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Development of a comprehensive multidisciplinary geriatric oncology center, the Thomas Jefferson University Experience

Journal of Geriatric Oncology

Abstract

Background

The proportion of older patients with cancer is expected to grow exponentially in the next two decades. This population has large heterogeneity and it is well known that chronologic age is a poor predictor of outcomes. Research has shown that these patients are best served with a Comprehensive Geriatric Assessment (CGA) to formulate individualized treatment plans for better outcomes. However, the best model for CGA has yet to be determined.

Materials and Methods

Our objective was to develop a highly functional model for the establishment of a comprehensive multidisciplinary geriatric oncology center in the setting of a university based NCI-designated cancer center. Each patient is evaluated by medical oncology, geriatric medicine, pharmacy, social work and nutrition. Expert navigation is provided to enhance the patient experience. At the conclusion, the inter-professional team meets to review each case and formulate a comprehensive treatment plan. The patient is classified as Fit, Vulnerable, or Frail based on the complete CGA.

Results

The average age of patients seen was 80.7 with the most common diagnoses being breast, colorectal and lung cancers. Twenty four percent of patients were determined to be Fit, 47% Vulnerable, and 29% Frail. Twenty one percent of patients determined to be Frail by CGA received an ECOG score of 0–1 by the oncologist. Our pharmacists made specific recommendations in over 75% of patients and social work provided assistance in over 50% of patients.

Conclusions

We were able to observe some interesting trends such as potential discordance with ECOG score and assessment of Fit/Vulnerable/Frail but due to limitations in the data, this paper is not able to illustrate definitive correlations. Several challenges with the development of the clinic include 1) patient related issues, 2) navigation, 3) financial reimbursement, 4) referral patterns, and 5) coordination of care during office hours. We feel that we have been able to establish a model for a comprehensive multidisciplinary geriatric oncology evaluation center in the setting of a university based cancer center.

Keywords: Geriatric, Adult, Oncology, Senior, Multidisciplinary, University, CGA.

1. Introduction

The US population over the age of 65 is expected to double in size by 2030, and the cancer incidence is 11 fold higher in this age group. About 60% of all cancers and 70% of all cancer mortalities occur in people over 65 years of age. 1 Despite the high incidence, we are only beginning to understand the best way to care for these patients.

Studies have shown that older patients with cancer frequently experience both over and under treatment of their disease. 5 One of the biggest challenges remains the heterogeneity of the older population. It is well documented that chronological age alone is a poor predictor of how a patient will tolerate treatment.2 and 3 Assessment of a patient's “functional” age is a much better predictor of outcome and is more useful in determining an individualized treatment plan 4 .

Aging is associated with physiologic changes that can affect cancer therapies including reduced renal function, decreased gastrointestinal absorption and decreased bone marrow reserve. 6 Older adults frequently have multiple co-morbid conditions and common geriatric syndromes including frailty, cognitive impairment, depression, failure to thrive and frequent falls. They are more likely to have functional dependence in instrumental activities and activities of daily living. Poly-pharmacy is a common problem and can lead to adverse events, as well as drug to drug interactions.

Historically, older adults have been woefully under-represented in oncology clinical trials. 6 A 2003 study found that adults over 65 years represented only 32% of the populations studied. 7 Older patients are often excluded due to co-morbid conditions, organ system impairment, or belief from providers that they are incapable of tolerating treatment or will have limited long term benefit. 6 With limited evidence from clinical trials, it is difficult to formulate evidence based treatment recommendations for this rapidly expanding population.

Furthermore, cancer biology may present differently in older adults, making evidenced based treatment recommendations even more important. For example, acute myeloid leukemia tends to be more aggressive and more resistant to treatment in older patients. Conversely, breast cancer in older women is usually less aggressive and more likely to be hormone receptor positive, allowing for targeted and hopefully less toxic therapies. 6

As chronological age is a poor predictor of treatment tolerance it is also not a reliable indicator of life expectancy. A person's “functional” age may not predict an exact life expectancy but can allow a physician to predict whether a patient will likely live longer or shorter than the average person of a similar age. Tools such as the Walter and Covinsky life data tables can assist with formulation of these predictions. 8 Other prognostic tools, such as the Lee Mortality Index can stratify patients into varying risk of mortality. 9 Predicted life expectancy is critical to formulating treatment recommendations in the context of the aggressiveness of a particular cancer diagnosis and the relative value of therapeutic options.

The above factors have made individualized treatment for older patients with cancer critical. Comprehensive Geriatric Assessment (CGA) refers to a multidisciplinary evaluation of an older individual's functional status, co-morbid medical conditions, cognition, medication regimen, psychological state, social support, and nutritional status. 10 CGA is considered the “gold standard” for geriatric assessment. 11 It has been shown in some studies to improve detection of medical, functional and pharmacologic problems that could affect prognosis and treatment decisions.12 and 14 It has been found that evaluation of instrumental activities of daily living provides a better assessment of functional status then Eastern Cooperative Oncology Group (ECOG) performance status alone. Specific to oncology, CGA has been shown to improve prediction of survival, chemotherapy toxicity, and post-operative morbidity and mortality.13 and 14 It is currently “strongly” recommended for all patients with cancer over the age of 70. 5

A CGA allows the clinician to classify patients into one of three “stages of aging” as described by Balducci et al.: Fit, Vulnerable, or Frail. Fit patients have the highest level of health, minimal co-morbidity and no functional dependence. Vulnerable patients have some dependence in instrumental activities of daily living, have co-morbidities that are well controlled, or may exhibit early symptoms of a geriatric syndrome. Frail patients have three or more co-morbidities, dependence in one or more activities of daily living, or a clinically significant geriatric syndrome. 15 Fit patients are candidates for almost any cancer treatment and have similar outcomes to their younger counterparts. Frail patients can be expected to do poorly with cancer treatment and may be best served by a recommendation for supportive care. Vulnerable patients require the most individualized approach and may benefit from modified therapy, as well as aggressive supportive care throughout treatment. 3

Despite the emerging evidence to support CGA in older patients with cancer, the best model for CGA remains to be determined. 5 Many current models involve a frailty screening process first, followed by a referral for additional assessment if the individual screens as vulnerable or frail. Additional evaluation should include assessment of functional status, a review of co-morbid medical conditions, screening for cognitive impairment, a complete review of medications, screening for psychological distress and poor social support, and a nutritional screen.

2. Materials and Methods

To provide better comprehensive cancer care to older patients, Thomas Jefferson University's Kimmel Cancer Center (KCC) developed the Senior Adult Oncology Center (SAOC) in September of 2010. This center provides a multidisciplinary evaluation for seniors aged 70 and above both newly diagnosed and established patients referred by different mechanisms including self-referral, medical oncology, primary care, and surgery. Each patient is evaluated by medical oncology, geriatric medicine, pharmacy, social work and nutrition during an approximately two hour visit. Expert navigation is provided to enhance the patient experience by enabling the health care professions to do their evaluations in a smooth, coordinated fashion.

The descriptive data analyses presented in this paper is intended to summarize the pertinent features of the geriatric population seen at Thomas Jefferson University. The data included in the tables are presented as means with corresponding standard deviations. Where applicable the data is presented to categorize by stages of aging (fit, vulnerable or frail). We choose the variables that are felt to be the most relevant to the geriatric population by the geriatric team and were used to determine the Fit, Vulnerable and Frail classifications. A series of tools and assessments are completed on every patient. Patients are asked to complete the Vulnerable Elders Survey (VES-13) 16 , a functional screening tool prior to the visit. Several screening tools have emerged in an attempt to quickly identify Vulnerable or Frail. We chose the VES-13 due to ease of administration and validity in the geriatric literature. All of our patients currently go on to complete a full CGA regardless of VES-13 score. The VES-13 has been validated to identify geriatric patients at risk for decline or death over two years. Combined risk of death and decline rises with higher VES scores with estimates of 20% for scores of 3 up to 60% for scores of 10 17 . The VES score gives an objective measure of functional status. They are also asked to complete the Functional Assessment of Cancer Therapy-General (FACT-G) 18 prior to arrival, a validated assessment of quality of life indicators for all types of cancers.

A complete review of medications and assessment of patient's knowledge and adherence is performed by the pharmacist. Patients are identified as at risk from polypharmacy or on inappropriate medications as determined by the Beer's criteria. 19 Compliance issues are discussed, as well as potential for drug–drug and drug disease interactions with current medications and with potential anti-cancer therapies. The dietitian performs the Mini Nutritional Assessment (MNA) 20 to stratify nutritional risk and provides education, recommendations and community resources to patients at risk or malnourished.

The geriatrician completes an assessment of functional status utilizing Katz and Lawton ADL/IADL scales 21 and timed up and go (TUG) 22 testing. Each patient undergoes cognitive screening, which is currently being done with the Mini-Cog assessment tool. 23 Patients are assessed for depression and emotional distress with the Geriatric Depression Scale 24 , administered by the geriatrician, and the Distress Thermometer 25 , administered by the social worker. An estimated life expectancy, in the absence of cancer, is determined using the Walter and Covinsky Life Expectancy Tables. 8 This helps put the cancer diagnosis in perspective of the patients' other comorbidities. The Lee Four Year Mortality Calculator 26 has recently been incorporated as an additional prognostic tool. The medical oncologist calculates a risk of toxicity score based on the CARG Chemotherapy Toxicity Calculator. 27 This calculator is currently being validated in an ongoing clinical trial. The variables to complete the CARG toxicity calculator were self reported by the patient to the medical oncologist and included falls, hearing, medication adherence, ambulation and social activity. This differed from the self administered original patient questionnaire instrument used to develop the chemotherapy toxicity calculator, in that the physician read the individual questions to each patient to complete the chemotherapy toxicity calculator. We feel that this should not adversely affect the accuracy or validity of the data collected. Each patient is also assigned an ECOG performance score (PS) 28 based on current oncology practice.

At the conclusion of each session, the entire inter-professional team meets to review each case and formulate a comprehensive treatment plan that incorporates the expertise from each discipline. A description of the contributions of each member of the inter-professional evaluation team is included in Table 1 . Based on the information collected from the completed CGA, the geriatrician classifies the patient, using the criteria for “stages of aging” described above as Fit, Vulnerable, or Frail. This consultative report can then help to frame an informed discussion between the primary oncologist and the patient/caregiver to individualize the treatment plan in efforts to best meet the patient's goals and avoid over or under treatment.

Table 1 Senior adult oncology multidisciplinary interventions.

Multidisciplinary subspecialty Interventions
Nutrition
  • Nutrition counseling/education
  • Meals on wheels (nutrition home-delivery)
  • MANNA (Metropolitan Area Neighborhood Nutrition Alliance)
  • Education and provision of high protein/high calorie supplements
  • Provide recommendations for tube feeding (formula and rate), if needed
Pharmacy
  • Patient education for current prescriptions/drug interactions
  • Counseling for adherence/avoidance
  • Verification of immunization history
  • Use of complimentary medications
  • Minimization of inappropriate medications
  • Identification Potential chemotherapeutic toxicities/drug interactions
Social Services
  • Use of distress thermometer to assess psychosocial stressors and identify barriers to treatment
  • Grief adjustment to illness counseling for patient and family members and ongoing support through referrals to support groups, psychoeducational programs, and one on one counseling sessions
  • Links to concrete services such as transportation, home health care, medical equipment, financial and insurance resources
  • Identification of barriers to treatment
Geriatric
  • Discontinuation of inappropriate medications
  • Symptom management recommendations including prescription of new medicines if appropriate
  • Physical therapy/occupational therapy referrals
  • Home care referrals
  • Physical medicine and rehabilitation referral
  • Psychiatry referral
  • Recommendations for vitamin D screening and repletion
  • Referral for audiology evaluation
  • Recommendations for further cognitive testing
  • Advanced care planning assistance.
Medical Oncology
  • Development of a individualized oncologic treatment plan based on CGA results and goals of care established by the patient/care giver
    • o Development of antineoplastic regimens to be considered
    • o Dose Modifications to be considered
    • o Referral(s) to include Radiation Oncology, Surgery and Palliative Care
  • Ordering of appropriate laboratory and radiographic assessments

Additional pertinent evaluations are arranged on an ad hoc basis including surgical oncology, radiation oncology, psychiatry, and rehabilitation medicine. Key experts in each of these disciplines were identified based on their expertise and interest in evaluating and treating elderly patients with cancer.

To date the center has evaluated over 200 Senior Adult Oncology patients. This report represents the experience of a University based multidisciplinary Geriatric Oncology program housed in an NCI designated Cancer Center. Permission to collect this data was approved by the Thomas Jefferson University Institutional Review Board.

3. Results

We reviewed data collected on the first 211 patients seen at SAOC at Thomas Jefferson University from 2010 to 2012. The average age of patients seen at our clinic was 80.7 years (youngest 61 years and oldest 95 years). The most common cancer diagnoses seen include breast (23%), colorectal (17%), and lung (16%), followed by hematologic cancers (12%) and upper gastrointestinal cancers (11%). This is somewhat reflective of the KCC as a whole. The most common diagnoses for the KCC include breast (14%), lung (9.3%), prostate (8.4%), pancreas (6.1%), and colorectal (5.3%).

Out of 211 patients, only 119 (56%) completed the Vulnerable Elders Survey (VES-13) which we recognize as a major limitation of the data collected. In the current model the VES-13 is mailed to patients along with an intake packet prior to their appointment. Many patients forgot to bring this with them. Our patient population may have additional barriers to completing a self-administered questionnaire including visual impairment, cognitive impairment and decreased health literacy. As the clinic has evolved, our patient navigator has focused attention on providing additional copies and assisting the patient if needed to improve rates of completion. We found that patients categorized as Fit by CGA scored an average of 2.1 on the VES-13. Patients categorized as Vulnerable scored an average of 5.3 and those deemed to be Frail scored an average of 7.8 on the VES-13. Table 2 compares CGA assessment, VES-13 score and ECOG performance status.

Table 2 CGA parameters by age group.

Age N VES-13 scores a ECOG Performance scores b Nutrition: % at risk or malnourished c Cognitive screening: % abnormal d
60–69 8 2.00 (3.37) 1.00 (0.58) 83.3% 0%
70–79 75 4.31 (2.88) 1.05 (0.83) 64.2% 21.7%
80–89 104 5.41 (3.05) 1.02 (0.88) 58.9% 30.1%
≥ 90 24 7.85 (2.34) 1.50 (1.14) 61.1% 34.4%

a VES scores are presented with sample mean and (standard deviation). In the 60s age group N = 4, in the 70s age group N = 39, in the 80s age group N = 63, in the ≥ 90 age group N = 13.

b ECOG scores are presented with sample mean and (standard deviation). In the 60s age group N = 7, in the 70s age group N = 74, in the 80s age group N = 102, in the ≥ 90 age group N = 24.

c Nutrition outcomes are based on the number of assessments made in each respective age group. The % correlates with patients assessed who either scored as “at risk” or “malnourished.” The total patient assessments per age group is as follows: in the 60s age group N = 6, in the 70s age group N = 53, in the 80s age group N = 73, in the ≥ 90 age group N = 18.

d Mini-COG outcomes are based on the number of assessments made in each respective age group. The % correlates with patients who scored “abnormal.” The total patient assessments per age group are as follows: in the 60s age group N = 6, in the 70s age group N = 60, in the 80s age group N = 93, in the ≥ 90 age group N = 23.

Twenty four percent of patients were deemed to be Fit. Forty seven percent were categorized as Vulnerable and 29% were thought to be Frail. Based on our data we were able to correlate the status determined by CGA with assigned ECOG scores ( Table 3 ). Patients determined to be Fit by CGA were shown to have an averaged ECOG performance of 0.3. Vulnerable patients averaged a performance of 0.9. Frail patients averaged a performance of 2. Interestingly despite the averages, 21% of patients determined to be Frail by CGA received an ECOG score of 0–1 by the oncologist, supporting the potential that usual ECOG performance score assessment by oncologists may miss frailty. Table 4 illustrates CGA status, VES-13 and ECOG performance status by age group.

Table 3 Stages of aging by age group.

Age N % Fit % Vulnerable % Frail
60–69 8 25.0% 75.0% 0%
70–79 75 32.0% 46.7% 21.3%
80–89 104 19.3% 32.7% 48.0%
≥ 90 24 20.8% 33.3% 45.9%

Table 4 Geriatric performance scores by stages of aging.

Clinical status N ECOG performance score a VES a
Fit 48 0.33 (0.48) 2.16 (1.97)
Vulnerable 99 0.94 (0.62) 5.25 (2.78)
Frail 61 2.0 (0.78) 7.79 (1.90)

a ECOG performance and VES scores are presented with sample mean and (standard deviation).

Cognitive screening was performed on 86% of patients evaluated in the clinic. Twenty seven percent of these were identified as scoring abnormal on cognitive testing. Some barriers to 100% completion have included language and occasionally physical inability (visual impairment, inability to write). The Geriatric Depression Screen was performed on 45% of patients per the geriatrician's discretion. Thirty five percent of those scored positive (score > 5) suggesting depression. As the clinic has evolved more attention has been placed on completing this screen on everyone, recognizing the potential for undiagnosed depression and its potential effects on treatment. One hundred and fifty patients (71%) underwent nutritional screening and 62% were found to be at risk for malnutrition or malnourished.

The clinical pharmacists have made specific recommendations in over 75% of patients evaluated. These included discontinuation or dose changes of potentially inappropriate medications, dose adjustments or medications to avoid due to decreased renal or hepatic metabolism, potential drug–drug interactions with proposed anti-cancer therapies and concerns regarding compliance and its effect on treatment plans. Ongoing research in this area is being conducted with the School of Pharmacy.

Geriatric patients often rely on assistance from support people while accessing healthcare. Not surprisingly, the majority of our patients (44%) came with adult children and 14% came with a significant other. Nine percent were accompanied by people other than immediate family and 17% came with a combination of support people. Sixteen percent came alone to the visit. Our social workers were able to provide resources or assistance in over 50% of our patients ranging from insurance and medication assistance programs, transportation and home care as well as advanced care planning.

4. Discussion

In developing the Senior Adult Oncology Center at Jefferson, several challenges emerged early on. These challenges primarily include 1) patient related issues, 2) navigation, 3) financial reimbursement, 4) referral patterns, and 5) coordination of care during office hours.

The geriatric oncology patient frequently requires assistance to get to the office. This assistance may be from a family member or through a transit service which requires time and organization. We noted that it is often difficult for these patients to make it to an early morning office visit, and on this basis, structured the morning office hours to begin at 9 AM. Due to the detailed nature of the information provided to these patients, and the complexity of the decision making in this patient population, it is essential that caregivers be integrated into the office visit. Conversely, office hours in the afternoon start at 12:30 PM, and we have noted that the patients may be exhausted at the end of their visit, which lasts approximately 2 h. To expedite the visit, New Patient Information packets are sent to the patient prior to their visit to enable completion with the help of their caregivers. This information is disseminated to all the healthcare professionals participating at the time of the visit in efforts to streamline the evaluation and avoid duplication of the patient interviewing process.

Navigation is a key component to making this complex multidisciplinary clinic truly patient centered. Elders may have more difficulty navigating the healthcare system to make appointments, obtain records and confirm locations leading to increased stress regarding their diagnosis. Additionally, they may be easily overwhelmed when multiple tests and/or other consultations (i.e. psychiatry, rehabilitation medicine, etc.) are needed to complete their evaluation prior to treatment. We have found that strong navigation with repeated interactions with the patient and caregivers both before and after our initial assessment leads to the highest rates of compliance and satisfaction for the patient and family. Our navigator also plays a crucial role in facilitating efficient, well-coordinated clinic sessions to avoid long patient wait times and resultant frustration.

Financial reimbursement poses a particular challenge since certain insurers have not previously recognized the geriatrician as a specialty provider and refused payment for their services if the patient was capitated to another primary care physician. Regulatory change was clearly needed to provide the consistent support for this specialty evaluation. Therefore, at the time this center was developed, it was important for the medical oncologist to have a working knowledge of geriatric principles with access to a geriatrician to review the case. Prior to the patient's appointment, their insurance coverage was reviewed. If there was an issue, then the patient was informed prior to the evaluation and notified of the out of pocket cost for geriatric evaluation should they wish to proceed with that part of the consultation. Fortunately, due to recent legislative changes, geriatricians are now recognized as specialists, and are able to bill for their services, thus alleviating this problem. Both the medical oncologist and the geriatrician are now able to bill for a high level new patient visit which generally requires about 45 min to one hour of their respective time. The labor intensive nature of a university based multidisciplinary center requires commitment from the institution to support the additional “non-billable” services including nutrition, social work and pharmacy. At our institution, both nutrition and social work support are provided through our cancer center, and pharmacy support is provided by the School of Pharmacy affording ample opportunity to teach pharmacy students.

Finally, there is an ongoing need to break down territorial barriers with referring primary care physicians and medical oncologists. We have structured our evaluation center to provide consultations only to these patients who are referred or do not yet have a primary treating oncologist, and are over the age of 70 years. In so doing we attempt to provide relevant information to the referring physician to aid in the decision making process in efforts to individualize the treatment plan and avoid over or under treatment of the patient. Patients who come to us without a treating oncologist and are planning to undergo anti-cancer therapies are often referred to the appropriate site specific medical oncologist within the center. To avoid delaying initiation of the oncologic treatment plan, we have structured our center to have office hours on Tuesdays and Fridays. This enables a patient to be seen within 1–2 business days of the initial referral call. The comprehensive consultative report (including a note from each health care professional) is then delivered within 48 h of the patient evaluation. Additionally, a summary sheet is faxed to the provider the day of the consultation which indicates that the patient was seen, and a full consultative report will follow. We remain available for further assessment at the request of the provider or patient, but we do not assume ongoing management of the oncologic treatment plan. Longitudinal care is provided for the patient by geriatrics, social work, pharmacy, and nutrition, and is determined on an as needed basis. The challenge remains to convince providers that this consultation will provide meaningful added value, will not delay initiation of treatment, and will not interfere with the ongoing relationship the patient shares with their primary oncologist.

Our data has several limitations and reflects the evolution of a multidisciplinary clinic. The intent of this manuscript is to provide a descriptive analysis of the steps taken in the centers development, and the methods utilized to evaluate the first 211 patients. Longitudinal data on patient outcomes is currently being collected and will be reported in a future manuscript. Completion for some of the evaluation tools was incomplete, specifically the VES-13, nutrition screening, cognitive screening, falls and depression screening as mentioned above. These deficiencies have been addressed and attempts have been made to increase completion rates. We were able to observe some interesting trends such as potential discordance with ECOG score and assessment of Fit/Vulnerable/Frail but due to limitations in the data, this paper is not able to illustrate definitive correlations.

It is the intention of the Senior Adult Oncology group at Jefferson to further disseminate the expertise of our center to the tri-state region in several ways. We continue to actively develop a clinical trials portfolio with trials focused on specific questions and treatments for geriatric oncology patients. As part of our mission we will train fellows interdepartmentally through medical oncology and geriatrics to enable dually boarded, fully certified geriatric oncologists. The first graduate of the program is slated for June 2014.

We recognize that completing a full CGA in every patient may not be feasible given lack of universal access to geriatricians. Our ongoing clinical research is focused on training nursing personnel to quickly determine if a patient is Fit or “not Fit” and to establish referral criteria for CGA (see Fig. 1 ). To help overcome the barrier of incomplete mailed questionnaires, we now request patient completion of any incomplete data including the VES-13 upon arrival to the office prior to the multidisciplinary evaluation. Finally, we are also planning to assess the benefit of a multidisciplinary; university based comprehensive consultation on both the patient's decision making and treatment outcomes. At this juncture, we feel that we have been able to establish an easily reproducible, highly functional model for a comprehensive multidisciplinary geriatric oncology evaluation center in the setting of a university based cancer center.

gr1

Fig. 1 Screening model for CGA referral.

Disclosures and Conflict of Interest Statements

All authors have declared no conflicts of interest.

Author Contributions

Concept and Design: A. Chapman, K. Swartz, J. Schoppe.

Data Collection: K.Swartz, J. Schoppe.

Analysis and Interpretation of data: A. Chapman, K. Swartz, J. Schoppe.

Manuscript writing and approval: A. Chapman, K. Swartz, J. Schoppe, C. Arenson.

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Footnotes

Thomas Jefferson University, 925 Chestnut St., Suite 420, Philadelphia, PA 19107, USA

lowast Corresponding author at: 925 Chestnut St., Suite 420, Philadelphia, PA 19107, USA. Tel.: + 1 215 923 5676 (office); fax: + 1 215 923 7390.


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