Considering age in the cancer treatment equation
Is a cancer patient ever too old or frail to undergo chemotherapy, or should fighting the disease with every tool available always be the primary concern?
“Every oncologist struggles with this to some degree,” said Hematologist/Medical Oncologist Peter Ward, MD, who practices at the Davenport-Mugar Cancer Center at Cape Cod Hospital in Hyannis. “In terms of the question, is there an upper age limit in considering not treating someone for cancer, I think it really has to be on a case-by-case basis. It also depends on the type of cancer that’s being treated and the type of treatment that’s being considered.”
To help patients arrive at the right decision for treatment, the Cancer Center has launched a Senior Oncology Clinic, which is led by Dr. Ward, who has training, experience and a deep interest in geriatric oncology. The Clinic began recently at the hospital, with lung and colon cancer patients only, to start.
“What we’re trying to do with this clinic is to tailor a treatment plan to not only a person’s age but more their physical functioning,” Dr. Ward said.
A patient’s physiological age – not their chronological age – should determine treatment, he said. A 70-year-old man with diabetes, peripheral vascular disease and COPD might actually present more like a 90-year-old and may not be able to tolerate chemotherapy treatment, he said. On the other hand, a 90-year-old who plays tennis four times a week and stays very active, might be able to tolerate the same treatment a healthy 70-year-old could.
“Then there is an in-between patient who’s what we call ‘pre-frail,’ where they may seem very healthy and robust, but it’s the treatment that makes them frail,” Dr. Ward said.
Chemotherapy patients, in general, are assessed prior to treatment using what is called the ECOG Performance Status, he explained. This test helps oncologists determine whether patients are well enough to go through chemotherapy. It uses a scale of zero to four, with zero being the most fit and four being someone who is confined to bed.
“We generally will treat someone with a performance status from zero to two,” said Dr. Ward. “Three and four will generally have more toxicity than what is worth the risk.”
But the ECOG scale has not bee validated in older patients, he explained, so the new Senior Oncology Clinic at CCH goes further with its assessment of geriatric patients, using several tools.
Most medical oncologists would consider themselves geriatric oncologists, in that the all are treating older patients and trying to make the best decisions for them, Dr. Ward said.
“And that’s true, but I think there’s something to be said for trying to be more formal in evaluation of these patients using validated tools,” he added.
Patients at the CCH Senior Oncology Clinic are scheduled for a 90-minute visit, where they first meet with a medical assistant who goes through a questionnaire that asks about their ability to do basic and more complex activities of daily life (ADLs). Part of the questionnaire also goes over past medical and social history.
The medical assistant also does a ‘timed get-up-and-go test” during which the patient sits in a chair and then is asked to stand without using their arms and walk six feet forward and then walk back unassisted.
A social worker then meets with the patient to do a cognitive assessment, called the ‘mini cog test.’ The patient is given three words to remember and is asked for an immediate recall of the words. The second part of the test involves giving the patient a piece of paper with a circle on it and asking them to draw a clock with hands at the hour of 10:50. After finishing with the drawing, the patient is asked again to recall the three words the social worker gave them at the beginning of the test.
Depression can play a role in whether a patient is a candidate for chemotherapy, Dr. Ward said. They may be fatigued and lack motivation. So, treating the depression before starting any cancer treatment may be called for, he said. Patients are screened for depression, which is a standard part of any geriatric evaluation, he said. A nutritional assessment is also part of the intake visit.
Once the initial assessment is done, the clinic doctors plug the information collected into two toxicity calculators, which can indicate who is a good candidate for chemotherapy. One of the calculators was designed by Moffitt Cancer Center in Tampa, FL. It factors in things like a patient’s blood pressure, ability to do basic ADLs, their nutritional score and their mini-cog test score.
The other calculator was developed by the Cancer and Aging Research Group, an umbrella organization for geriatric oncology research. It factors in some of the same physical functioning scores, as well as laboratory tests like hemoglobin and LDH levels. (When someone’s LDH is high, it can be a marker for a more aggressive type of cancer, Dr. Ward said.)
“We kind of use a lot of different data points,” he said. “Not all of the things we measure in the geriatric assessment are necessarily plugged into these calculators. But there’s a fair amount of the information that does go into them and we hope the two scores come out pretty similar. If they don’t, then we know there’s something we may be missing and something else we need to take into account.”
Dr. Ward said geriatric oncology has traditionally been a void in oncology. Older patients are generally under-represented in clinical trials, he said.
“Up until the 2000s, most clinical trials would exclude patients over the age of 75, and so the argument of proponents of geriatric oncology is that we are treating older patients without any data as to whether these treatments are safe for older patients,” he said.
An Interest in Geriatrics
Dr. Ward became interested in geriatric oncology when he did a geriatric rotation during an internal medicine residency at Fletcher Allen Health Care in Burlington, VT. His interest solidified during a fellowship in medical oncology and geriatric medicine at David Geffen School of Medicine at UCLA Medical Center in Los Angeles, CA.
“My older sister (Katherine Ward, MD, Chief of General Internal Medicine and Director of Geriatrics at Harbor-UCLA Medical Center) introduced me to the UCLA program. She has always been my mentor,” he said.
Others who he considers mentors include the late Arti Hurria, who is considered the original pioneer of Geriatric Oncology, and Hyman B. Muss, MD, currently at the University of North Carolina School of Medicine. Dr. Ward worked with Dr. Muss when Dr. Muss was at the University of Vermont, where Dr. Ward did his residency.
“They kind of spearheaded this idea that we should try to evaluate older patients to see if they are fit, meaning physically active and have few co-morbidities, or deficits in their ADLs, or whether they’re frail where they wouldn’t be able to withstand treatment, or where they would have a lot of side effects,” Dr. Ward said.
After graduation, Dr. Ward had the opportunity to stay in academics, but wanted to be involved in a community oncology practice. He was hired by Dana-Farber Cancer Institute and started a Senior Oncology Clinic at St. Ann’s Hospital in Fall River, where he was until two years ago when he came to Cape Cod Hospital.
A Multi-Disciplinary Staff
Some of the CCH Senior Oncology Clinic patients may be eligible for a program where the clinic partners with pharmacists to screen patients for high-risk medication concerns. The proposed chemotherapy would be sent through something called the Beers Criteria, a tool that identifies drugs that are considered high-risk to older adults, Dr. Ward said. For instance, some drugs can increase a patient’s risk of falling and some may induce delirium, he said.
“We don’t want to make someone whose quality of life is pretty good have a very poor quality of life or lose their independence. I think that’s what older patients fear the most and that would be the worst-case scenario.”
The multi-disciplinary team at the CCH Senior Oncology Clinic includes Practice Nurse Marion Spang, RN; New Patient Coordinator Yvette Brailey; Medical Assistant Nicole White; Social Worker Mary Sprout; and Clinical Dietitian Diana Carpentieri.
If a patient fits the current criteria for the Clinic, they are offered the opportunity to participate and be assessed. Surgeons are the ones who generally refer patients, Dr. Ward said. While it is currently only available to lung and colon cancer patients, he hopes to eventually expand the criteria to patients with other types of cancer.