- Email: [email protected]
Socioeconomic Considerations and Shared-Care Models of Cancer Care for Older Adults
Socioeconomic Considerations and S h a re d - C a re Mo d e l s o f C a n c e r C a re f o r O l d e r A d u l t s William Dale, MD, PhDa,b,*, Selina Chow, MDa,b, Saleha Sajid, MDa,b KEYWORDS Models of care Geriatrics Oncology Geriatric oncology Aging Cancer KEY POINTS Older patients are the largest and fastest-growing group of patients with cancer. Older adults currently account for the most expensive segment of the population in overall costs of cancer care, which is growing with the advent of costly new therapies. Principles of care and assessment tools from geriatrics can be used to assessment life expectancy, identify age-associated deficits, and target therapies to optimize care for older patients with cancer. Specific models of care exist to implement a geriatric oncology approach into clinical practice that can optimize and improve quality, reduce costs, and optimize care for older adults with cancer.
GERIATRICS APPROACH TO CANCER CARE CAN IMPROVE THE DELIVERED VALUE
The geriatrics approach to the care of older adults is centered on decision-making for complex patients in the face of uncertainty, based on 2 fundamental principles: 1. Using the highest-quality evidence available appropriately applied to clinical circumstances 2. Incorporating patients’ goals to maximize quality of life. By matching the available evidence to those goals, then communicating clearly with the patient, an informed and shared decision guides all management. These principles must be kept clearly in mind when treating older patients with cancer.
a Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA; b Section of Hematology/Oncology, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA * Corresponding author. Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, MC6098, 5841 South Maryland Avenue, Chicago, IL 60643. E-mail address: [email protected]
Clin Geriatr Med 32 (2016) 35–44 http://dx.doi.org/10.1016/j.cger.2015.08.007 geriatric.theclinics.com 0749-0690/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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What challenges currently prevent an evidence-based care for older adults with cancer? First, there is a dearth of sufficient high-quality evidence on which to base management decisions. Too often, older patients are excluded from clinical trials. Even when included, those older adults are typically not representative, being sicker and frailer, and therefore not generalizable, to older adults most commonly being treated. Management decisions are typically made in a busy clinical setting with little time to weigh treatment alternatives, making subtle decisions even more difficult. Although better evidence is awaited, a practical approach to cancer care for older adults with cancer is necessary. Such an approach will bring the “art” of geriatrics to the oncology clinic, providing an approach for providers to use based on current evidence. Broadly speaking, there are 2 common errors made in treating older patients: undertreatment and overtreatment. Undertreatment results from ageism— making management choices based on chronologic age rather than physiologic age. Medical decisions for fit older adults should be indistinguishable from any other patient with cancer—they should be treated with the most appropriate treatment compatible with their care goals. Conversely, overtreatment results from inappropriately aggressive cancer-directed therapy while ignoring patient vulnerability, remaining life expectancy (RLE), and treatment toxicities. Treating older adults with cancer requires navigating between undertreatment due to ageism—denying life-enhancing treatment to fit older patients with cancer—and overtreatment—giving toxic therapy to vulnerable older patients and lowering the quality of their survival. Delivering high-value care requires avoiding both errors. With this is mind, the authors recommend the following a 3-step approach to deliver such high-value care and guide care models. First, a clinician should use geriatric assessment (GA) to estimate remaining life-expectancy for an older adult with cancer. Estimating remaining life-expectancy is done through the application of the validated tools from GA to older patients, allowing the assignment of patients into 3 categories: fit, vulnerable, or frail. This categorization avoids undertreating the fit elderly, avoids overtreating the frail elderly, and targets further assessment for the vulnerable. Second, it is important to both stage the cancer and “stage the aging” to predict the likelihood of complication and toxicities from possible treatment. Finally, one must match the available care options with the preferences and goals of patients, communicating carefully to reach an informed, shared decision. In taking such an approach, one can be sail safely through the troubled waters of caring for older adults with cancer. SOCIOECONOMIC CONSIDERATIONS OF PROVIDING HIGH-VALUE CANCER CARE
It has long been recognized that age is associated with increased costs of care. According to the 1992 to 1998 Medicare Current Beneficiary survey data, older adults in better health had a longer RLE than those in poorer health, but had similar cumulative health care expenditures until death.1 A person with no functional limitations at 70 had an RLE of 14.3 years and expected cumulative health care expenditures of $136,000, whereas a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of $145,000. Expenditures varied little according to self-reported health at the age of 70. Persons who were institutionalized at the age of 70 had cumulative expenditures that were much higher than those for persons who were not institutionalized. Age is clearly an important contributor to the costs of care. Medicare’s expenditures on cancer care are substantial and vary by phase of care, tumor site, stage at diagnosis, and survival. A SEER (Surveillance, Epidemiology, and End Results) database review (2008) found the mean net costs of cancer care were
Cancer Care for Older Adults
highest in the initial and last year-of-life phases of care and lowest in the continuing phase.2,3 Mean 5-year net costs varied significantly by tumor type, from less than $20,000 for patients with breast cancer or melanoma to more than $40,000 for patients with cancers of the brain, esophageal, gastric, ovarian cancers, or lymphoma. In patients with acute myeloid leukemia, 80% of costs are related to inpatient hospitalization. In 2004, the 5-year net costs of cancer care to Medicare for older patients were approximately $21.1 billion. In short, cancer costs have long been substantial. With the creation of several new agents in the last decade, the per month costs of anticancer agents has more than doubled, from $4500 to more than $10,000. Of the 12 anticancer drugs approved by the US Food and Drug Administration in 2012, only 3 prolonged survival (2 of them by <2 months): 9 were priced at more than $10,000 per month.4 Many so-called targeted agents have been priced between $6000 to 12,000 per month or approximately $70,000 to 115,000 per patient annually.5 The high cost may prevent many older patients from being able to obtain such medications, leading to nonadherence. This nonadherence, in turn, results in costs exceeding $100 billion annually, due to increased health services utilization, higher hospital admission rates, and adverse drug events associated with nonadherence.6 The economic impact of cancer survivorship is considerable, remains high years after a cancer diagnosis, and is approximately the same in younger and older cancer survivors. Given the high and rising costs of cancer care for older adults, combined with the rapidly rising numbers of older adults with cancer as the baby boomers age, it is more important than ever to use resources wisely and is best accomplished through a geriatrics approach to cancer for older patients. Creating care models based on a geriatrics approach and using geriatrics tools are the most economical way to deliver such care. GERIATRIC ASSESSMENT AND TARGETED INTERVENTIONS ACROSS THE CANCER CARE CONTINUUM
Coordination and collaboration across the cancer care continuum are emerging ideals. A geriatric oncology model of care consists of constructing a multilevel clinical and organizational system that: 1. Provides cancer-specific, fitness-appropriate, and individualized geriatric care; 2. Provides strong integration between medical care, supportive care, and social services; 3. Can design and implement age-appropriate health care policies and practices. Older patients with cancer are a heterogeneous group with a high prevalence of comorbid conditions and vulnerabilities to cancer treatment.7 Identifying first those at highest risk of chemotherapy or surgical morbidity during subsequent therapy may improve treatment and prognosis in these patients and generally requires a 3-step approach. First, they should be assessed using validated tools such as the comprehensive geriatric assessment (CGA) before treatment.8 Second, the risk of therapyrelated toxicity during treatment should be completed using validated tools such as Cancer and Aging Research Group and the Chemotherapy Risk-Assessment Scale for High-Age Patients.9,10 Third, those at highest risk for toxicity should receive appropriate interventions to mitigate against these risks. CGA helps determine a patient’s level of frailty, thereby guiding treatment choices.11 However, institutions often have organizational constraints limiting providers’ ability to administer CGA.12 For this reason, attention to using prescreening tests such as the Vulnerable Elders Survey-13.13–17 Using screening tools decreases resources needed
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for assessments of older adults. The CGA is best administered at times of clinical decision-making to identify vulnerable patients such as during initial treatment consultations or during changes in clinical condition, including new or worsening pain, fatigue, hospitalizations, or disease progression requiring a change in therapy.9 The impact of CGA for informing treatment decisions was of greatest value when unidentified medical problems were found, which occurred in 70% of patients.18 Screening during the course of chemotherapy found that the CGA directly influenced oncologic treatment in 40% of patients; it ensured continuity/coordination of care in 70%, and the success rate in addressing problems was 87%, in which Functional Assessment of Cancer Treatment–Breast scores improved and function and independence were maintained during therapy.19,20 Sequential CGA assessment is appropriate as patients progress through the continuum of cancer experience. Consideration must be given to the phase of disease where disability or death from the cancer will outpace treatmentrelated toxicities. Several studies have showed that frail patients identified using CGA had poorer outcomes compared with fit patients, and specifically shortened overall survival.21,22 CGA can help to frame discussions with patients and families, during the course of cancer therapy, allowing for realistic expectations from offered treatments. Studies have shown that the use of chemotherapy in frail patients is associated with increased risk of cardiopulmonary resuscitation, mechanical ventilation, or both, and dying in an intensive care unit.23–30 Thus, treatment-related decisions, before, during, and after chemotherapy, are complex and should be individualized. Geriatric assessments can predict treatment-related toxicities and adverse geriatrics outcomes, which are independent from oncologic, tumor-based predictors. Appropriate geriatrics parameters to predict adverse outcomes to guide treatment modifications have not yet been established for different cancer types or treatments.31 Nevertheless, results from this assessment can be effectively used to guide various treatment options across tumor types (Fig. 1).
Fig. 1. Individualized treatment plan in older adults with cancer.
Cancer Care for Older Adults
The International Society of Geriatric Oncology has created a task force to address tumor-specific therapies in the elderly, including for screening, surgery, radiation, (neo)adjuvant therapies, chemotherapies, and metastatic diseases on several tumor types in the elderly.32–34 The CGA can help identify deficits within geriatrics domains to guide targeted interventions. The CGA has been used in patient selection for multimodality treatment in cancers, such as head and neck, breast, and colorectal cancers, which has improved geriatrics outcomes.35,36 In patients with head and neck cancer where prevalence of malnutrition is high, the CGA identifies nutritional deficiencies early and allows timely interventions, thus improving quality of life.37 In leukemia patients undergoing bone marrow transplant, the CGA identifies fit older patients who have an overall survival benefit from reduced-intensity conditioning hematopoietic stem cell transplantation.38 Regardless of the tumor type, the approach remains the same: use the CGA to predict competing causes of morbidity and mortality before cancer therapy (surgery, radiation, chemotherapy, or multimodality therapy), use it as a tool to define patient fitness, use it to longitudinally assess patient frailty during therapy, and potentially to decide when to discontinue therapy (see Fig. 1). ORGANIZATIONAL MODELS OF CANCER CARE
Geriatric oncology has evolved over the past 2 decades, combining these 2 disciplines to develop the optimal approach to care for older patients with cancer. Bringing the principles of care from geriatrics, applying them to older adults with cancer, and coordinating that care to deliver high-value, cost-effective care is more important than ever. Cancer centers in the United States have taken several approaches to develop different models of geriatric oncology care that may be specific to their treatment populations, to availability of specialty-trained providers, and that operates within their local institutional infrastructure and constraints. Although there is not a universal model of geriatric oncology care, the rationale for developing a geriatric oncology clinic includes39: Identifying patients potentially at risk for cancer treatment toxicity; Reducing the time required by the medical oncologist to manage the complexity of older patients; Crafting treatment plans after CGA or by managing the nononcologic issues of older patients with cancer in separate clinics; Providing patient-centered care with an assessment that takes into account a patient’s values and social support network; Being a research hub to further the understanding of treating older patients with cancer; Providing fellow, resident, and medical student education in geriatric oncology. The first geriatric oncology clinic that opened in the United States was at the H. Lee Moffitt Comprehensive Cancer Center in Tampa, Florida in 1993 under the leadership of Lodovico Balducci, MD. Since then, a small number of such clinics have evolved. Over these past 2 decades, 4 distinct geriatric oncology clinical models have been described: 1. 2. 3. 4.
Screen-and-referral model Primary-provider model Multidisciplinary consultative model Embedded, geriatrics-driven, comprehensive care model.
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Of course, some of these models can overlap, and blended care models are possible. However, for reasons of conceptual clarity, each is considered separately in later discussion. Primary Provider Model
This care model incorporates a formally trained geriatric oncologist, geriatrician, and palliative medicine provider as the primary medical care provider for older patients with cancer. In cancer centers such as H. Lee Moffitt Comprehensive Cancer Center, John Theurer Cancer Center at Hackensack University Medical Center in New Jersey, UNC Lineberger Comprehensive Cancer Center, and the Specialized Oncology Care and Research in the Elderly (SOCARE) clinic at the University of Chicago and University of Rochester, these programs have the ability to perform the initial comprehensive assessment, devise the overall treatment plan, and manage a patient’s care from the time of diagnosis to the end of life.40–42 The advantages of this primary provider model include care continuity for this vulnerable patient population, a medical home for patients with complex care needs, and a concentration of resources on the most vulnerable patients with cancer. The disadvantages to this care model are the limits of expertise due to the small number of dually trained geriatric oncologists that could carry out this role, the limits on numbers of patients as panel sizes grow, and the need for specialized resources (eg, space, equipment, time, training) to be invested. Such care models are difficult to develop outside of large organizations with the ability to invest in these resources; however, they typically deliver the highest value care for frail older adults with cancer. Multidisciplinary Consultative Model
In this care model, used by centers such as the SOCARE Clinics at the University of Rochester and University of Chicago, Thomas Jefferson University, and the Cleveland Clinic, the use of a cancer-specific GA is the basis for these clinics with self-reported assessments and in-clinic evaluations.39,43,44 These consultative clinics typically evaluate older, frailer patients with cancer with solid tumor malignancies, typically at the request of other oncologists. At the University of Chicago, with the Transplant in Older Patients program, and the Dana-Farber/Brigham and Women’s Cancer Center with their Older Adult Hematology Malignancy Program, some centers have developed disease-specific multidisciplinary consultative clinics for older patients with leukemia and related blood disorders.45,46 As described above, GA is used to develop appropriate treatment plans adapted for older adults with cancer.13,47 Typically, GA is performed in the outpatient setting by a multidisciplinary team led by a geriatrician or geriatric oncologist. Other key members of this multidisciplinary team may include advanced practice nurses or physician assistants, pharmacists, social workers, nutritionists, physical therapists, occupational therapists, and patient navigators. The availability of these providers varies depending on local resources, but the goal is to provide a comprehensive evaluation that leads to a personalized treatment plan for patients and their treating oncologists. A significant advantage of this care model is that a larger number of patients can be evaluated, receive advice, and derive benefit to their cancer care while maintaining continuity with their primary oncologist. However, the ability to provide continued guidance from experts in the care of aging patients during a patient’s treatment course is more limited with this clinical model. Geriatrics-Driven and Embedded Consultative Model
At centers such as Memorial Sloan-Kettering Cancer Center, MD Anderson Cancer Center, and the University of California, Los Angeles, geriatricians have been either embedded within the oncology clinics or perform the GA assessments within their
Cancer Care for Older Adults
own, separate location.48,49 This model has emerged within larger cancer centers, but where geriatrics’ expertise has a notable, but geographically separate existence. This care model is similar to the multidisciplinary consultative model, in which geriatrics expertise is infused into an on-going oncology care plan. This model works best where geriatrics has a strong institutional presence, but where dually trained geriatric oncologists are not readily available to provide comprehensive assessments and the ability to assume care for patients. In some institutions, a geriatrician-led team may be available to assist with non-oncologic-related issues as they arise during a patient’s treatment course. This care model is a partnership, with the infusion of aging expertise into ongoing cancer care. Screen and Refer Clinic Model
This care model typically takes place at a university setting, with assessments that can take several hours to complete, and is resource-intensive due to coordination of a multidisciplinary team of health care providers. With most cancer care taking place in a community practice setting, geriatric oncology providers have developed ways to conduct GA evaluations that could be feasible in the busy community clinical practices. In a study conducted by Williams and colleagues50 from the UNC Lineberger Comprehensive Cancer Center, a validated GA tool consisting of a self-reported questionnaire with a brief in-clinic assessment by a health professional is used to determine the feasibility of performing this assessment in a community setting. The median time to completing the entire assessment was comparable to the academic setting (30 minutes vs 22 minutes, respectively) with a modest commitment of professional time. The authors are now examining the feasibility of providing timely GA-based recommendations for referrals and services similar to that practiced at the academic institution level. In a study performed at the Joan Karnell Cancer Center at Pennsylvania Hospital, a community affiliate of the University of Pennsylvania Health System, a brief screening tool was administered by the geriatric social worker evaluating for nursing, social work, psychological, nutrition, prescription, and caregiver needs.51 If older patients were identified as having needs beyond that which could be provided through social work intervention, referrals were made to appropriate clinicians and outside community resources. In both of these cases, it was shown that significant elements of GA can be implemented in busy community settings with relatively limited resources. Whether this care model will prove cost-effective is not known. REFERENCES
1. Lubitz J, Cai L, Kramarow E, et al. Health, life expectancy, and health care spending among the elderly. N Engl J Med 2003;349(11):1048–55. 2. Yabroff KR, Lamont EB, Mariotto A, et al. Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 2008;100(9):630–41. 3. Kantarjian HM, Fojo T, Mathisen M, et al. Cancer drugs in the United States: Justum Pretium–the just price. J Clin Oncol 2013;31(28):3600–4. 4. Dusetzina SB, Winn AN, Abel GA, et al. Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia. J Clin Oncol 2014; 32(4):306–11. 5. IMS Institute for Healthcare Informatics Avoidable costs in U.S. healthcare: The $200 billion opportunity from using medicines more responsibly. Available at: http://www. imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Institute/ RUOM-2013/IHII_Responsible_Use_Medicines_2013.pdf. Accessed August 15, 2015.
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6. Guy GP Jr, Ekwueme DU, Yabroff KR, et al. Economic burden of cancer survivorship among adults in the United States. J Clin Oncol 2013;31(30):3749–57. 7. Stafford RS, Cyr PL. The impact of cancer on the physical function of the elderly and their utilization of health care. Cancer 1997;80:1973–80. 8. Rubenstein LZ, Wieland D. Comprehensive geriatric assessment. Annu Rev Gerontol Geriatr 1989;9:145–92. 9. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol 2011;29(25): 3457–65. 10. Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer 2012;118(13):3377–86. 11. Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment. Cancer 2005;104(9):1998–2005. 12. McCarthy AL, Cook PS, Yates P. Engineering the fitness of older patients for chemotherapy: an exploration of Comprehensive Geriatric Assessment in practice. Health (London) 2014;18(2):196–212. 13. Ingram SS, Seo PH, Martell RE, et al. Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology. J Clin Oncol 2002;20(3): 770–5. 14. Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691–9. 15. Mohile SG, Bylow K, Dale W, et al. A pilot study of the Vulnerable Elders Survey13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007;109(4):802–10. 16. Kim J, Hurria A. Determining chemotherapy tolerance in older patients with cancer. J Natl Compr Canc Netw 2013;11(12):1494–502. 17. Luciani A, Ascione G, Bertuzzi C, et al. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable elders survey-13. J Clin Oncol 2010;28(12):2046–50. 18. Horgan AM, Leighl NB, Coate L, et al. Impact and feasibility of a comprehensive geriatric assessment in the oncology setting: a pilot study. Am J Clin Oncol 2012; 35(4):322–8. 19. Extermann M, Meyer J, McGinnis M, et al. A comprehensive geriatric intervention detects multiple problems in older breast cancer patients. Crit Rev Oncol Hematol 2004;49(1):69–75. 20. Extermann M, Bonetti M, Sledge GW, et al. MAX2—a convenient index to estimate the average per patient risk for chemotherapy toxicity: validation in ECOG trials. Eur J Cancer 2004;40(8):1193–8. 21. Merli F, Luminari S, Rossi G, et al. Outcome of frail elderly patients with diffuse large B-cell lymphoma prospectively identified by Comprehensive Geriatric Assessment: results from a study of the Fondazione Italiana Linfomi. Leuk Lymphoma 2014;55(1):38–43. 22. Aaldriks AA, Maartense E, le Cessie S, et al. Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Crit Rev Oncol Hematol 2011;79(2):205–12. 23. Wright AA, Zhang B, Keating NL, et al. Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death: prospective cohort study. BMJ 2014;348:g1219.
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24. Goldstein NE, Morrison RS. The intersection between geriatrics and palliative care: a call for a new research agenda. J Am Geriatr Soc 2005;53(9): 1593–8. 25. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older adults. J Am Geriatr Soc 2002;50(6 Suppl):S205–24. 26. Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003;51(4):556–7. 27. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA 1999;282(23):2215–9. 28. Waltson J, Fried L. Frailty and its implications for care. In: Meier DE, Morrison RS, editors. Geriatric palliative care. New York: Oxford University Press; 2003. p. 93–109. 29. Penrod JD, Morrison RS. Challenges for palliative care research. J Palliat Med 2004;7(3):398–402. 30. Casarett DJ. The future of the palliative medicine fellowship. J Palliat Med 2000; 3(2):151–5. 31. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 2014;32(24):2595–603. 32. Wildiers H, Kunkler I, Biganzoli L, et al. Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology. Lancet Oncol 2007;8(12):1101–15. 33. Pallis AG, Gridelli C, van Meerbeeck JP, et al. EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIOG) experts’ opinion for the treatment of non-small-cell lung cancer in an elderly population. Ann Oncol 2010;21(4):692–706. 34. Droz JP, Balducci L, Bolla M, et al. Management of prostate cancer in older men: recommendations of a working group of the International Society of Geriatric Oncology. BJU Int 2010;106(4):462–9. 35. Bernardi D, Barzan L, Franchin G, et al. Treatment of head and neck cancer in elderly patients: state of the art and guidelines. Crit Rev Oncol Hematol 2005; 53(1):71–80. 36. Kristjansson SR, Nesbakken A, Jordhøy MS, et al. Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study. Crit Rev Oncol Hematol 2010;76(3):208–17. 37. Ortholan C, Benezery K, Dassonville O, et al. A specific approach for elderly patients with head and neck cancer. Anticancer Drugs 2011;22(7):647–55. 38. Koreth J, Pidala J, Perez WS, et al. Role of reduced-intensity conditioning allogeneic hematopoietic stem-cell transplantation in older patients with de novo myelodysplastic syndromes: an international collaborative decision analysis. J Clin Oncol 2013;31(21):2662–70. 39. Magnuson A, Dale W, Mohile S, et al. Models of care in geriatric oncology. Curr Geriatr Rep 2014;3(3):182–9. 40. McNeil C. Geriatric oncology clinics on the rise. J Natl Cancer Inst 2013;105(9): 585–6. 41. Geriatric Oncology Program. UNC Linberger Comprehensive Cancer Center. Available at: https://unclineberger.org/patientcare/programs/geriatric. Accessed August 15, 2015. 42. Geriatric Oncology. SOCARE Clinic. Available at: http://www.uchospitals.edu/ specialties/cancer/geriatric-oncology/. Accessed August 15, 2015.
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43. Chapman AE, Swartz K, Schoppe J, et al. Development of a comprehensive multidisciplinary geriatric oncology center, the Thomas Jefferson University Experience. J Gen Orthod 2014;5:164–70. 44. Taussig Oncology Program for Seniors (TOPS). Cleveland Clinic. Available at: http:// my.clevelandclinic.org/services/cancer/treatments-procedures/taussig-oncologyprogram-for-seniors. Accessed August 15, 2015. 45. Blood and Bone Marrow Stem Cell Transplantation for Older Adults. Older Adults: Blood and Bone Marrow Stem Cell Transplantation. Available at: http://www. uchospitals.edu/specialties/cancer/stem-cell-transplant/older-adults.html. Accessed August 15, 2015. 46. Older Adult Hematologic Malignancy (OHM) Program - Dana-Farber Cancer Institute j Boston, MA. Older Adult Hematologic Malignancy (OHM) Program Dana-Farber Cancer InstitutejBoston, MA. Available at: http://www.dana-farber. org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/ Hematologic-Oncology-Treatment-Center/Older-Adult-Hematologic-Malignancy(OHM)-Program.aspx. Accessed August 15, 2015. 47. Hurria A, Wildes T, Blair SL, et al. Senior adult oncology, version 2.2014: clinical practice guidelines in oncology. J Natl Compr Canc Netw 2014;12(1):82–126. 48. Help for Older Patients. Counseling & Support. Available at: https://www.mskcc. org/cancer-care/treatments/symptom-management/help-older-patients. Accessed August 15, 2015. 49. Geriatric Oncology j David Geffen School of Medicine at UCLA. Geriatric Oncology David Geffen School of Medicine at UCLA. Available at: http:// people.healthsciences.ucla.edu/education/institution/groups-detail?group_id5 13268. Accessed August 15, 2015. 50. Williams GR, Deal AM, Jolly TA, et al. Feasibility of geriatric assessment in community oncology clinics. J Gen Orthod 2014;5:245–51. 51. Lynch MP, Marcone D, Kagan SH, et al. Developing a multidisciplinary geriatric oncology program in a community cancer center. Clin J Oncol Nurs 2007; 11(6):929–33.
GERIATRICS APPROACH TO CANCER CARE CAN IMPROVE THE DELIVERED VALUE
The geriatrics approach to the care of older adults is centered on decision-making for complex patients in the face of uncertainty, based on 2 fundamental principles: 1. Using the highest-quality evidence available appropriately applied to clinical circumstances 2. Incorporating patients’ goals to maximize quality of life. By matching the available evidence to those goals, then communicating clearly with the patient, an informed and shared decision guides all management. These principles must be kept clearly in mind when treating older patients with cancer.
a Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA; b Section of Hematology/Oncology, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA * Corresponding author. Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago, MC6098, 5841 South Maryland Avenue, Chicago, IL 60643. E-mail address: [email protected]
Clin Geriatr Med 32 (2016) 35–44 http://dx.doi.org/10.1016/j.cger.2015.08.007 geriatric.theclinics.com 0749-0690/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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What challenges currently prevent an evidence-based care for older adults with cancer? First, there is a dearth of sufficient high-quality evidence on which to base management decisions. Too often, older patients are excluded from clinical trials. Even when included, those older adults are typically not representative, being sicker and frailer, and therefore not generalizable, to older adults most commonly being treated. Management decisions are typically made in a busy clinical setting with little time to weigh treatment alternatives, making subtle decisions even more difficult. Although better evidence is awaited, a practical approach to cancer care for older adults with cancer is necessary. Such an approach will bring the “art” of geriatrics to the oncology clinic, providing an approach for providers to use based on current evidence. Broadly speaking, there are 2 common errors made in treating older patients: undertreatment and overtreatment. Undertreatment results from ageism— making management choices based on chronologic age rather than physiologic age. Medical decisions for fit older adults should be indistinguishable from any other patient with cancer—they should be treated with the most appropriate treatment compatible with their care goals. Conversely, overtreatment results from inappropriately aggressive cancer-directed therapy while ignoring patient vulnerability, remaining life expectancy (RLE), and treatment toxicities. Treating older adults with cancer requires navigating between undertreatment due to ageism—denying life-enhancing treatment to fit older patients with cancer—and overtreatment—giving toxic therapy to vulnerable older patients and lowering the quality of their survival. Delivering high-value care requires avoiding both errors. With this is mind, the authors recommend the following a 3-step approach to deliver such high-value care and guide care models. First, a clinician should use geriatric assessment (GA) to estimate remaining life-expectancy for an older adult with cancer. Estimating remaining life-expectancy is done through the application of the validated tools from GA to older patients, allowing the assignment of patients into 3 categories: fit, vulnerable, or frail. This categorization avoids undertreating the fit elderly, avoids overtreating the frail elderly, and targets further assessment for the vulnerable. Second, it is important to both stage the cancer and “stage the aging” to predict the likelihood of complication and toxicities from possible treatment. Finally, one must match the available care options with the preferences and goals of patients, communicating carefully to reach an informed, shared decision. In taking such an approach, one can be sail safely through the troubled waters of caring for older adults with cancer. SOCIOECONOMIC CONSIDERATIONS OF PROVIDING HIGH-VALUE CANCER CARE
It has long been recognized that age is associated with increased costs of care. According to the 1992 to 1998 Medicare Current Beneficiary survey data, older adults in better health had a longer RLE than those in poorer health, but had similar cumulative health care expenditures until death.1 A person with no functional limitations at 70 had an RLE of 14.3 years and expected cumulative health care expenditures of $136,000, whereas a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of $145,000. Expenditures varied little according to self-reported health at the age of 70. Persons who were institutionalized at the age of 70 had cumulative expenditures that were much higher than those for persons who were not institutionalized. Age is clearly an important contributor to the costs of care. Medicare’s expenditures on cancer care are substantial and vary by phase of care, tumor site, stage at diagnosis, and survival. A SEER (Surveillance, Epidemiology, and End Results) database review (2008) found the mean net costs of cancer care were
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highest in the initial and last year-of-life phases of care and lowest in the continuing phase.2,3 Mean 5-year net costs varied significantly by tumor type, from less than $20,000 for patients with breast cancer or melanoma to more than $40,000 for patients with cancers of the brain, esophageal, gastric, ovarian cancers, or lymphoma. In patients with acute myeloid leukemia, 80% of costs are related to inpatient hospitalization. In 2004, the 5-year net costs of cancer care to Medicare for older patients were approximately $21.1 billion. In short, cancer costs have long been substantial. With the creation of several new agents in the last decade, the per month costs of anticancer agents has more than doubled, from $4500 to more than $10,000. Of the 12 anticancer drugs approved by the US Food and Drug Administration in 2012, only 3 prolonged survival (2 of them by <2 months): 9 were priced at more than $10,000 per month.4 Many so-called targeted agents have been priced between $6000 to 12,000 per month or approximately $70,000 to 115,000 per patient annually.5 The high cost may prevent many older patients from being able to obtain such medications, leading to nonadherence. This nonadherence, in turn, results in costs exceeding $100 billion annually, due to increased health services utilization, higher hospital admission rates, and adverse drug events associated with nonadherence.6 The economic impact of cancer survivorship is considerable, remains high years after a cancer diagnosis, and is approximately the same in younger and older cancer survivors. Given the high and rising costs of cancer care for older adults, combined with the rapidly rising numbers of older adults with cancer as the baby boomers age, it is more important than ever to use resources wisely and is best accomplished through a geriatrics approach to cancer for older patients. Creating care models based on a geriatrics approach and using geriatrics tools are the most economical way to deliver such care. GERIATRIC ASSESSMENT AND TARGETED INTERVENTIONS ACROSS THE CANCER CARE CONTINUUM
Coordination and collaboration across the cancer care continuum are emerging ideals. A geriatric oncology model of care consists of constructing a multilevel clinical and organizational system that: 1. Provides cancer-specific, fitness-appropriate, and individualized geriatric care; 2. Provides strong integration between medical care, supportive care, and social services; 3. Can design and implement age-appropriate health care policies and practices. Older patients with cancer are a heterogeneous group with a high prevalence of comorbid conditions and vulnerabilities to cancer treatment.7 Identifying first those at highest risk of chemotherapy or surgical morbidity during subsequent therapy may improve treatment and prognosis in these patients and generally requires a 3-step approach. First, they should be assessed using validated tools such as the comprehensive geriatric assessment (CGA) before treatment.8 Second, the risk of therapyrelated toxicity during treatment should be completed using validated tools such as Cancer and Aging Research Group and the Chemotherapy Risk-Assessment Scale for High-Age Patients.9,10 Third, those at highest risk for toxicity should receive appropriate interventions to mitigate against these risks. CGA helps determine a patient’s level of frailty, thereby guiding treatment choices.11 However, institutions often have organizational constraints limiting providers’ ability to administer CGA.12 For this reason, attention to using prescreening tests such as the Vulnerable Elders Survey-13.13–17 Using screening tools decreases resources needed
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for assessments of older adults. The CGA is best administered at times of clinical decision-making to identify vulnerable patients such as during initial treatment consultations or during changes in clinical condition, including new or worsening pain, fatigue, hospitalizations, or disease progression requiring a change in therapy.9 The impact of CGA for informing treatment decisions was of greatest value when unidentified medical problems were found, which occurred in 70% of patients.18 Screening during the course of chemotherapy found that the CGA directly influenced oncologic treatment in 40% of patients; it ensured continuity/coordination of care in 70%, and the success rate in addressing problems was 87%, in which Functional Assessment of Cancer Treatment–Breast scores improved and function and independence were maintained during therapy.19,20 Sequential CGA assessment is appropriate as patients progress through the continuum of cancer experience. Consideration must be given to the phase of disease where disability or death from the cancer will outpace treatmentrelated toxicities. Several studies have showed that frail patients identified using CGA had poorer outcomes compared with fit patients, and specifically shortened overall survival.21,22 CGA can help to frame discussions with patients and families, during the course of cancer therapy, allowing for realistic expectations from offered treatments. Studies have shown that the use of chemotherapy in frail patients is associated with increased risk of cardiopulmonary resuscitation, mechanical ventilation, or both, and dying in an intensive care unit.23–30 Thus, treatment-related decisions, before, during, and after chemotherapy, are complex and should be individualized. Geriatric assessments can predict treatment-related toxicities and adverse geriatrics outcomes, which are independent from oncologic, tumor-based predictors. Appropriate geriatrics parameters to predict adverse outcomes to guide treatment modifications have not yet been established for different cancer types or treatments.31 Nevertheless, results from this assessment can be effectively used to guide various treatment options across tumor types (Fig. 1).
Fig. 1. Individualized treatment plan in older adults with cancer.
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The International Society of Geriatric Oncology has created a task force to address tumor-specific therapies in the elderly, including for screening, surgery, radiation, (neo)adjuvant therapies, chemotherapies, and metastatic diseases on several tumor types in the elderly.32–34 The CGA can help identify deficits within geriatrics domains to guide targeted interventions. The CGA has been used in patient selection for multimodality treatment in cancers, such as head and neck, breast, and colorectal cancers, which has improved geriatrics outcomes.35,36 In patients with head and neck cancer where prevalence of malnutrition is high, the CGA identifies nutritional deficiencies early and allows timely interventions, thus improving quality of life.37 In leukemia patients undergoing bone marrow transplant, the CGA identifies fit older patients who have an overall survival benefit from reduced-intensity conditioning hematopoietic stem cell transplantation.38 Regardless of the tumor type, the approach remains the same: use the CGA to predict competing causes of morbidity and mortality before cancer therapy (surgery, radiation, chemotherapy, or multimodality therapy), use it as a tool to define patient fitness, use it to longitudinally assess patient frailty during therapy, and potentially to decide when to discontinue therapy (see Fig. 1). ORGANIZATIONAL MODELS OF CANCER CARE
Geriatric oncology has evolved over the past 2 decades, combining these 2 disciplines to develop the optimal approach to care for older patients with cancer. Bringing the principles of care from geriatrics, applying them to older adults with cancer, and coordinating that care to deliver high-value, cost-effective care is more important than ever. Cancer centers in the United States have taken several approaches to develop different models of geriatric oncology care that may be specific to their treatment populations, to availability of specialty-trained providers, and that operates within their local institutional infrastructure and constraints. Although there is not a universal model of geriatric oncology care, the rationale for developing a geriatric oncology clinic includes39: Identifying patients potentially at risk for cancer treatment toxicity; Reducing the time required by the medical oncologist to manage the complexity of older patients; Crafting treatment plans after CGA or by managing the nononcologic issues of older patients with cancer in separate clinics; Providing patient-centered care with an assessment that takes into account a patient’s values and social support network; Being a research hub to further the understanding of treating older patients with cancer; Providing fellow, resident, and medical student education in geriatric oncology. The first geriatric oncology clinic that opened in the United States was at the H. Lee Moffitt Comprehensive Cancer Center in Tampa, Florida in 1993 under the leadership of Lodovico Balducci, MD. Since then, a small number of such clinics have evolved. Over these past 2 decades, 4 distinct geriatric oncology clinical models have been described: 1. 2. 3. 4.
Screen-and-referral model Primary-provider model Multidisciplinary consultative model Embedded, geriatrics-driven, comprehensive care model.
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Of course, some of these models can overlap, and blended care models are possible. However, for reasons of conceptual clarity, each is considered separately in later discussion. Primary Provider Model
This care model incorporates a formally trained geriatric oncologist, geriatrician, and palliative medicine provider as the primary medical care provider for older patients with cancer. In cancer centers such as H. Lee Moffitt Comprehensive Cancer Center, John Theurer Cancer Center at Hackensack University Medical Center in New Jersey, UNC Lineberger Comprehensive Cancer Center, and the Specialized Oncology Care and Research in the Elderly (SOCARE) clinic at the University of Chicago and University of Rochester, these programs have the ability to perform the initial comprehensive assessment, devise the overall treatment plan, and manage a patient’s care from the time of diagnosis to the end of life.40–42 The advantages of this primary provider model include care continuity for this vulnerable patient population, a medical home for patients with complex care needs, and a concentration of resources on the most vulnerable patients with cancer. The disadvantages to this care model are the limits of expertise due to the small number of dually trained geriatric oncologists that could carry out this role, the limits on numbers of patients as panel sizes grow, and the need for specialized resources (eg, space, equipment, time, training) to be invested. Such care models are difficult to develop outside of large organizations with the ability to invest in these resources; however, they typically deliver the highest value care for frail older adults with cancer. Multidisciplinary Consultative Model
In this care model, used by centers such as the SOCARE Clinics at the University of Rochester and University of Chicago, Thomas Jefferson University, and the Cleveland Clinic, the use of a cancer-specific GA is the basis for these clinics with self-reported assessments and in-clinic evaluations.39,43,44 These consultative clinics typically evaluate older, frailer patients with cancer with solid tumor malignancies, typically at the request of other oncologists. At the University of Chicago, with the Transplant in Older Patients program, and the Dana-Farber/Brigham and Women’s Cancer Center with their Older Adult Hematology Malignancy Program, some centers have developed disease-specific multidisciplinary consultative clinics for older patients with leukemia and related blood disorders.45,46 As described above, GA is used to develop appropriate treatment plans adapted for older adults with cancer.13,47 Typically, GA is performed in the outpatient setting by a multidisciplinary team led by a geriatrician or geriatric oncologist. Other key members of this multidisciplinary team may include advanced practice nurses or physician assistants, pharmacists, social workers, nutritionists, physical therapists, occupational therapists, and patient navigators. The availability of these providers varies depending on local resources, but the goal is to provide a comprehensive evaluation that leads to a personalized treatment plan for patients and their treating oncologists. A significant advantage of this care model is that a larger number of patients can be evaluated, receive advice, and derive benefit to their cancer care while maintaining continuity with their primary oncologist. However, the ability to provide continued guidance from experts in the care of aging patients during a patient’s treatment course is more limited with this clinical model. Geriatrics-Driven and Embedded Consultative Model
At centers such as Memorial Sloan-Kettering Cancer Center, MD Anderson Cancer Center, and the University of California, Los Angeles, geriatricians have been either embedded within the oncology clinics or perform the GA assessments within their
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own, separate location.48,49 This model has emerged within larger cancer centers, but where geriatrics’ expertise has a notable, but geographically separate existence. This care model is similar to the multidisciplinary consultative model, in which geriatrics expertise is infused into an on-going oncology care plan. This model works best where geriatrics has a strong institutional presence, but where dually trained geriatric oncologists are not readily available to provide comprehensive assessments and the ability to assume care for patients. In some institutions, a geriatrician-led team may be available to assist with non-oncologic-related issues as they arise during a patient’s treatment course. This care model is a partnership, with the infusion of aging expertise into ongoing cancer care. Screen and Refer Clinic Model
This care model typically takes place at a university setting, with assessments that can take several hours to complete, and is resource-intensive due to coordination of a multidisciplinary team of health care providers. With most cancer care taking place in a community practice setting, geriatric oncology providers have developed ways to conduct GA evaluations that could be feasible in the busy community clinical practices. In a study conducted by Williams and colleagues50 from the UNC Lineberger Comprehensive Cancer Center, a validated GA tool consisting of a self-reported questionnaire with a brief in-clinic assessment by a health professional is used to determine the feasibility of performing this assessment in a community setting. The median time to completing the entire assessment was comparable to the academic setting (30 minutes vs 22 minutes, respectively) with a modest commitment of professional time. The authors are now examining the feasibility of providing timely GA-based recommendations for referrals and services similar to that practiced at the academic institution level. In a study performed at the Joan Karnell Cancer Center at Pennsylvania Hospital, a community affiliate of the University of Pennsylvania Health System, a brief screening tool was administered by the geriatric social worker evaluating for nursing, social work, psychological, nutrition, prescription, and caregiver needs.51 If older patients were identified as having needs beyond that which could be provided through social work intervention, referrals were made to appropriate clinicians and outside community resources. In both of these cases, it was shown that significant elements of GA can be implemented in busy community settings with relatively limited resources. Whether this care model will prove cost-effective is not known. REFERENCES
1. Lubitz J, Cai L, Kramarow E, et al. Health, life expectancy, and health care spending among the elderly. N Engl J Med 2003;349(11):1048–55. 2. Yabroff KR, Lamont EB, Mariotto A, et al. Cost of care for elderly cancer patients in the United States. J Natl Cancer Inst 2008;100(9):630–41. 3. Kantarjian HM, Fojo T, Mathisen M, et al. Cancer drugs in the United States: Justum Pretium–the just price. J Clin Oncol 2013;31(28):3600–4. 4. Dusetzina SB, Winn AN, Abel GA, et al. Cost sharing and adherence to tyrosine kinase inhibitors for patients with chronic myeloid leukemia. J Clin Oncol 2014; 32(4):306–11. 5. IMS Institute for Healthcare Informatics Avoidable costs in U.S. healthcare: The $200 billion opportunity from using medicines more responsibly. Available at: http://www. imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Institute/ RUOM-2013/IHII_Responsible_Use_Medicines_2013.pdf. Accessed August 15, 2015.
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6. Guy GP Jr, Ekwueme DU, Yabroff KR, et al. Economic burden of cancer survivorship among adults in the United States. J Clin Oncol 2013;31(30):3749–57. 7. Stafford RS, Cyr PL. The impact of cancer on the physical function of the elderly and their utilization of health care. Cancer 1997;80:1973–80. 8. Rubenstein LZ, Wieland D. Comprehensive geriatric assessment. Annu Rev Gerontol Geriatr 1989;9:145–92. 9. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol 2011;29(25): 3457–65. 10. Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer 2012;118(13):3377–86. 11. Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment. Cancer 2005;104(9):1998–2005. 12. McCarthy AL, Cook PS, Yates P. Engineering the fitness of older patients for chemotherapy: an exploration of Comprehensive Geriatric Assessment in practice. Health (London) 2014;18(2):196–212. 13. Ingram SS, Seo PH, Martell RE, et al. Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology. J Clin Oncol 2002;20(3): 770–5. 14. Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001; 49(12):1691–9. 15. Mohile SG, Bylow K, Dale W, et al. A pilot study of the Vulnerable Elders Survey13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007;109(4):802–10. 16. Kim J, Hurria A. Determining chemotherapy tolerance in older patients with cancer. J Natl Compr Canc Netw 2013;11(12):1494–502. 17. Luciani A, Ascione G, Bertuzzi C, et al. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable elders survey-13. J Clin Oncol 2010;28(12):2046–50. 18. Horgan AM, Leighl NB, Coate L, et al. Impact and feasibility of a comprehensive geriatric assessment in the oncology setting: a pilot study. Am J Clin Oncol 2012; 35(4):322–8. 19. Extermann M, Meyer J, McGinnis M, et al. A comprehensive geriatric intervention detects multiple problems in older breast cancer patients. Crit Rev Oncol Hematol 2004;49(1):69–75. 20. Extermann M, Bonetti M, Sledge GW, et al. MAX2—a convenient index to estimate the average per patient risk for chemotherapy toxicity: validation in ECOG trials. Eur J Cancer 2004;40(8):1193–8. 21. Merli F, Luminari S, Rossi G, et al. Outcome of frail elderly patients with diffuse large B-cell lymphoma prospectively identified by Comprehensive Geriatric Assessment: results from a study of the Fondazione Italiana Linfomi. Leuk Lymphoma 2014;55(1):38–43. 22. Aaldriks AA, Maartense E, le Cessie S, et al. Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Crit Rev Oncol Hematol 2011;79(2):205–12. 23. Wright AA, Zhang B, Keating NL, et al. Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death: prospective cohort study. BMJ 2014;348:g1219.
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24. Goldstein NE, Morrison RS. The intersection between geriatrics and palliative care: a call for a new research agenda. J Am Geriatr Soc 2005;53(9): 1593–8. 25. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older adults. J Am Geriatr Soc 2002;50(6 Suppl):S205–24. 26. Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003;51(4):556–7. 27. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA 1999;282(23):2215–9. 28. Waltson J, Fried L. Frailty and its implications for care. In: Meier DE, Morrison RS, editors. Geriatric palliative care. New York: Oxford University Press; 2003. p. 93–109. 29. Penrod JD, Morrison RS. Challenges for palliative care research. J Palliat Med 2004;7(3):398–402. 30. Casarett DJ. The future of the palliative medicine fellowship. J Palliat Med 2000; 3(2):151–5. 31. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 2014;32(24):2595–603. 32. Wildiers H, Kunkler I, Biganzoli L, et al. Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology. Lancet Oncol 2007;8(12):1101–15. 33. Pallis AG, Gridelli C, van Meerbeeck JP, et al. EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIOG) experts’ opinion for the treatment of non-small-cell lung cancer in an elderly population. Ann Oncol 2010;21(4):692–706. 34. Droz JP, Balducci L, Bolla M, et al. Management of prostate cancer in older men: recommendations of a working group of the International Society of Geriatric Oncology. BJU Int 2010;106(4):462–9. 35. Bernardi D, Barzan L, Franchin G, et al. Treatment of head and neck cancer in elderly patients: state of the art and guidelines. Crit Rev Oncol Hematol 2005; 53(1):71–80. 36. Kristjansson SR, Nesbakken A, Jordhøy MS, et al. Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study. Crit Rev Oncol Hematol 2010;76(3):208–17. 37. Ortholan C, Benezery K, Dassonville O, et al. A specific approach for elderly patients with head and neck cancer. Anticancer Drugs 2011;22(7):647–55. 38. Koreth J, Pidala J, Perez WS, et al. Role of reduced-intensity conditioning allogeneic hematopoietic stem-cell transplantation in older patients with de novo myelodysplastic syndromes: an international collaborative decision analysis. J Clin Oncol 2013;31(21):2662–70. 39. Magnuson A, Dale W, Mohile S, et al. Models of care in geriatric oncology. Curr Geriatr Rep 2014;3(3):182–9. 40. McNeil C. Geriatric oncology clinics on the rise. J Natl Cancer Inst 2013;105(9): 585–6. 41. Geriatric Oncology Program. UNC Linberger Comprehensive Cancer Center. Available at: https://unclineberger.org/patientcare/programs/geriatric. Accessed August 15, 2015. 42. Geriatric Oncology. SOCARE Clinic. Available at: http://www.uchospitals.edu/ specialties/cancer/geriatric-oncology/. Accessed August 15, 2015.
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43. Chapman AE, Swartz K, Schoppe J, et al. Development of a comprehensive multidisciplinary geriatric oncology center, the Thomas Jefferson University Experience. J Gen Orthod 2014;5:164–70. 44. Taussig Oncology Program for Seniors (TOPS). Cleveland Clinic. Available at: http:// my.clevelandclinic.org/services/cancer/treatments-procedures/taussig-oncologyprogram-for-seniors. Accessed August 15, 2015. 45. Blood and Bone Marrow Stem Cell Transplantation for Older Adults. Older Adults: Blood and Bone Marrow Stem Cell Transplantation. Available at: http://www. uchospitals.edu/specialties/cancer/stem-cell-transplant/older-adults.html. Accessed August 15, 2015. 46. Older Adult Hematologic Malignancy (OHM) Program - Dana-Farber Cancer Institute j Boston, MA. Older Adult Hematologic Malignancy (OHM) Program Dana-Farber Cancer InstitutejBoston, MA. Available at: http://www.dana-farber. org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/ Hematologic-Oncology-Treatment-Center/Older-Adult-Hematologic-Malignancy(OHM)-Program.aspx. Accessed August 15, 2015. 47. Hurria A, Wildes T, Blair SL, et al. Senior adult oncology, version 2.2014: clinical practice guidelines in oncology. J Natl Compr Canc Netw 2014;12(1):82–126. 48. Help for Older Patients. Counseling & Support. Available at: https://www.mskcc. org/cancer-care/treatments/symptom-management/help-older-patients. Accessed August 15, 2015. 49. Geriatric Oncology j David Geffen School of Medicine at UCLA. Geriatric Oncology David Geffen School of Medicine at UCLA. Available at: http:// people.healthsciences.ucla.edu/education/institution/groups-detail?group_id5 13268. Accessed August 15, 2015. 50. Williams GR, Deal AM, Jolly TA, et al. Feasibility of geriatric assessment in community oncology clinics. J Gen Orthod 2014;5:245–51. 51. Lynch MP, Marcone D, Kagan SH, et al. Developing a multidisciplinary geriatric oncology program in a community cancer center. Clin J Oncol Nurs 2007; 11(6):929–33.