Beatriz Korc-Grodzicki

Surgical Considerations in Older Adults With Cancer

PURPOSE The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment. METHODS This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality. RESULTS Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization. CONCLUSION Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.

Older adult oncology, version 2.2016: Featured updates to the NCCN guidelines

Cancer is the leading cause of death in older adults aged 60 to 79 years. Older patients with good performance status are able to tolerate commonly used treatment modalities as well as younger patients, particularly when adequate supportive care is provided. For older patients who are able to tolerate curative treatment, options include surgery, radiation therapy (RT), chemotherapy, and targeted therapies. RT can be highly effective and well tolerated in carefully selected patients, and advanced age alone should not preclude the use of RT in older patients with cancer. Judicious application of advanced RT techniques that facilitate normal tissue sparing and reduce RT doses to organs at risk are important for all patients, and may help to assuage concerns about the risks of RT in older adults. These NCCN Guidelines Insights focus on the recent updates to the 2016 NCCN Guidelines for Older Adult Oncology specific to the use of RT in the management of older adults with cancer.

A new care paradigm in geriatric head and neck surgical oncology

Perioperative management of elderly patients with head and neck cancer poses unique challenges. Our objective is to describe the implementation and feasibility of a novel intervention designed to improve perioperative care in geriatric head and neck surgery.

Geriatric assessment for oncologists

The world is experiencing aging of its population. Age-specific incidence rates of cancer are higher and cancer is now recognized as a part of aging. Treating older patients can be challenging. The clinical behavior of some tumors changes with age and the aging process itself brings physiological changes leading to decline in the function of organs. It is essential to identify those patients with longer life expectancy, potentially more likely to benefit from aggressive treatment vs. those that are more vulnerable to adverse outcomes. A primary determination when considering therapy for an older cancer patient is a patient’s physiologic, rather than chronologic age. In order to differentiate amongst patients of the same age, it is useful to determine if a patient is fit or frail. Frail older adults have multiple chronic conditions and difficulties maintaining independence. They may be more vulnerable to therapy toxicities, and may not have substantial lasting benefits from therapy. Geriatric assessment (GA) may be used as a tool to determine reversible deficits and devise treatment strategies to mitigate such deficits. GA is also used in treatment decision making by clinicians, helping to risk stratify patients prior to potentially high-risk therapy. An important practical aspect of GA is the feasibility of incorporating it into a busy oncology practice. Key considerations in performing the GA include: available resources, patient population, GA tools to use, and who will be responsible for using the GA results and develop care plans. Challenges in implementing GA in clinical practice will be discussed.

Prevention of post-operative delirium in older patients with cancer undergoing surgery

Prevention has been shown to be the most effective strategy for minimizing the occurrence of delirium as well as delirium-associated complications.(5) Therefore prevention of delirium in older adults undergoing surgery is a top research priority given the extent of the problem in this patient population. In this review, we will describe the POD syndrome, previously identified risk factors that predict POD in surgical cancer patients, long-term outcomes of POD and both non-pharmacologic and pharmacologic therapies aimed at preventing POD.

How We Care for an Older Patient With Cancer

As the number of older patients with cancer is increasing, oncology disciplines are faced with the challenge of managing patients with multiple chronic conditions who have difficulty maintaining independence, who may have cognitive impairment, and who also may be more vulnerable to adverse outcomes. National and international societies have recommended that all older patients with cancer undergo geriatric assessment (GA) to detect unaddressed problems and introduce interventions to augment functional status to possibly improve patient survival. Several predictive models have been developed, and evidence has shown correlation between information obtained through GA and treatment-related complications. Comprehensive geriatric evaluations and effective interventions on the basis of GA may prove to be challenging for the oncologist because of the lack of the necessary skills, time constraints, and/or limited available resources. In this article, we describe how the Geriatrics Service at Memorial Sloan Kettering Cancer Center approaches an older patient with colon cancer from presentation to the end of life, show the importance of GA at the various stages of cancer treatment, and how predictive models are used to tailor the treatment. The patients needs and preferences are at the core of the decision-making process. Development of a plan of care should always include the patients preferences, but it is particularly important in the older patient with cancer because a disease-centered approach may neglect noncancer considerations. We will elaborate on the added value of co-management between the oncologist and a geriatric nurse practitioner and on the feasibility of adapting elements of this model into busy oncology practices.

The Older Adult With Locoregionally Advanced Head and Neck Squamous Cell Carcinoma: Knowledge Gaps and Future Direction in Assessment and Treatment

Older adults with head and neck squamous cell carcinoma (HNSCC) pose unique treatment and supportive care challenges to oncologists and other cancer care providers. The majority of patients with HNSCC present with locoregionally advanced disease, for which combined-modality treatment integrating chemotherapy and radiation therapy is often necessary to maximize tumor control. However, applying these approaches to an older population with concomitant comorbidities and a higher risk of functional impairments remains challenging and is exacerbated by the paucity of studies involving older adults. The purpose of this article is to identify knowledge gaps in the evaluation and management of older adults with HNSCC-particularly those undergoing concurrent chemoradiation therapy-and their caregivers through a review of the literature conducted by clinicians, researchers, and patient advocates. The findings highlight the importance of a geriatric assessment and the therapeutic paradigms and challenges relevant to this population. Furthermore, we identify the need for additional research and interventions related to key supportive care issues that arise during and after treatment in older adults with locoregionally advanced HNSCC. On the basis of our findings, we prioritize these issues to guide future patient-oriented research endeavors to address these knowledge gaps and thus better serve this growing patient population.

Discharge disposition disagreements and re-admission risk among older adults: a retrospective cohort study

Objectives Re-admissions after hospitalisation are a burden for patients and costly. Our objective was to examine whether re-admissions were increased among older patients when they or their surrogates disagreed with the discharge disposition recommended by the clinical team at hospital discharge. Design Retrospective cohort study. Setting Large academic medical centre in New York, NY. Participants 514 hospital discharges of older patients admitted to a geriatric inpatient service between 1 July 2007 and 30 June 2008. Primary outcome measure and main independent variable Re-admissions for any reason to any hospital within 30 days after discharge were identified. Agreement or disagreement with the discharge disposition recommended by the clinical team at hospital discharge was assessed. Results Among 514 hospital discharges of older patients, the mean age was 83.1 years (SD=8.3), 75.7% were women, and approximately 90% were living at home prior to hospitalisation, despite 47.1% having some degree of cognitive impairment and 56.4% requiring assistance for activities of daily living or independent activities of daily living. There were 42 (8.2%) disposition disagreements; the majority (n=25; 59.5%) were discharged home despite the clinical teams recommendation for discharge to an acute or subacute facility. Overall, 158 (30.7%) were re-admitted within 30 days. There was no difference in re-admission rates between discharges with and without disposition disagreements (33.3% (144 of 472) vs 30.5% (14 of 42), respectively; OR=1.14, 95% CI 0.57 to 2.19; p=0.71). Adjusted analyses were consistent with these findings. Conclusions Discharge disposition disagreements occurred relatively infrequently after hospitalisation among a group of older patients managed by a geriatrics inpatient service. In addition, we found no differences in re-admission when comparing patients who agreed or disagreed with the clinical teams recommended discharge disposition.

Cancer in Long-Term Care

This article describes the range of cancer patients in longterm care and provides a framework for clinical decision making. The benefits and burdens of providing standard therapy to a vulnerable population are discussed. To give more specific guidelines for advocates of treatment, skeptics, and others, the authors present best estimates of the current burden of cancer in the long-term care population and current screening guidelines that apply to the elderly under long-term care. Experience-based suggestions are offered for oncologists and clinicians involved in long-term care to help them respond to patient and family concerns about limitations of cancer care.

Geriatric Oncology Education for the Oncologist is Overdue

Beatriz Korc-Grodzicki, MD, PhD, is Chief of the Geriatrics Service at Memorial Sloan Kettering Cancer Center and Professor of Clinical Medicine at Weil Cornell Medical College in New York. She has clinical expertise in the consultative and management roles of the geriatrician in providing clinical care to older patients with cancer and other comorbidities in a cancer center environment. She is the Principal Investigator of a Geriatric Workforce Enhancement Program (GWEP) HRSA grant to provide education to oncologists and primary care physicians about the care of the geriatric patient with cancer.