The Right Way to Treat Cancer

Kudos to Judith Graham of Kaiser Health News for yet again identifying a new development that has the potential to enormously affect the medical care of older people. Her article, “Geriatric Assessments Could Fine Tune Cancer Care for Older Adults,” pointed me to the American Society of Clinical Oncology's (ASCO) new guidelines for the management of patients over age 65 with cancer. The headline (and I know that journalists don’t generally write the headlines for their articles) is the only part of the article that’s misleading: the changes suggested would not merely “fine tune” oncologic care for older people, they would radically transform it.

Here’s the situation: 70 percent of cancer patients are over age 65 and that number will rise in the next 20 years. Looked at differently, the risk of developing cancer at some point if you are a man over age 70 is one in three, and the risk for women is one in four. Despite the predominance of older cancer patients, most clinical trials of chemotherapy drugs include few if any older people: they have too many other problems to meet the eligibility criteria for participating in the study. But those same people, with all their other medical problems and functional impairments, are regularly given chemotherapy, based on the results of studies that didn’t involve anyone like them. That’s a problem. 

What we do know is that 50 percent of older patients with advanced cancer experience severe toxicity from chemotherapy in the first three months of treatment. We also know that the Institute of Medicine’s recent study, “Delivering High Quality Cancer Care," found that the current delivery system is “ill-equipped to address the needs of older patients.” Oncologists agree with this assessment, stating that “the care of older adults with cancer needs to be improved” and putting the responsibility on themselves. Specifically, only one quarter or less of oncologists felt confident in their ability to recognize dementia, identify a fall risk, or assess functional status. And we know from a recent study that patients shift their priorities from sheer survival to quality of life as functional status declines. In light of these observations, what does ASCO recommend?

The new guideline, “Practical Assessment and Management of Vulnerability in Older Patients Receiving Chemotherapy,” makes a series of evidence-based suggestions. From the perspective of patients and their families, what’s important to know is that oncologists who are contemplating administering chemotherapy to people over age 65 should provide a geriatric assessment to identify problems they might not otherwise recognize. Specifically, they should take simple steps to look for falls, to determine how well patients can function day to day, to identify all other medical diagnoses besides the cancer that might impact treatment, to screen for depression, to evaluate cognition and nutrition, and to assess the social support system. Because the guideline is meant to be practical, it suggests specific tools that oncologists can use to achieve these ends. The guideline also advocates determining the approximate life expectancy, both the cancer life expectancy and the non-cancer life expectancy. 

What is the point of all this? How might it help older patients with cancer? The main objective is to avoid both over-treatment and under-treatment, where “too much” and “too little” must be assessed in light of the best available data about what treatment could achieve and knowledge of the patient’s preferences. How the oncologist presents the options should reflect the facts about what the consequences of treatment are likely to be. How much misery a person is willing to endure might well be affected by how much he or she has to gain in the best-case scenario and how much there is to lose in the worst-case, given the nature of the cancer and the patient’s other medical conditions. In short, the information from a geriatric assessment should guide the process of shared decision-making involving the physician, the patient, and the patient’s family, leading to an “integrated, individualized plan of care.”

But there’s another potential outcome, one that perhaps paradoxically undermines the accuracy of the predictive tools on which the recommendations rely. There is the possibility that performing a geriatric assessment will lead to implementing the recommendations of that assessment with resultant improved capacity to withstand the rigors of chemotherapy. The authors of the guideline recognize this possibility. They say, “While there are not yet completed RCTs [randomized controlled trials] that demonstrate that GA-guided care, or ‘GA with management,’ definitely improves outcomes of older patients with cancer, this care model has been shown to improve outcomes in older noncancer populations.”  Randomized controlled trials are reportedly ongoing to evaluate the ability of “GA-guided care” to actually improve outcomes in older cancer patients—not merely to modify their willingness to undergo chemotherapy in the first place, but also their longevity and quality of life if they do accept chemotherapy.

The first step is for patients and caregivers to request and oncologists to perform geriatric assessment. The second step is to act on the findings of the assessment. That doesn’t just mean using the information to guide decision-making about cancer treatment; it means, first and foremost, making some changes that will optimize the patient’s overall condition. These changes might include physical therapy, modification of the non-cancer medical regimen, or providing more social support. 

It might be necessary to delay instituting chemotherapy, and delay talking about whether to start chemo until certain basic interventions have taken place. 

One analogy that may be helpful is rehab. When a patient and family are struggling to decide if it’s going to be possible to return home after a debilitating hospitalization, it’s often helpful to begin with a stay at a rehab facility. The goal is to optimize the patient’s condition before making important decisions about where to live. A second analogy is depression. Depression may color a patient’s decisions about preferences for care. In general, whenever feasible, it’s desirable to treat depression before accepting a patient’s views about, say, limiting care for some other medical condition, as representing his or her true wishes. 

So, by all means, let’s do geriatric assessments on older patients with cancer. How, exactly, that will shape care remains to be determined.

All that Glitters...

          Admissions to American Intensive Care Units (ICUs) from hospital emergency departments are on the rise—they doubled from 2003 to 2009—and admissions among patients aged 85 and older growing the most rapidly of all: they increased 25 percent every two years. What we still don’t know is whether or when the ICU helps them. This past week, French researchers published a study in which they shed some light on the question. What they found is that ICU admission in basically high functioning people over age 75 did not improve their chance of survival—and may have made it worse. The ICU probably didn’t make any difference in their level of function or health-related quality of life six months after discharge (if they were still alive)—but there is some suggestion it caused a deterioration.

         In a nutshell, what the researchers did was to come up with a standardized protocol for determining who should be admitted to the ICU, based on the particular conditions they had and how severe the conditions were. They then randomized hospitals to either use this special protocol or to rely on whatever they normally did to make decisions about ICU admission. To be eligible for the study, you had to be at least 75 years of age and at baseline, ie before you got acutely ill, you had to be independent in almost all your daily activities. When physicians used the special triage system, older patients were far more likely to be admitted to the ICU (61 percent) than when they did not (34 percent). But the death rate in the ICU, and the length of stay in the hospital were the same in the two populations. Overall hospital mortality was higher in the intervention group (30 percent) than in the controls (21 percent). Moreover, decline in independent functioning was greater at six months in the intervention group than in the controls.

         What should we make of all this? I think it’s reasonable to conclude something about what we're not doing. We’re not currently depriving many older patients of care that would be beneficial for them. Maybe all those physicians who don’t admit certain elderly individuals to the ICU aren’t discriminating against them; maybe they’re on to something. What we don’t know is whether the doctors who provide “routine care,” those who use criteria other than the officially sanctioned ones for determining who gets in to the ICU, are still over-utilizing the ICU. What we don’t know, although it’s a bit implausible, is whether there are older patients who are excluded both by the seat-of-the-pants criteria and the rigorously-determined criteria, who would nonetheless benefit from a trip to the ICU.

         Behind all the methodological considerations and the statistical conclusions, we have two inescapable realities: first, there are many older people who are so sick and so close to the end of life that no technology, no medication, no amount of monitoring or nursing care will keep them alive—and that’s true even for the population addressed in this study, which excluded anyone who was frail. Second, the ICU is a medical intervention, much like a drug or a procedure, and it comes with side effects. For older individuals, those side effects may outweigh any potential benefits of the intervention. So when the physician recommends the ICU for you or your older relative, think twice before agreeing.

American medicine is best at taking care of people who have a single, very serious disease. We’re even better at taking care of them when they are in the throes of an exacerbation of that disease, when we can control everything that goes into their bodies and monitor whatever comes out, usually in the acute care hospital, often in the ICU. That means, for example, patients with severe heart failure who develop acute pulmonary edema, or people with leukemia who are in “blast crisis.” People who have multiple interacting conditions or one disease that isn’t necessarily fulminant but affects many aspects of their daily lives—those are the people we’re not so good at taking care of. And it turns out that these ill-defined groups of people not only get mediocre medical care, but they also cost the health care system a great deal of money.

It’s finally become clear to a number of influential health policy types that this group deserves attention—doing a better job caring for them could potentially improve health and save money. David Blumenthal, president of the Commonwealth Fund, recently published an article in the New England Journal of Medicine saying it was time we paid attention to “high need, high cost” patients. CTAC, the Coalition to Transform Advanced Care, just held a national forum on “advanced illness care,” advocating payment and delivery reform of the most vulnerable patients. CAPC, the Center for Advancing Palliative Care, has for a number of years promoted the use of “an added layer of support” for patients with “serious illness” throughout the course of their disease. But how can we identify just who it is who stands to benefit from the kind of care that all these groups recognize as crucial: integrated, coordinated, team-based, and patient-centered care?

Our neighbors to the north have long recognized the importance of frailty as a concept that gets at what’s common to people with multiple co-morbidities, patients with one advanced illness, and some patients who have dementia or mental illness. What’s unique about frailty is that it identifies patients who are vulnerable to external stresses. It doesn’t matter whether the vulnerability arises from the interaction between several different medical conditions or the effects of a single disease on many bodily functions; it’s the precariousness of their condition that makes frail people both difficult and costly to care for. 

Dr. Kenneth Rockwood, together with colleagues at Dalhousie University in Canada, has developed a powerful Clinical Frailty Scale that categorizes patients based on a mixture of disease burden and function. Studies show the Clinical Frailty Scale can predict decline and mortality among community dwelling older individuals; it can predict unplanned hospitalization and death in outpatients with cirrhosis; and it can predict length of stay in older patients admitted to the acute medical service of a general hospital. But a Google search fails to turn up a single article in which the CFS is used in a US hospital. It’s been tried in Australia. It’s used in Canada. But not the US. Why not?

Let’s have a look at the CFS. I think it offers some clues:

Two observations about the scale. First, although the outcome is quantitative (every patient gets a score between 1 and 9), the assessment that goes into determining the outcome is fundamentally qualitative. Second, and not unrelated, there’s no way the score can be computed from information already entered into an electronic medical record. That’s because the rating is not based on things like the serum albumin or the mini-mental score. It’s based on one person, a clinician, deciding which of 9 very short, illustrated descriptions best fits another person. There’s nothing complicated about the process—a good primary care physician be sufficiently knowledgeable about his patient to determine the answer without asking doing any kind of special evaluation, and even a not-so-good primary care physician should be able to find out enough to choose the best description after 1 or 2 minutes of questioning. But introducing the CFS into the practice of medicine in the US would require physicians to be aware of their patients’ level of functioning in everyday life, not just the functioning of their individual organs. And it would require accepting the notion that sometimes qualitative reasoning trumps the quantitative. Both concepts are alien to standard American medicine.

CTAC and CAPC and all those others who argue that we need to do a better job caring for our most medically vulnerable patients—for the sake of their well-being and for the sake of our pocketbook—argue about what exactly is wrong with the patients they want to serve. Are they dying? Do they have lots of problems? Are they suffering from advanced illness? I would argue it's not just people who are dying, though many of the most vulnerable are dying. It’s not just people with multi-morbidity, though many of the vulnerable do in fact have multiple conditions. And it’s not just those with advanced illness, though many of the most vulnerable have an advanced illness. It’s people whose illness(es) affect sufficiently many aspects of their daily functioning that they have become frail. 

Frailty is the final common pathway, whether you're frail because of dementia or metastatic cancer or Parkinson's disease or some combination of arthritis, diabetes, and COPD. So let’s borrow from our northern neighborhood and begin using the Clinical Frailty Scale. It’s really very simple.

I stumbled on it purely by accident. I was looking for a picture to illustrate "diversity" for a talk I am preparing, and I seemed to remember that the World Health Organization had some beautiful photos in its earlier reports. Maybe what I liked best about those photos is that they capture the beauty and the humanity of their subjects without insisting that everyone smile for the camera. As it turns out, I didn't find what I was looking for but I discovered that on the very day I was searching, the WHO released a brand new report. It doesn’t have a very snazzy title—it’s called World Report on Ageing and Health—but it’s a remarkable and inspiring document. 

Not surprisingly, none of the major US newspapers breathed a word about its release. Maybe the reporters just haven’t had time to go over it: it is, after all, 260 pages. Or maybe they figure that what’s happening in the rest of the world isn’t terribly germane to the US. Perhaps--and I suspect this is the real reason--the media don't want to think about aging. In fact, the report is brimming with fascinating observations and interesting insights, many of which are relevant to the United States both in terms of our own aging population and in terms of national security. There is so much in here worth commenting on, that I think I will devote more than one blog post to the report. Let me begin by sharing some of the most astonishing things I learned in the first half of the report.

The report begins by suggesting that rather than thinking about expenditures on older people as pure costs, they should be seen as investments. It points to a study done in the UK a few years ago which calculated that if you put everything that the government spends on old people in one column (pensions, health care, other social welfare programs) and you put the contributions of older people in another column (taxes, consumer spending, work), you come up with a positive balance. At least in England, the net contribution of older people amounts to 40 billion pounds per year.

One of the most startling differences between this new report and its predecessor is that today's version defines healthy aging as the process of developing and maintaining the functional ability that enables well-being in older age. iI like that. All health care systems in all countries, the authors argue, should have as their single goal fostering the functional ability of older people by supporting and maintaining their intrinsic capacities and by enabling those with diminished functional capacity to do the things most important to them. This is a marked improvement, in my view, from the last major WHO report, Active Ageing, which came out in 2002, that talked about "optimizing opportunities for health." Then, health was the ultimate objective; now, health and healthcare are means to an end and that end has to do with the ability to function in society.

The description of what health in older age looks like in different countries is both intriguing and sobering. My attention was drawn to a single chart showing the percent of the population age 65-74 and the percent age 75 and older with limitations in one or more activities of daily living, by country. Only a handful of countries were listed. But the gap between the worst off and the best off was shocking—as was the revelation of who occupied the extremes. In first place is Switzerland, with fewer than 10% of the 65-74 year olds suffering a limitation in function and fewer than 20% of those over 75. In last place is Russia, with 60% of the younger old and 80% (that’s not a typo) of the older old reporting at least one ADL deficit. I haven’t quite figured out how this relates to Putin’s policy in Ukraine and Syria, but I suspect there’s a connection. There's something very rotten in the state of Russia.

On a more optimistic note, the chapter on “Health Systems” gives some uplifting examples of countries that have introduced novel approaches to improving the well-being of their older populations. Ghana is making an effort to harness its well-established system of community health workers to meet the needs of older people. And Brazil has begun integrating aging into its national family health strategy: it is using multidisciplinary teams comprised of physicians, nurses, and physical therapists, psychologists, nutritionists, occupational therapists, and others to work in community centers and to go into patients’ homes to deliver care.

More to follow…