Wednesday, July 1, 2009
To address the special challenges of treating cancer in older patients, Memorial Sloan Kettering recently established a Geriatrics Service in the Department of Medicine.
Among all known risk factors for developing cancer, the most powerful is aging. According to the National Cancer Institute, Americans 65 and older account for 55 percent of new cancer cases and 70 percent of all cancer deaths. This 65-and-older population will grow dramatically in the next few decades and by 2030 will account for 20 percent of all Americans.
To address the special challenges of treating cancer in older patients, Memorial Sloan Kettering recently established a Geriatrics Service in the Department of Medicine. George J. Bosl, Chair of the Department of Medicine, and Memorial Hospital Physician-in-Chief Robert E. Wittes led the effort to expand services for older patients. “We know that such patients have unique clinical needs,” said Dr. Wittes. “There is also important clinical and fundamental research potential in this area. The new service provides the consultative support of geriatric specialists to improve the care of elderly cancer patients. It also will serve as the focal point for ongoing clinical research.”
The new service is headed by Beatriz Korc-Grodzicki, who came to Memorial Sloan Kettering from New York’s Mount Sinai Medical Center. It includes another full-time geriatrician, Kouta Ito, and a geriatric nurse practitioner, Heidi Yulico. The recruitment of a third geriatrician is underway. “It’s important to establish this broadly based effort at the Center because geriatricians are trained to look for subtleties in the way older patients respond and how their medical illnesses manifest themselves,” explained Dr. Bosl. “To draw a parallel with infectious disease, every physician should know how to take care of a fever, but there are certain times when the illness is complex and requires the consultation of an infectious disease physician.”
Unique Needs of Older Patients
When considering cancer treatment for older patients, one size does not fit all. Many older people remain healthy and strong into their 70s, 80s, and even 90s and may tolerate standard treatment protocols remarkably well — but others do not. Elderly patients may have health conditions such as diabetes, high blood pressure, heart or lung disease, cognitive impairment, and fragile bones, and the medications they take for these conditions can interact negatively with certain chemotherapies. In addition, older patients may be more socially isolated than younger patients — perhaps living alone or acting as the primary caregiver for a spouse — and may need the specialized attention of a social worker or a psychiatrist.
In 2002, Dr. Bosl explained, the need for a program oriented toward geriatric patients became compelling, and the institution recruited Arti Hurria, an oncologist and geriatrician on the Breast Cancer Medicine Service. (Dr. Hurria is now Director of the Cancer and Aging Research Program at City of Hope, outside Los Angeles.)
With support from a gift from the Joachim Silbermann Family Foundation, Dr. Hurria worked with social worker Anne Martin to create the 65+ Program, a multidisciplinary initiative encompassing experts from various fields at Memorial Sloan Kettering, including physical therapy, psychiatry, pharmacy, and social work. With continued funding from the Silbermann family, the 65+ Program has expanded its services throughout the Center.
For example, socially isolated patients can receive counseling from social workers with psychological training. “Our three social workers do face-to-face consultations with individual patients, couples, and families struggling to deal with cancer,” said Dr. Martin. “We also offer telephone consultations, which is particularly important for patients who may have difficulty getting to the Center.”
Social workers assist older patients in other essential ways, including helping them develop a system for adhering to a medication schedule at home and providing car service to Memorial Sloan Kettering medical appointments for those who meet certain financial criteria. The 65+ Program also offers a monthly educational lecture series that addresses topics such as nutrition, coping with sleep difficulties, and memory loss. It hosts workshops, ongoing support groups, and an annual health fair focused on a specific issue that older cancer patients may face. In addition, the service publishes a quarterly 65+ newsletter for Memorial Sloan Kettering staff.
Dr. Martin pointed out, however, that the concept of a “geriatric patient” may need to be revised. “As more people maintain good health into their later years, we’ve discussed that the program may eventually change from 65-plus to 70-plus,” she said. “We’re finding that 65- to 70-year-olds are really quite functional — physically and emotionally — in ways you didn’t see three or four decades ago.”Back to top
An Evolving Geriatrics Effort
By 2007, it was clear that, in addition to the 65+ Program, the Center needed a Geriatrics Service staffed with physicians and nurses dedicated to addressing the needs of older cancer patients. In 2008, Memorial Sloan Kettering recruited Dr. Ito, who had completed his training in geriatrics at NewYork-Presbyterian Hospital. Dr. Ito consults with MSKCC oncologists who seek his input on how well a patient may tolerate a specific cancer therapy. He also sees patients who have finished treatment and are referred to him as part of their follow-up care.
Dr. Korc, a geriatric specialist, came to Memorial Sloan Kettering in 2009 to head the new service. “The Geriatrics Service is not starting in a vacuum,” she observed. “We have a chance to collaborate with others at the Center who have research initiatives in their own specialties, such as in lymphoma or psychiatry.”
Dr. Korc went on to note that older patients with several health conditions who may be receiving treatment from multiple physicians “need someone to provide a comprehensive evaluation so they are not put at risk for avoidable complications.”
Ms. Yulico, the Geriatric Service’s nurse practitioner, also brings a unique perspective. “An oncologist might recommend that a patient get out of bed following an operation, and we’ll actually go there and work with the nurses and therapists to help him or her move from the bed to a chair,” she said. “For older patients, this can make a huge difference in preserving mobility and independence.”
The service will oversee ongoing efforts to educate medical staff about the care of geriatric patients. Ms. Yulico currently makes presentations to nurses in many departments, describing the characteristics of patients who may be appropriate candidates for referral to one of Memorial Sloan Kettering’s geriatric specialists. She also trains nurses from around the Center so that they can become familiar with geriatric issues and can return to their own departments with the knowledge and skills necessary to train their colleagues.Back to top
The Geriatric Service also seeks to advance the nascent field of geriatric oncology through research. “In bringing any new service to Memorial, we expect the physicians to practice the most current standard of care and also to ask questions about that standard of care,” Dr. Bosl said. “And there are lots of important questions to ask.”
Dr. Ito, for example, recently conducted a cost-effectiveness study regarding patients who receive hormonal therapy to treat prostate cancer. Because this treatment can accelerate bone loss and thus increase the risk of hip fracture, the question arose about the most efficient way to counteract this side effect. By comparing various risks and benefits — both economic and quality-of-life impacts of hip fracture — Dr. Ito concluded that it was cost-effective to obtain dual-energy x-ray absorptiometry (DXA) for all such patients and give a drug, alendronate, that slows bone loss to those who need it. “It seems like a simple question, but it’s a complex study addressing a very important issue,” Dr. Bosl said.
Older patients have been underrepresented in cancer trials for many years — often excluded due to other health problems that could confound the results — but that is beginning to change. An upcoming clinical trial at Memorial Sloan Kettering will investigate the effectiveness of an oral drug, lenalidomide, against chronic lymphocytic leukemia (CLL) in patients who are 65 and older. CLL is the most common leukemia in adults, with an average age at diagnosis of 72. The main goal of the study, led by Memorial Sloan Kettering hematologists Nicole Lamanna and Mark A. Weiss, is to control the disease with the lowest effective dose of lenalidomide. In this way the investigators are attempting to change the basic treatment strategy away from aggressive and toxic therapies in favor of an approach that can control the leukemia with a minimum of side effects.
“Geriatric oncology is still just getting started as a field,” Dr. Korc concluded, “and the Geriatrics Service provides a much-needed opportunity to investigate cancer therapies in this older population. We are now commonly offering treatment to people in their 80s and even 90s. These are patients we didn’t see ten years ago, and we will certainly see many more of them in the future.”Back to top