Supportive Care Stuart M. Lichtman, MD - PowerPoint Presentation

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Supportive Care

Stuart M. Lichtman, MD65+ Clinical Geriatrics ProgramAttending Physician, MSKCCProfessor of Medicine, Weill Cornell Medical CollegePresident, International Society of Geriatric Oncology

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Disclosure

No conflict of interests

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SIOG

Thank you…for attendingfor your dedicationfor your enthusiasmYou are now part of a new familyYou are never alone

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We’ve come a long way…

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Where we’ve been

1980s: what’s geriatric oncology?1990s: sounds interesting; maybe we should review what is known-CALGB Cancer in the Elderly2000: SIOG begins2000s: lets start doing studies and study patient outcomes2007-CARG2010s: we are starting to learn about older cancer patients and how to treat them2018: we know a lot, but need to know more; we are great at predicting; we have to intervene and prove the benefit

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SIOG Priorities

Viability of the organizationIncrease SIOG membership with emphasis on trainees; need to emphasize the value of membershipFundingIncorporate geriatric oncology principles into routine practiceRaise professional awareness of geriatric oncology and SIOG

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Viability of the organization

Increasing membershipMaintain current membersBringing in new member particularly traineesWe need to ‘sell’ the idea that all adult oncologist are geriatric oncologists, i.e. need to know some aspect of basic geriatric principlesthis is particularly true to those feel that GO is irrelevant to their practiceDemographics should sell itselfProblem: too little time, too many organizations and memberships

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SIOG Involvement

Need to expand the ‘big tent’ of SIOGIncrease involvement of other specialtiesNursingPT/OTGeriatric pharmacyRadiation oncologySurgical subspecialtiesRadiologists, i.e. interventionalistsNutritionNon traditional treatments, i.e. acupunctureYoung SIOG

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Value of membership

Annual meetingJournalCMEE-learningGuidelinesParticipation in committees

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Recent Guidelines

Management of prostate cancerRadiopharmaceuticalsAdherence to oral cancer therapyNutritionMelanomaPractical aspects of GAPlanning: renal cell, quality of life, corticosteroids, APL

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Raise professional awareness of geriatric oncology and SIOG

ASCO, ESMO, EONS, ONS, etc etcHave to actively participate and be advocatesGrass roots efforts in home institutionsEncourage fellowsJournal reviews

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Engagement in SIOG

MentorshipCommitteesTaskforcesYoung SIOGNAHSpeakersJournal ReviewersNot intimidating—inclusive

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Incorporate geriatric oncology principles into routine practice

Why do I need to know Geriatric Oncology; I know how to take care of older patients…Show that developing predictive models add to or are better than clinical judgment, i.e. CARG and CRASH scoresPerformance status does not correlate with functional statusMuch of the assessment can be self administered or with help; role of technology; does not have to be time consuming or complicatedIncreasing data in medical oncology and surgery that some GA is useful

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2015

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ASCO

Geriatric guidelinesMohile SG, Dale W, Somerfield MR, et al.: Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol 2018Modernizing clinical trial eligibilityLichtman SM, Harvey RD, Smit M-AD, et al. Modernizing Clinical Trial Eligibility Criteria: Recommendations of the American Society of Clinical Oncology–Friends of Cancer Research Organ Dysfunction, Prior or Concurrent Malignancy, and Comorbidities Working Group. Journal of Clinical Oncology 2017Clinical trial design

Wildiers H, Mauer M, Pallis A, et al. End points and trial design in geriatric oncology research: a joint European

organisation

for research and treatment of cancer--Alliance for Clinical Trials in Oncology--International Society Of Geriatric Oncology position article. J Clin Oncol 2013

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All adult oncologists are geriatric oncologists…

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All adult oncologists are geriatric oncologists…

they just don’t know it yet

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National Cancer Institute

Sponsored Trials

Essentially no data for patients 80+

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Geriatric Oncology

Expanding older patient populationUnique needsRoutine evaluation is inadequateTruly personalized medicine

Some form of comprehensive geriatric assessment modified for oncology care

Predictive models of survival and functional decline exist (Soubeyran, 2012;

eprognosis

; G8)

Predictive models of toxicity (CARG and CRASH scores)

Clinical trials have not met the needs of older patients

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Palliative Care Definition

Palliative care End of life care

…particularly for older patients

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WHO Definition of Palliative Care

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. 

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WHO Definition

provides relief from pain and other distressing symptoms;affirms life and regards dying as a normal process;intends neither to hasten or postpone death;integrates the psychological and spiritual aspects of patient care;

offers a support system to help patients live as actively as possible until death;

offers a support system to help the family cope during the patients illness and in their own bereavement;

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WHO Definition

uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;will enhance quality of life, and may also positively influence the course of illness;is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

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ASCO 2012: Integration of palliative care…

Palliative care as part of standard cancer care for all patients with metastatic disease and/or significant symptom burdenRecognizes that palliative care is a source of confusion and controversyWho should provide it?

Who it encompasses?

When and how it can help patients and their families?

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Palliative Care in Older Patients

The best way to provide palliative/supportive care is to:Evaluate the patients in a geriatric specific manner including setting realistic goalsDose patients appropriately accounting for functional and physiologic status, i.e.

endorgan dysfunction

Provide appropriate supportive care

Antiemetics, pain, hydration, etc.

Understand patients desires and beliefs

Beneficial in older patients

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Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer

2010

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Temel, et al. Palliative Care

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Temel, et al. Palliative Care

Half the patients were older than 65 years

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Mean Change in Quality-of-Life Scores from Baseline to 12 Weeks in the Two Study Groups

Temel JS et al. N Engl J Med 2010;363:733-742

Early intervention improves all quality of life outcomes

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Twelve-Week Outcomes of Assessments of Mood

Temel JS et al. N Engl J Med 2010;363:733-742

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Kaplan–Meier Estimates of Survival According to Study Group

Temel JS et al. N Engl J Med 2010;363:733-742

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Early Palliative Care: Improved Outcomes

Symptom managementPain, nausea, etc.Quality of life

Prognostic understandingCaregiver outcomes

Mood

End of life outcomes

Survival

Resource utilization

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Quality of end of life care

Patients face many issues at the end of lifeCoping issuesComplications of dying

Practical issuesPhysical symptoms; fear of suffering

Family

Spouse

Children

MacKenzie, ASCO 2016

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Evaluation

NutritionMini nutritional assessmentDoes the patient want to eat?Has there been significant weight loss

Cognition

Mini cog

Capacity to understand situation and make decisions

Delirium

Functional Status

ADL/IADL

Gait speed

Falls

Decline in IADL associated with greater frailty

ADL needs

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Evaluation

Geriatric syndromes-increased risk of mortality and can worsen end of life symptomsSensory impairmentIncontinence

Falls/mobilityDepression

Delirium

Patient preferences and values

Discuss early and often; patient alone

“Based on your health...”

“Based on your values…”

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Older Patients Symptom Burden

Palliative care may be considered to extend to survivorshipSurvivorship includes not just patients in remission but where cancer is a chronic diseaseChronic toxicity of therapy will require various forms of palliation

Particularly important in older patients

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Palliative Care Key Points

Improves important outcomes for patients with cancer as been shown in five randomized controlled trialsASCO recommends early integration of palliative care into comprehensive cancer care for patients with advanced disease and/or significant symptom burdenOutcome improvements seen with early intervention

More research in specific circumstances, particularly older patients with their unique needs

Chronic toxicity

Survivorship issues

Clinical trials of survivorship and end of life need to performed in older patients similar to therapeutic trials

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Vulnerable Populations

Quality of lifeAvoidance of toxicityAppropriate evaluationSurvivorship

Long term toxicities

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Some of the issues to consider

Risk of febrile neutropeniaNausea and vomitingBone health

AnemiaDepression

Sleep Disorders

Fatigue

Pain

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ASCO Guidelines-Universal Dataset?

Mohile, et al. JCO, 2018

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Assessment tools

Maintenance of independence and function is criticalADL/IADLCGA (comprehensive geriatric assessment)

VES-13 (in NCCN guidelines)

G8

PS

Measures of comorbidity (Charlson, CIRS-G)

History and physical

Observation of patient; memory

Laboratory

Chemistries particularly renal function (calculate CrCl), anemia, albumin

Cardiovascular evaluation

Weight and BMI

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Assessment Does Not Have to Be Complicated

Gait speed-ability to walk 1-2 blocksHistory of fallsWhere does the patient live?

Eliminate unnecessary medications-polypharmacyAsk about ADL/IADL

Social supports

Memory/cognition

Patients can do this while waiting

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Avoidance of Toxicity

(1) impaired functional status - modification of cancer treatment regimen and evaluation of fall risk(2) in patients with impaired cognition assessing the presence of a caregiver and limiting the complexity of treatment.(3) in patients with poor social support assessing patient safety/tolerability and caregiver support(4) assessing the safety of treatment for patients with impaired physical performance and

(5) addressing supportive care and evaluating drug tolerance

for patients with poor nutritional status.

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Avoidance of Toxicity

Appropriate dose and scheduleFunctional status, organ functionSocial supportsHematopoietic supportAntiemetic supportMay require more frequent visit to monitor labs, hydration status, etc.

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Survivorship

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Survivorship

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Survivorship by Age

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Survivorship by Age

46% of cancer survivors are 70 years and older

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All oncologists are geriatric oncologists….

Survivorship Makes Us All GeriatriciansAging of the population

Risk of cancer increases with age

Specific needs of older patients

More complex options for treatment with toxicities

Markedly heterogeneous population

Comorbidity complicates toxicity of therapy and long term outcomes

Truly personalized medicine

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Age at prevalence

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Geriatric Knowledge Required

New York Times

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Life Expectancy

Walter, et al. 2001

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Survival

Incorporates:

-cancer vs. no cancer

-comorbidities

-dependence

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Specific Toxicities

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Long Term Toxicity into Survivorship

Shahrokni, Wu, Carter, Lichtman. Clin Geriatr Med, 2016

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Long Term Toxicity into Survivorship

Shahrokni, Wu, Carter, Lichtman. Clin Geriatr Med, 2016

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Chronic toxicity

Cognitive impairmentCardiotoxicityDepression and anxietyOtotoxicity

Imbalance and lack of coordination

Osteoporosis

Metabolic syndrome

Second malignancy

Sexual and vaginal dysfunction

Shahrokni A, Wu AJ, Carter J, Lichtman SM: Long-term Toxicity of Cancer Treatment in Older Patients. Clin Geriatr Med 32:63-80, 2016

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Cognitive Impairment

Unrecognized, pre-existing problems may exacerbate, i.e. dementiaOften important to evaluate for depressionEliminate unnecessary medication: Beer’s list

HypnosedativesNarcotics

Anticholinergic drugs

May need formal evaluation, i.e. neuropsychologic testing

Hormonal evaluation particularly in immunotherapy era (checkpoint inhibitors, etc.)

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Cardiotoxicity

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Cardiotoxicity

Increased number of cardiotoxic drugs associated with prolonged survival requiring followup:Doxorubicin and other anthracyclinesLiposomal doxorubicin

Trastuzumab (Herceptin) and associated compounds

Control of hypertension

Increased use of anti-VEGF drugs,

i.e

bevacizumab (Avastin); trastuzumab emtansine (Kadcyla)

Control of diabetes

Pericardial and myocardial disorders in patients receiving prior thoracic irradiation

Volume status

QT interval-arrhythmias, electrophysiology

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Balance and coordination

Chemotherapy induced peripheral neuropathy from taxanes, vinca alkaloidsLack of balance and coordination can lead to falls and subsequent injuriesFalls affect overall survival

Older patients more susceptible to toxicityComorbidities such as preexisting neuropathy, diabetes increase risk

Lichtman SM, Hurria A, Cirrincione CT, et al. Paclitaxel efficacy and toxicity in older women with metastatic breast cancer: combined analysis of CALGB 9342 and 9840. Ann Oncol 23:632-8, 2012

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Balance and coordination

Recognize issueConsequences of peripheral neuropathyGait disturbancesRisk of falls

Driving; climbing stairsOccupational therapy helpful particularly to help hand function, i.e. dressing, opening jars, etc.

Physical therapy for fall prevention, increase lower extremity strength

Exercise programs

Drugs for symptom management are minimally effective and have toxicity, i.e. gabapentin

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Muscle and bone health

Higher risk of osteoporosis and fracturesRisk factors:Therapy induced menopauseUse of aromatase inhibitors

Androgen deprivation therapy

Bone density evaluation

Treatment

Calcium and vitamin D supplementation

Exercise, sunlight

Bisphosphonates (zolendronic acid-Reclast)

Rank ligand inhibitors (denosumab-Prolia)

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Fatigue

One of the most common long-term side effects of cancer therapy is fatigue. Exacerbated by comorbidity, i.e. heart and lung disease, anemia renal dysfunctionSymptom of fatigue that patients with cancer experience is different; not often alleviated by sleep and rest.

Patients who have undergone cancer treatment get fatigued after less activity than those who have not had cancer.  The cause of this symptom is multifactorial:

Long term effects of therapy (eg, chemotherapy, radiation, biologic therapy, surgery), anemia, nutrition, anxiety and depression, sleep disorders, and drugs.

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Fatigue-Polypharmacy can contribute

Polypharmacy, which is common in the elderly, can contribute.  Specific drugs, such as anxiolytics, sleeping medicine, narcotics, and drugs that treat neuropathy (eg, gabapentin, pregabalin)Difficult issue; consider nonpharmacologic interventions such as exercise programs, psychological support in event of depression/anxiety

Avoid pharmacologic therapy

Amphetamines, modafinil

Corticosteroids

Cancer chemotherapy premedication

Symptom may be prolonged into survivorship, months to years

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Long term effect of radiation therapy in elderly

Chronic fibrosis and its sequelae, i.e. obstructive uropathyEffect on CNS; may exacerbate cognitive impairmentXerostomia from head and neck therapy; impair nutrition; dental issues (not covered by Medicare)

Pulmonary fibrosisHeart disease, coronary disease, pericardial disease

Chronic GI effects, ie. Diarrhea, incontinence

Insufficiency fractures; painful, should not be confused with metastases, DJD, osteoporosis

Sexual dysfunction, i.e. vaginal dryness and stenosis; discomfort and inability to be appropriately examined

Secondary malignancy

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Secondary malignancy as chronic toxicity

Older cancer survivors have approximately 15-20% incidence of a second cancerAML/MDS from chemotherapyTopoisomerase II inhibitors-less than 5 yearsAlkylators-greater than 5 years

Breast cancer from thoracic radiationIssue of genetic predisposition, i.e. BRCA, Lynch syndrome

Pelvic radiation

Radiation therapy for prostate cancer increase risk of cancer of the bladder, colon and rectum but absolute incidence is low

No increase risk in patients treated for rectal or endometrial cancer (Wiltnick, et al. JCO 2014)

Increase risk of external beam RT for endometrial cancer in patients less than 60 years (Onstrud, et al. JCO 2013)

Continue standard screening recommendations

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Second Malignancy

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Conclusion

Elderly patients are the majority of cancer survivors and their numbers are increasingComorbidity and the problems of aging combined with the effects of therapy will pose a challenging problem for clinicians and the health care systemSome form of geriatric assessment will be required to adequately evaluate the patients

Controlling comorbidity will be critical

Preventive health measures will be of critical importance

All clinicians will need to become geriatricians and/or geriatric oncologists

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Thank you very much

lichtmas@mskcc.org

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Thank you