By 2030, our largest shift in growth is going to be in the 80-plus population, a group where we really have had very limited data in best practices.
—Arti Hurria, MD
Dr. Hurria’s comments came during the B.J. Kennedy Lecture entitled “Cancer in Older Adults: The Top Five Things Oncologists Need to Know” that she delivered at the 2013 ASCO Annual Meeting after receiving the B.J. Kennedy Award for Scientific Excellence in Geriatric Oncology.1 Dr. Hurria is Director of the Cancer and Aging Program at the City of Hope Comprehensive Cancer Center in Duarte, California, and a founding member of the Cancer and Aging Research Group.
The following highlights were excerpted from Dr. Hurria’s lecture.
Increasing Number of Older Adults with Cancer
“We know that cancer is a disease associated with aging,” Dr. Hurria said, pointing out that 60% of cancers and almost 70% of cancer deaths occur in people over the age of 65. By 2030, she continued, “our largest shift in growth is going to be in the 80-plus population, a group where we really have had very limited data in best practices.”
Shortage of Health-care Professionals
Crediting ASCO for leading the way in helping us understand the workforce needs in oncology, Dr. Hurria said that in 7 years there is going to be “a clear discrepancy between supply and demand.” Currently, in the United States, there is one geriatrician for every 2,620 patients over the age of 75, but by the year 2030, the number of patients per geriatrician is expected to increase to 3,798.
“This is going to have clear implications during our time as oncologists in terms of our workforce, and it is going to lead to evolving models of care,” Dr. Hurria said. “We are going to be partnering with our allied health professionals, physician assistants, and nurses. We’ll be involving rehab, pharmacists, and social workers to help us with this care. And probably most importantly, we are going to be partnering at home, with families, family caregivers, and home care aides,” Dr. Hurria said.
“If we are all going to be caring for this population, there is a clear need for education and for training,” Dr. Hurria continued. “The health-care workforce receives very little geriatric training and is not prepared to deliver the best possible care to older patients,” she added. According to the Institute of Medicine workforce report, only 1% to 2% of physicians, less than 1% of nurses, less than 1% of physician assistants, less than 1% of pharmacists, and about 4% of social workers are certified in geriatrics.2
Heterogeneous Aging Process
Dr. Hurria enumerated the lessons of pediatrics—that treating a young population requires a unique skill set, that these patients have age-related changes in physiology, are vulnerable to toxicity, dependent in their daily activities, and that the long-term effects of treatment raise concerns in this very vulnerable population.
“These are the same things that make our geriatric population potentially vulnerable,” Dr. Hurria said. “In fact, it might be even a bit more complicated because in pediatrics there are clear milestones,” and for that population, chronological age generally equals functional age.
Aging is a more heterogeneous process, and for older adults, chronological age doesn’t equal functional age. Aging is, however, “associated with a linear decline in organ reserve,” which might not be obvious when you look at patients or their laboratory values. But the decline in organ reserve becomes apparent when you stress the patient, and “chemotherapy is the perfect physiological stressor that can unmask the decline in physiological reserve,” Dr. Hurria noted.
The good news, she said, is that patients can build this reserve at any age, through lifestyle changes and physical activity. “This is a really important lesson for us to share with our patients,” she added.
Geriatric Assessment Tools
Developing a geriatric assessment for oncologists began about a decade ago and represents a melding of the fields of geriatrics and oncology. The assessment takes into account factors that identify individuals at risk for toxicity and factors other than chronological age that predict the risk of morbidity and mortality. It evaluates functional status, comorbid medical conditions, nutritional status, cognitive function, psychological state, social support, and whether the patient is taking other medications and if those could interfere with cancer treatment.
The model was internally validated, and Dr. Hurria reported that she and her colleagues are now working on externally validating it. “I hope to be able to share those results with you next year at ASCO,” she said.
Moving Beyond Prediction
Dr. Hurria acknowledged that a major research need she heard expressed at the Annual Meeting was moving beyond prediction and using the assessment tools to guide practical intervention. She walked the audience through different domains of geriatric assessment to demonstrate how it might influence oncology practice and interventions.
For example, asking questions about functional status could help determine upfront whether a visiting nurse or social worker is needed to engage family members and help them prepare for anticipated toxicity. Being able to perform basic activities, such as shopping, managing finances, and taking medications at the right times and doses, allows patients to maintain independence. “Once they lose the ability to perform these activities, the need for either 24-hour care or increased levels of care go up,” Dr. Hurria said.
Another domain involves comorbidities and whether they will impact the ability of patients to tolerate cancer treatments. “We as oncologists actually do a really good job of thinking about these other comorbidities. So if they have neuropathy, maybe we won’t use the taxane,” she said. “But I think where we struggle is how do we put these medical conditions together and try to understand what is the impact of these on life expectancy.”
Tools that are currently available can predict toxicity of treatments and survival of older patients with cancer and can uncover problems that might go undetected in a routine history and physical. These findings can lead to practical interventions, Dr. Hurria said. “What the question really comes down to is: Is it feasible to incorporate these tools into oncology practice?”
Using Technology to Integrate Geriatrics and Oncology Care
Dr. Hurria asserted that geriatric assessment is feasible in oncology practice. “We can utilize technology to capture the information, predict the risk of chemotherapy toxicity, and pinpoint areas of vulnerability in order to guide practical interventions that we can implement ahead of time.”
Dr. Hurria’s colleagues at City of Hope have developed touch screen technology and have helped incorporate the geriatric assessment into this technology, she said. This technology can be utilized to show summaries of results or risk prediction tools to start a conversation with patients about preparing together for high-risk situations. ■
Disclosure: Dr. Hurria has received research support from Abraxis Oncology, Celgene, and GlaxoSmithKline. She has served as a consultant to GTX and Seattle Genetics.
1. Hurria A: Cancer in older adults: The top five things oncologists need to know. B.J. Kennedy Award and Lecture for Scientific Excellence in Geriatric Oncology. 2013 ASCO Annual Meeting. Presented June 3, 2013.
2. Committee on the Future Health Care Workforce for Older Americans, Institute of Medicine: Retooling for an aging America: Building the health care workforce. Washington, DC: The National Academies Press, 2008.