(mg/dL)

CrCl*

(ml/min)

40 1.4 79

50 1.4 71

60 1.4 63

70 1.4 55

80 1.4 47

90 1.4 39

100 1.4 32

Decline in Organ Function Not Obvious

Creatinine: Not an adequate measure of renal function

Renal Function Decreases with Aging

Decline in Organ Function Becomes Apparent with a Stressor

Maximum

HR

Age

Maximum HR = 208 – (0.7 x age)Tanaka, JACC 2001

Older Heart: Poorer Response to Stress Decreased Maximum Heart Rate with Aging

Hallmark of Aging:Decreased Physiologic Reserve

Physiologic Reserve = Fuel Available

Age

30

5065

80

100

Building Reserve Can Occur at Any Age

“Banana George” Blair

Barefoot Water Skier

Age 92

Fauja Singh

Marathon Runner

Age 100Age 86

Johanna Quaas

Top Senior Gymnast

Take-Home Message #2: Chronological Age ≠ Functional Age

Understanding Physiologic Reserve

� Aging is heterogenous

� The aging trajectory is modifiable

� A hallmark of aging: decline in organ reserve

� May not be obvious at rest

� Becomes apparent with a stressor

Understanding Physiologic Reserve:Integrating Geriatrics into Oncology

� Functional status

� Comorbid medical conditions

� Nutritional status

� Cognition

� Psychological state

� Social support

� Medications (polypharmacy)

Factors other than chronological age that predict

morbidity & mortality in older adults

Geriatric

Assessment

Using Geriatric Assessment in Oncology Practice

to Guide Practical Interventions

Functional Status

Key Questions

� Does my patient need

assistance with daily

activities?

� If my patient gets sick:

� how would they get to the

hospital?

� who will help care for

them at home?

Visiting nurse

Home health aide

Family support

Social work

Family support

Geriatric Assessment: Functional Status

Instrumental Activities of Daily Living

Required to maintain independence in the

community

Shopping

Housekeeping

Transportation

Laundry

Telephone

Finances

Medications

Preservation of functional status is key

Loss of Physical Function Predicts Distress in Older Adults with Cancer

� 250 older adults with cancer completed a geriatric assessment

Hurria et al, JCO 2009

Greatest predictor of distress is impaired physical function

P value = 0.015

Assistance Needed

Assistance with IADLs ���� Worse Survival in Patients with Lung Cancer

Maione et al, J Clin Oncol 2005

Categories of IADLs:

� Better:

Score of 100%

� Intermediate:

Score of 51-99%

� Worse:

Score of 0-50%

Better

Intermediate

Worse

ComorbidityKey Questions

� Will other medical problems impact the ability to

tolerate cancer treatments?

� Can these conditions be optimized prior to

treatment?

� How do these other medical conditions impact life

expectancy?

0

5

10

15

20

25

70 75 80 85 90 95

Assessing Life Expectancy

Walter et al, JAMA 2001

Age

Yea

rs

WomenTop 25th Percentile

50th Percentile

Lowest 25th Percentile

13

8.6

4.6

www.eprognosis.org

Nutritional StatusKey Questions

� Does my patient have:

� BMI < 22kg/m2

� unintentional weight loss > 5%

� If my patient gets sick,

� do they have access to food?

Nutritional

consultation

Social work

Family support

Meal on

Wheels

� Can my patient:

� Follow complex directions

� Take medications on schedule

� Recognize toxicity and seek help

Cognitive FunctionKey Questions

Visiting nurse

Family/

Caregiver

Worldwide Statistics: Cases of Dementia

Mill

ion

s

World Alzheimer Report 2010

Dementia in Older Adults

Four Components to Assessing Capacity

1. Understands the relevant information

2. Appreciate their situation

3. Uses reason to make a decision

4. Communicates their choice

Does the Patient Have Decision Making Capacity?

Sessums et al. JAMA 2011

Psychological Status & Social SupportKey Questions

� Is my patient depressed, anxious,

or distressed?

� Does my patient have a caregiver?

� Is my patient the caregiver for

someone else?

Psychiatry

Social work

Social work

Family

Correlation Between

Social Support & Psychological State

Kornblith et al, Cancer 2001

Who Provides Care for Older Adults with Cancer?

Informal Caregivers(family and friends)

Formal Caregivers(paid)

Family Caregiving Alliance, 2008

80%20%

Who Are the Informal Caregivers?

Spouse

Adult Children

� 80% family caregivers ≥ age 50

� Average age 75

National Alliance for Caregiving, 2008

20%80%

� Does my patient take medications

that:

� will interact with the cancer-

directed therapy?

� duplicative or not needed?

� potentially “inappropriate”:

risk of side effects

PolypharmacyKey Questions

Medication

reconciliation

Pharmacist

review

Take-Home Message #3: A Geriatric Assessment Can Identify

Older Adults At Risk

Is it feasible to incorporate these tools into

oncology practice?

� Uncover problems not detected by routine H&P

� Leads to practical interventions

� Predict risk of chemotherapy toxicity

(to be discussed on July 2nd in the Supportive Care session)

� Predict survival of older patients with cancer

Too little time…Too much to do

Development of a Short Geriatric

Assessment Tool for Oncologists

World-Wide Workforce Shortage

� There is a shortage of 7.2 million health-care workers world-

wide today

� In 2035, there will be a shortage of 12.9 million health-care

workers

� Shortages of 2 million across all EU countries by 2020

� <80% healthcare coverage for the population: 57 countries

� Compounding the problem: The health workforce is aging

“A Universal Truth: No Health Without a Workforce”, Global Health Workforce Alliance ReportWorld Health Organization

Erikson et al, Journal of Oncology Practice 2007

Now 2020

ASCO Workforce Study:Future Supply and Demand for Oncologists

Year

Anticipated Decline in Geriatricians

American Geriatrics Society:

Geriatrics Workforce Policy Studies Center

2030 Projection:1 Geriatrician : 3,798 Patients

http://www.siog.org/content/comprehensive-geriatric-assessment-cga-older-patient-cancer

Developing a Geriatric Assessment for Oncologists

• Functional Status:Activities of Daily Living (subscale of MOS Physical Health)

Instrumental Activities of Daily Living (subscale of the OARS)

Karnofsky Performance Rating Scale

Timed Up & Go

Number of Falls in Last 6 Months

• Comorbidity: Physical Health Section (subscale of the OARS)

• Cognition: Blessed Orientation-Memory-Concentration Test

• Psychological: Hospital Anxiety and Depression Scale

• Social Functioning: MOS Social Activity Limitations Measure

• Social Support:MOS Social Support Survey: Emotional and Tangible Subscales

Seeman and Berkman Social Ties

• Nutrition:Body Mass Index

% Unintentional Weight Loss in the Last 6 Months

- Validity

- Reliability

- Length

- Time to complete

- Ability to self-

administer

- Multidisciplinary

input

- Alliance Cancer in

Elderly Committee

Geriatric Assessment is Feasible CALGB 360401 (PI: Hurria)

Pre-chemo

Geriatric

assessment

Feasibility

data

Eligibility Criteria

- Age 65 or older

- Diagnosis of cancer

- To start treatment

on a cooperative

group clinical trial

Treatment and

follow-up per

protocol

Geriatric Assessment is Feasible in Oncology Trials

(Time to Complete: Median 22 min.)

Hurria et al, JCO 2011

Primarily self-administered (Paper/Pencil)

Geriatric Assessment Questions are Acceptable to Patients

87% Completed patientquestionnaire w/o assistance

95% Easy to comprehend96% Not upsetting

92% Length is ““““Just Right””””

94% Completed healthcare provider portion

Hurria et al, JCO 2011

94%

Utilizing Technology to Capture Geriatric Assessment

Where to get a CGA?

Geriatric Assessment Tool available in English, Spanish, & Mandarin

• Geriatric Assessment (Patient)

• Geriatric Assessment(Healthcare Team )

Cancer and Aging Research Group

www.MyCARG.org

Take-Home Message #4: Technology can be Utilized to

Integrate Geriatrics & Oncology Care

� Geriatric assessment is feasible in oncology

� Utilize technology to:

� Capture the geriatric assessment

� Pinpoint areas of vulnerability and intervene

“…to meet the healthcare needs of thenext generation of older adults,

the geriatric competence of the entire workforce needs to be enhanced…

innovative models need to be developed and implemented…”

Retooling for an Aging America:Institute of Medicine Report

Workforce Shortage:

Evolving Models of Care

Patient

Physician

Pharmacist

Home Care

Aides

Social Work

Principles of Geriatrics: Multidisciplinary Care

Physician

Assistants

Rehab

Family/

Caregivers

Nurses

Institute of Medicine Workforce Report:“The healthcare workforce receives very little geriatric training

and is not prepared to deliver the best possible care

to older patients.”

Need for Education and Training

Healthcare ProfessionalsGeriatric Specialization

or Certification

Physicians 1% - 2%

Nurses < 1%

Physician’s Assistant < 1%

Pharmacists < 1%

Social Workers ~4%

IOM Report, Retooling for an Aging America: Building the Health Care Workforce 2008

The IOM report calls for a

“substantial focus” in our

healthcare infrastructure to provide

skilled care to this vulnerable population

Who sets the bar for

education and training?

Geriatric Training for Direct-Care Workers

Need to Change the Bar

Educating Nurses in Geriatric Oncology to Improve Quality Care

� Educate 400 nurses from across the nation in caring for

older adults with cancer

� “Train the trainer”

� Geriatric oncology initiatives at their own institution

� Follow-up with participants 6, 12, and 18 months post-

course

� Monthly conference calls

Delivering High-Quality Cancer Care:Institute of Medicine Report

“A system that provides competent, trusted,

interprofessional cancer care teams that are

aligned with patients’ needs, values, and

preferences, as well as coordinated with the

patients’ noncancer care teams and their

caregivers”

Functional Status

Comorbidities

Key Factors Contributing to

Decision Making

Finances

Age

Individual’s Treatment

Decision

Cancer Stage

Psychological Status

Cancer Therapeutics

Organ Function

Cognition

Spirituality

Polypharmacy

Social Support

Culture Literacy

Take-Home Messages

� Cancer is a disease of aging

� The number of older adults with cancer is on the rise

� Several unique considerations in caring for older adults

� Decline in organ function

� Chronological age ≠ Functional age

� A geriatric assessment can identify older adults at risk

� Treatment must be individualized

� There is a workforce shortage

� Evolving models of care

� Education in geriatrics is needed

� Utilize technology to integrate geriatrics & oncology

Aging begins from the minute we are born.

Geriatrics

Oncology

Geriatric Oncology

Thank you!