The multidisciplinary team - PowerPoint Presentation

Slide1

The multidisciplinary team organisation for older cancer patients: portraits of Geriatric Oncology Programmes worldwide

Silvio Monfardini, MDGeriatric Oncology Program Istituto Palazzolo, Fondazione  Don Gnocchi, Milano

Slide2

Disclosure Session Chairman at a Meeting sponsored by Cellgene

Recipient of a Bristol-Myers Squibb grantfor the Project ‘the Italian Road Map for Geriatric Oncology’

Slide3

What are your projects foreseen following this Course ? A small sample of Your Answers(Pre-event evaluation)We plan to establish an organised interdisciplinary (geriatrics and oncology) management of the older cancer

patients…… We would like to bring some more methodology and knowledge to this topic……..………create a oncogeriatric unit or functional team……….designing

and having my institution participate in trials geared toward the geriatric population.

Slide4

This is then the need

MULTIDISCIPLINARY TEAMS: A BETTER INTEGRATED APPROACH BETWEEN ONCOLOGY AND GERIATRICS, WORLDWIDE

Slide5

If You are here

1) You are already convinced of the usefulness of the CGA2) Most of You

probably

believe

in the

interaction

Clinical Oncologists-Geriatricians

But

returnig

to Your

Institutions

…,

somebody

will

not really believe in this approach

Slide6

Why They should believe

You?

Caravaggio: Incredulity of St Thomas

Slide7

One of the best ways to convince them on the usefulness

of an integrated approach before the proposition of a multidisciplinary

team organisationan

To

present

and

discuss

with

them

( and

possibly

with

Geriatricians

)

real clinical casesof frail and vulnerable

old

cancer

patients

,

taken from Your daily activity

Unknown

painter,Florence

Slide8

Possible lessons from clinical cases

An MGA, better if performed by a Geriatrician, before offering a treatment :

Can provide information on:

hearing

defect

, visual deficit and cognitive

impairments

leading

to the

lack of understanding of the real meaning of the information

The

knowledge

of

these

elements can be clinically useful in order to

obtain

the

patients

consensus

for treatment

Slide9

Possible lessons from clinical cases

Some information obtained with the help of Geriatricianscan be useful in order to identify obstacles to cancer treatment:- Limited family and social support, Lower education

- Difficulty in:

having access to a mean of transport,

telephone calls

self administration of drugs

Monfardini S. et al, ASCO Proceedings 1996,

Eur

J Cancer 2002

Slide10

What may in Your Institute Medical Oncologists

learn,especially in presence of Geriatricians ?Geriatricians have a better

knowledge of the conditions

/

diseases

affecting elderly

patients

and

interfering

with

their

treatment

They

are

better able to deal with the social problems impeding the management of the neoplastic

diseases

Slide11

What else to be made understandable to Your Medical Oncology Collegues

through the discussion of clinical cases with the partecipation

of Geriatricians?

The

role

of

Geriatricians

as

partners

in

-

V

unerability

prevention- Rehabilitation home - S

topping

inappropriate

medications

-

Tumor

independent life expectancy evaluation

Slide12

To have this Orchestra w

e need Geriatric Oncology Programmes worldwide

GERIATRIC

ONCOLOGY

Primary

care

Clinical

Oncol

. (

Surgical

,

Medical

Oncology

, RT)

Epidemiology

.

Clinical

and

Laboratory

Research

Geriatrics

,

Gerontology

Palliative care

Supportive

therapy

Rehabilitation

,

pharmacy

,

nutrition

,

social

services

Clinical

Oncologists

,

Geriatricians

and

other

partners

Slide13

GOALS of a dedicated

Geriatric Oncology Program (GOP):To provide comprehensive care through a multidisciplinary

approach (age-associated conditions

and

cancer

management) To

conduct clinical trials in

representative

older

pts

.

To educate

health

professionals(, older patients, their families and the public ) S Monfardini et al: Report of a SIOG

task

force

.

Crit

Rev

Oncol/Hematol,2006

Slide14

How difficult is it to transfer such specific approach

in the real world?Which is the status of the Geriatric Oncology Programmes worldwide?Bosch,

Hieronymus

the

Ship

of

Fools

Slide15

Liberism and happinessIn the USA emphasis on training and acquisition of data

Geriatrics/Oncology Training Program Development Grant ASCO/TheJohn A. Hartford Foundation, (2001): Dual Training Grants to NCI-NIA (National Institute of Aging)designated Cancer Centers to study Age integrated aspects (2005):

Emphasis on ResearchThe

U13 conference series of Cancer and Aging Research Group NCI,NIA and the Alliance Clinical Trials in Oncology (

2010-2016):

Areas of highest research priorities in

Geriatric Oncology

Slide16

Formal Geriatric Oncologyfellowships in both the US and Canada Boston University, McGill University,Montreal,Thomas Jefferson University, Philadelphia

University of California, LosAngeles (UCLA), University of Chicago, University of North Carolina,University of Rochester, University of Toronto

Slide17

Goals of U13 Grant :“Geriatric Oncology Research to Improve Clinical Care Care.”

To identify the present level of evidence & areas of high research priority in Geri Onc To identify strengths in research methodology, from the fields of Geriatrics and Oncology

To foster collaboration between multidisciplinary scholarly teams

To foster and promote the research of existing and new investigators in Geriatric Oncology

To disseminate findings from this conference grant program with easily adaptable recommendations

Training

&

Education

Research

Methodology

Slide18

Clinical Research helps

in developing multidisciplinary clinical and

teaching

activities

Starting

up a

clinical

research

activity

can help

in

developing

a

comprehensive

approach

because

in

order

to

conduct

an

oncogeriatric

study

is

necessary

to

build

a new team

with

different

competences

of

the

participants

This

team

approach

will

provide

the

background

for

further

projects

implementation

and

teaching

Slide19

Diversity across the US SPECIALIZED ONCOLOGY CARE AND RESEARCH IN THE ELDERLY (SOCARE) ROCHESTER AND CHICAGO UNIVERSITY

Pre-operative setting: evaluation prior to cancer surgery Pre-treatment assessment: evaluation and weight of the risks and benefits of multiple treatment options Survivorship: assistance through the management of geriatric-related conditions Magnuson A , Dale W and Mohile S, Curr Geriatr Rep 2014

Slide20

Who were the first ones:L Balducci, M Extermann, Senior Adult Oncology Program .Tampa CGA performed by a nurse

Separate clinic within the center with physicians, nurses, pharmacist, social worker, dietitian and support staff Cases discussed at weekly team meeting

Slide21

Global Geriatric Oncology: Achievements and challenges E.Soto-

Perez-de-Celis et al J Ger Oncol2017Selected Geriatric Oncology Initiatives in the United States and Canada.

Slide22

Oncologist Refers Patient

Reasons for referral:

Geriatric assessment & intervention recommendations

Treatment recommendations

Comprehensive

Geriatric

Assessment

Performed

by

Geriatrician

and

Multidisciplinary

Team

Geriatric assessment results and recommendations provided to the oncologist

Courtesy of

Arti

Hurria

From the American

experience:The

possible

models:Consultative

Model

Slide23

Shared Care Model

Oncologist Refers Patient

Comprehensive

Geriatric

Assessment

Performed

by

Geriatrician

/Geriatric

Oncologist

and

Multidisciplinary

Team

Interdisciplinary

Meeting

to

Review

the

Results

and

Care

Plan

Geri

-Oncology Team

Collaborates

with

Treating

Oncologist &

Provides Concurrent Care Across the Disease Trajectory

Reasons for referral:

Geriatric assessment & intervention recommendations

Treatment recommendations

Courtesy of

Arti

Hurria

Slide24

Comprehensive Care Model

The Geriatric Oncologist is the Treating Oncologist

Comprehensive

Geriatric

Assessment

Performed

Referrals

to

the

Multidisciplinary

Team

Results and Recommendations are

Reviewed with the Patient

Reasons for referral:

Cases where geriatric oncology expertise is needed

The Geriatric Oncologist is the Patient’s Treating Physician Throughout the Patient’s

Disease

Trajectory

Courtesy of

Arti

Hurria

Slide25

Selected Geriatric Oncology Initiatives in Latin America (E.Soto-Perez-de-Celis et al J Ger Oncol2017)

Slide26

Lack of a common European Union Framework :the different national situations ( France……

.)Belgium, Holland, Norway and Switzerland: successful models of care delivery and cooperation between Clinical Oncologists and Geriatricians developed Italy: some central funding for research. A dozen of Units

with Geriatric Oncology

activity

,

scarce cooperation

with

Geriatricians

.

In

other EU Nations: no established collaboration

with

Geriatricians

.

Monfardini S,J Ger Oncol 2013

Slide27

The GOP at

the Istituto Oncologico Veneto, Padova, Italy (2004-2008)All patients > 70 years referred

to the Divisione di Oncologia Medica

offered

an

MGE

·In

 

all

cases

ADL,IADL,MMS,GDS

questionnaires

administered

by a psycologist ( 30 to 45 minutes).

·

 

Determination

and rating

of

comorbidity

(CIRS) performed afterwards by a

Medical Oncologist

· All most complex cases

evaluated

weekly

by

the

Geriatricians

.

Slide28

THEORIES AND DIFFERENT MODELS OF INTERPLAY H.Wildiers

et Al :J.C.O. 20141)Creation of

Geriatric Oncology Units

(

Geriatric

Oncologist alone?)2)

Bring

Geriatric

consultation teams to patients

3) In settings where geriatric expertise is not nearby GA can be performed (by the Clinical Oncologist) to identify high-risk patients who could be referred to Geriatricians

H.Wildiers et Al

:SIOG Consensus on

Geriatric Assessment in Older Patients With Cancer.J.C.O

.

AUGUST 2014

Slide29

1

.potential patient withdrawal from familiartreating oncologist

2.financial incentives might

drive general oncologists not to refer patients;

3.only limited No. of patients can be reached

4. general geriatric oncologists might

miss

detailed

,

rapidly evolving knowledge of

broad

field

of

oncology

r H.Wildiers et Al :J.C.O. 2014 s,JCO

(

Advantage

and)

Disadvantage

of a

Geriatric

Oncology Unit

2014

Slide30

Selected Geriatric Oncology Initiatives in Asia and the Middle East,modified (E.Soto-Perez-de-Celis et al J Ger Oncol2017)

Empty

area

Empty

area

Slide31

Selected Geriatric Oncology Initiatives in Australia and New Zealand(E.Soto-Perez-de-Celis et al J Ger Oncol2017)

Empty

area

Slide32

Emerging problems: The strategy of the interaction

should be probably rethought in the GOPs according to

1) organ

involved

(

eg breast

ca

.)

2

)

phase

of management:

-

Initial

therapeutic decision- Support after initial therapy

-

Follow

up

Slide33

Medical Oncologists: the trend toward various

subspecialties in Cancer Research Institutions,but also in the Surgical Oncology activityBreast

, Gyn,Gi

, GU

Lung

, HN

Ematol. ,Soft

tissue

,

Brain,

Etc

Where

and

how

an

Interaction

with Geriatricians ?How

should

be

the GOP work

be

organized

?

Slide34

Phase of management:consider also

an integrated approach during the follow up

The 3rdrd U13 Conference in 2016 focused on improving the quality of life and

survivorship

of older and frail adults with cancer(S.G. Mohile et al, Cancer 2016)

.

Slide35

FOLLOW-UP OF ELDERLY PATIENTS WITH UROGENITAL CANCERS: EVALUATION OF GERIATRIC CARE NEEDS AND RELATED ACTIONS MGA items collected at the beginning after Radiotherapy or Surgery in 453 patients >70 years > 60% of patients with prostate cancer

and > 70% of patients with renal and bladder cancers werefrail or vulnerable but only one case was referred to a GeriatricianOf 16 patients with ADL impairment and 63 with IADL impairment, only 4 (25%) and 6 (10%), respectively, were referred to a rehabilitation service..Conclusion: should older patients with urological neoplasia be seen by a Geriatrician at the initial follow up ?S Monfardini et al J.GER.ONCOL:2017

Slide36

Problems in implementing specific activities for cancer in the elderly

in some countries within cancer institutes,universities and general hospitals Open issues

Geriatrics

does

not

exist in some region

or a country

Geriatric

Units

in

other

cities

nearby Oncology and Geriatrics in different

hospitals of the

same

city

Slide37

Open issues POSSIBLE SOLUTIONS

Geriatrics does not exist

in some region or a country

Geriatric Units

in other cities nearby

Oncology and Geriatrics

in different hospitals

of

the same city

Geriatric Oncologist

Geriatric Oncologist, multidisciplinary meetings, teleconferences

Geriatric consultations

Slide38

One last recommendation to the

Medical Oncologistsembarking into

an interdisciplinary

game…

Geriatricians

shortfall

,

professionals

difficult

to

recruit

Geriatrician's

tools

and know-how

often

perceived

ambiguously

:

Oncologists

unclear

as

to the

Geriatricians

role

Geriatricians

may

:

feel

confined

to the

periphery

of

organisation

of

cancer

treatment,

be

involved

with

other

multiple

role

within

their

Institutions

Suffer

from a

time

constraint

:

overhelming

number

of

elderly

cancer

patients

Sifer-Riviere

L.

et

al,

Ann

Oncol

, 2011

Holmes

HM.

and

Allbrand

G. In Cancer and

aging

Ed by

M

Extermann

Extermann

M., 2013

Bruegel, Pieter the Elder

The Peasant Dance

Slide39

No uniform universal model of the Geriatric Oncology Program can be proposedDifferent characteristics in various Countries,on the basis of the local health organization and available resources. The models can vary depending on the needs of the individual patient,family and caregiver,the availability and expertise of the involved professionals and support services

.And You should find Your Way!

Slide40

The possible next step for You:after establishing a GOP

think of promoting this activity in smaller hospitals treating cancer patients

An example:

A

small

Italian Task

Force-One

Medical

Oncologist

and

one

Geriatrician-

to ask all Specialists :What

is

done

now

in

this hospital for older cancer

patients and what do

You plan for the future?In the year 2017-2019

metings

in

Avellino

Catania

Firenze

IOV,Padova

Torino

Bergamo

INT,Milano

CRO Aviano

UNModena

INT Napoli

FBF Roma

UN Palermo