Earlier palliative care is needed. End-of-life care should be a new standard. We should get these discussions out on the table early in the course of care for patients and families.
—Andrew E. Chapman, DO, FACP
The “graying of America” poses increasing challenges for the cancer community in terms of rising numbers of cases of cancer and costs associated with geriatric care. The scope of this problem and potential solutions were explored by Andrew E. Chapman, DO, FACP, at the ASCO Quality Care Symposium in Boston.1 Dr. Chapman is Director of Regional Cancer Care and Co-Director of the Jefferson Senior Adult Oncology Center at the Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia.
Aging and Cancer
“The ‘silver oncologic tsunami’ is coming. Demographics drive the issues. Cancer is a disease associated with aging,” he said. Factors associated with aging—telomere shortening, telomerase activity, chronic inflammation, DNA instability, and loss of immune surveillance—are also thought to be implicated in cancer.
“Geriatric patients have a high disease burden,” he continued. Sixty percent of all cancers occur in people aged 65 or older, and 69% of cancer-related deaths occur in the same age group.2,3 The exploding population of elderly people coupled with the rising costs of cancer care and the fragmentation of delivery of complex geriatric care creates a perfect storm.
“To address this, we have developed an urgent to-do list with some basic goals,” Dr. Chapman said. They include empowering the health-care workforce to improve health-care delivery in the geriatric setting, develop health-care delivery models focused on the elderly, develop oncology-based relevant data sets, and establish new standards of care to be able to implement the data and modeling in clinical practice.
Over the next 15 years, even with nurse practitioners and physician assistants, there is a projected shortage of practitioners. On top of that, there are inadequate numbers of geriatricians. “In 2030, there will be one geriatrician for every 4,000 persons aged 75 and older,” he said.2,3
Empowering the workforce entails recognizing the needs of elderly patients. Geriatric patients pose unique challenges in terms of comorbidities, nutritional status, cognitive impairment, geriatric syndromes, polypharmacy, psychological status, and social support.
“These issues are not commonly encountered in younger adult populations and raise major risks,” Dr. Chapman noted. Data are limited from clinical trials on management of elderly cancer patients. There are risks of overtreatment and undertreatment due to inadequate assessment of cognitive and functional status, he added.
The health-care community needs to develop core competencies geared toward treating elderly patients and incorporate those into health-care training and education. New models are needed to promote team-based care coordination, he continued. Possible ways to improve delivery of care include funding the National Workflow Commission and eliminating reimbursement barriers to team-based care (ie, the siloing of care and payment models).
The development of deeper data sets is another goal. “We want to give elderly patients the treatment they need and want. They need to be enrolled in clinical trials, and this may require incentives for pharmaceutical companies to do these trials. One way to do this could be to lengthen drug patents so that compounds can be studied in aging populations,” he suggested.
Elderly patients should be engaged in the process of developing new standards of care based on their needs, values, and preferences, Dr. Chapman said. Communication with patients should rely on giving understandable, relevant, and evidence-based information. Development of decision aids would be helpful, but this must be done in collaboration with patients and palliative care experts, he said.
End-of-life care is a critical area that needs to be addressed. “Earlier palliative care is needed. End-of-life care should be a new standard. We should get these discussions out on the table early in the course of care for patients and families, emphasizing palliative care early on,” he contended. “We need to create payment models for these discussions.”
He added, “We can improve care of the elderly if we ‘right-size’ the care, make it coordinated, meet patients’ values and preferences, provide early palliative care and psychosocial support, and refer them to hospice in a timely manner. We need studies of drugs in the elderly, Medicare to negotiate drug pricing, and efficient coordinated health-care delivery system models.”
Dr. Chapman concluded with a call to action for addressing cancer care in geriatric patients. “A new battle is emerging in this war on cancer, with significant moral, ethical, and financial implications. It is a battle we cannot afford to lose. We need your help,” he told the audience. ■
Disclosure: Dr. Chapman reported no potential conflicts of interest.
1. Chapman AE: Healthcare delivery in senior adult oncology patients. ASCO Quality Care Symposium. Presented October 17, 2014.
2. Levit LA, Balogh EP, Nass SJ, et al: Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Institute of Medicine, National Academies Press, Washington, DC, 2014.
3. Hurria A, Naylor M, Cohen HJ: Improving the quality of cancer care in an aging population: Recommendations from an IOM report. JAMA 310:1795-1796, 2013.