Transcription:
Providing Effective Cancer Care for Geriatric Patients

Melanie Cole (Host):  With the population increasingly aging, the worldwide cancer burden is growing rapidly. Recognizing the urgent need for more and stronger research on the diagnosis and treatment of geriatric cancer and survivorship care for older adults. Joining me today Dr. June McKoy. She’s an Associate Professor of Medicine in the Division of Internal Medicine and Geriatrics and a member of the Robert H. Lurie Comprehensive Cancer Center. Her research and clinical work focuses on cancer treatment and survivorship in older adults. She’s joining me today to share her insights. Dr. McKoy, I’m so glad to have you join us today. Thank you so much. Can you start off by telling us a little bit about yourself and your role in the Division of Geriatrics?

June McKoy, MD, MPH, JD, MBA (Guest):  So, I am also in addition to providing clinical care, the primary educator of all trainees who rotate through the Division of General Internal Medicine and Geriatrics but particularly in the section of geriatrics. So, I serve as the program director for the fellowship program. In addition to those roles, I also serve as the Director of Geriatric Oncology for the cancer center. In my role as a cancer and aging researcher, I serve on the older adult oncology panel for the National Comprehensive Cancer Network or the NCCN. And interestingly enough, in that role, I’ve now been for the last I would say two years or so been an Associate Editor of the Journal of the National Comprehensive Cancer Network. And I might add, an additional role I play in the aging and cancer space is membership on the editorial board of the Journal of Geriatric Oncology. So, I do wear a lot of hats.

Host:  Well you certainly do. So comprehensive and it’s such a great topic Dr. McKoy. It’s so very much needed right now. So, let’s talk about some of the unique challenges that older adults with cancer face and what are some of the most common cancers that seniors are confronted with?

Dr. McKoy:  You know it’s very difficult as we all get older because our bodies undergo so many different changes. And we talk a lot about the physiologic aging changes. And as my peers and colleagues out there who are listening to this podcast will know, we use the term physiologic aging changes, basically the normal things that happen to us as we get older but in the older person, it’s not a so-called normal change. I think the most significant things that we see is that our kidney function decreases and with that comes a myriad of problems. But our liver blood flow also decreases, worse so for women than for men. And in concert with the changes in the kidney and the changes in the liver; what happens is that medications that patients take just for their regular medical problems and also medications that they will take later if they are unfortunate to be diagnosed with cancer; are metabolized either through the kidneys or through the liver.

And so the liver blood flow is decreasing, it will be very difficult to get medications processed without some side effects. And if the kidney function is not that good and I’ll take a little side step and say that my residents, my medical students are alarmed when I tell them that they start having decreased kidney function in their 30s. So, the kidney function decreases and medications need to be processed through the kidneys, you can see how side effects could occur but cancer drugs that actually have their own toxicities. So these are some of the challenges we see as the body changes with aging.

The population of patients that we see in geriatrics and in geriatric oncology are also more frail because of other changes. They are not as strong, their muscle mass is not as good as when they were younger and in addition, they are traveling with what they call multiple chronic comorbid illnesses. And my colleagues know the challenges that they see in their clinics every day when the patient comes in with diabetes, hypertension and other medical problems. In the oncology clinic, it becomes a great challenge because now you are not only treating the cancer, but you have to do the treatment within the context or the environment of someone with other medical problems.

The common cancers that we are seeing facing our patients and they actually in and of themselves because of their treatment post specific problems include breast cancer, very common in young women but also quite common in older women, prostate cancer in our men and for both genders colorectal cancer and bladder cancers are challenges. And one cancer people don’t really think about that much, melanoma. So, these are the common cancers primarily that we see as patients age.

Host:  Well as long as we’re talking about comorbid conditions and we’re going to talk about the geriatric assessment Dr. McKoy. But since you said that seniors are prone to comorbidity; what are some of the important considerations that you would like other providers to know about when it comes to treatment decisions for the elderly? How can you better identify which patients can tolerate intensive chemotherapy and which patients may need modified treatment regimens because of underlying conditions, cognitive impairment, any of those comorbid conditions that you are discussing?

Dr. McKoy:  I think I will talk a little bit generally about the multiple comorbidities and the importance in the context of cancer treatment and then go back to answering the question what can we do. And that question of what can we do really will take us back to looking at how do we assess our patients.

So, in terms of the multiple comorbidities; in general, given these problems, I find it critically important that we have coordinated care, that we communicate across all specialties. We often send our patients to see an orthopedist if the arthritis in their knees or hips is getting really quite bad and our current treatments might not be as effective. In those cases and I’ll give you that as a standing example; the orthopedist might give them an NSAID and as my peers know, those NSAIDS or nonsteroidal anti-inflammatory drugs carry problems. They can cause bleeding from the stomach. They can affect the kidney function. We talked earlier about kidney function decreasing with aging. They can further that decrease in kidney function. And so, if we’re not communicating with the orthopedist, and if we’re not asking the orthopedist to send us a copy of their notes and what their treatment plans are, we won’t know what’s going on until we see that patient again maybe in three or four months. By that time, problems might have arisen.

So, the first thing to do given the multiple comorbidities is to coordinate care and to make sure that we’re communicating across specialties. Something that I do in my clinic and I’m sure many of my peers out there are doing something similar is to actually have a list of all the specialists who my patients see at the very beginning of my clinical notes. And when I finish seeing my patients and I close my notes; I make sure to email each specialist a copy of my notes, so they know what’s going on. So, communication and coordinating care is extremely important. We need to have our nurses what I do in clinic is because we are so busy, have our nurses and our medical assistants also work with us and start looking at medication lists when the patients come in. if you have trainees, they can be recruited as a group to actually look at these medication lists and make recommendations and it’s part of the whole education of our trainees.

Going back from comorbidities as to what we can do; well when we are faced with all these comorbidities, we turn to something we call the geriatric assessment. And it’s not just the geriatric assessment, but it’s the comprehensive geriatric assessment or the CGA. And I think it’s time that we talk about that because that falls in really nicely into what we can do as physicians.

The CGA is a multidisciplinary diagnostic and treatment process and we target all domains of function. In geriatrics, we call it our gold standard for care planning. And this is because we need to have a standard to apply to people as they get older. In terms of multidisciplinary, in our clinic, we use a nurse, a social worker, and we have a relationship with a psychologist/neuropsychologist to who we may refer our patients later on. But the assessments will include looking at just a general physical examination, the usual, the heart, the lungs and so on and we also do a full neurological exam. In addition, we have our social worker who does a psychosocial evaluation looking at life history, support systems, substance abuse or issues, nutrition and the risk of nutritional problems down the road.

In addition, we check function. So we are looking at gait, we are looking at balance and we do do a vision and a hearing evaluation. I know that in many clinics that’s very hard and especially in oncology clinic. Oncologists have limited time so what we have done through this older adult oncology panel and we have folded that into our geriatric oncology program here at Northwestern is to find ways to do the comprehensive geriatric evaluation or assessment but truncating it so we are covering all the measures of domain of function that we talked about earlier but we can do that in a more shorter period of time.

So, the CGA in essence allows us to get what we call a lovely 360 view of our patient and help us to formulate a coordinated careful and individualized plan to maximize their overall health.

Host:  It is such an important topic Dr. McKoy because as we said at the beginning, there’s so many people aging and it’s such an increasing population. You published a book chapter examining the use of alternative medicine for cancer care. Can you tell us briefly about this work and it’s implications for geriatric cancer care and while you’re telling us that, do you feel that there’s a need for more research on the diagnosis and treatment of geriatric cancer and survivorship care for older adults?

Dr. McKoy:  So, I wrote a book chapter for a textbook on cancer poly pharmaceutical safety. And my chapter on use of alternative medications I felt was very important given the numbers of aging patients and the fact that many of the patients have comorbid illnesses. Many of the drugs that we would normally give to a younger person will cause problems in that population. So, if you have got a patient who is older with cancer for instance, and they’ve got nausea because of chemotherapy, rather than giving them one of the usual anti-nausea medications like Zofran or Compazine; trial of alternative medications like medical marijuana with patients that are not averse to that or the breakdown products of medical marijuana can be helpful. When you give the usual drugs, they have drug-drug interactions that can be harmful to the patients. Trial of a certain herbal medications for patients who are having side effects from chemotherapy we find can be cost effective and can also be very effective in treating these patients.

We have tried acupuncture and what we call massage and just meditation in those patients rather than using many of the drugs that we use like the anti-anxiety medications to which patients can become addicted and also that increases the risk of patients falling or becoming confused. So, we have looked at herbal drugs which have been very important in our patient population and we have seen studies show that the outcomes can be quite good, and the risk and side effects can be lowered.

Host:  As we wrap up, is there anything else you’d like providers to know about treating seniors who have cancer, those comorbid conditions and research on the diagnosis and treatment of geriatric cancer and survivorship?

Dr. McKoy:  Robert H. Lurie Comprehensive Cancer Center of Northwestern University is what I call mission driven. We have a survivorship institute and that follows individuals from adolescence through aging. And what we have found is that while treatment of our older individuals within the survivorship institute is challenging, we have been able to actually improve our outcomes by having individual care plans instituted for these patients. When your 98 year old patient goes to surgery for say ovarian cancer and comes back after chemotherapy and survives, I think is a wonderful thing to see. We know that survival in and of itself is not the victory but the survival when it occurs and there’s a good quality of life, it keeps me passionate about what I do. People say that a patient is in their 80s, they have lived a long life; and I will say back to them, if they can live to 81, 82 or beyond, if they can be with their spouses, their children, their grandchildren; with a good quality of life, I think that’s even better than just surviving.

Host:  So, well put. Really such a great segment Dr. McKoy. Thank you so much for coming on and sharing your incredible expertise about this very important topic. And that concludes this episode of Better Edge a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at www.nm.org to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.