Implementation Pearls and Barriers: Our approach to a consultative multidisciplinary CARE model was to fulfill a need for aging adults with cancer. The CARE clinic model has evolved since conception, the clinic has grown in capacity to care for patients with all cancer types, at any stage. The clinic was initially targeted for octogenarians with hematologic malignancy. This patient population was selected due to vulnerabilities and an inherent need to address multifactorial geriatric health conditions. Over three years, the clinic was expanded to include patients with all malignancies, at any stage of their illness (newly diagnosed, active treatment, previously treated) in addition our clinic now includes Geriatric Oncologists. Notably, there is not a specific age-threshold for consultation; rather, the CARE clinic is designed to address the unique needs of aging with cancer, as the patient and provider deem appropriate.. There is significant heterogeneity in aging. For example, a 60 year old with significant comorbidities and frailty may be “older” and at higher-risk for poorer cancer outcomes as compared to a 75 year old who is still playing tennis and regularly socializing and/or volunteering within their community. For this reason, the CARE clinic model focuses on physiologic rather than chronologic age
The creation of the multi-disciplinary team model was not a new concept to the institution, but had previously consisted of physicians with different expertise (i.e. surgical oncologist partnered with a medical oncologist). The creation of a multi-disciplinary team with providers from many different departments required a project team and several months of planning to execute a clinic that was interdisciplinary and resourced appropriately. The final disciplines (nursing, case management, nutrition, physical therapy, pharmacy, audiology, physician hematology/oncology) were selected based on the domains of geriatric assessment and clinical time commitment. During the planning phase, many disciplines were approached that were not included in the clinic due to time constraints of the clinic and/or available resources (e.g. integrative oncology, occupational therapy (OT), social work, ophthalmology, dentistry). These additional disciplines are still accessible on a referral basis based on the CARE clinic assessment.
The initial planning of the clinic required commitment and investment from institutional leadership including hospital administration, support of clinical physician faculty from the College of Medicine, and department/divisional support. The planning phases included managerial teams dedicated to streamlining a complex need into an organized service line including allocation of staff with department managerial approvals, creation of memorandum of understanding (MOUs) for staff time commitment, creation of unique templates within the electronic medical record, formation of standardized patient note templates, financial analysis and billing checks, insurance inquires, formatting to allow multiple providers to access a single patient encounter, marketing tools and space allocation. Some initial challenges to overcome included system limitations, consistent staffing, and referral building. Reimbursement is billed separately by each discipline and issues with insurers (Medicare, Medicaid, or private) have occurred in <1% of all patients evaluated. The CARE model need and purpose required dissemination and education to staff from scheduling, nursing, physicians, patients, and caregivers. Creating the infrastructure to support a Geriatric Oncology clinic required planning, investment, education, and ultimately resulted in a sustainable, novel, clinic to support the community of aging adults with cancer.
Geriatric Oncology Intersects with Varying Cancer Subtypes
The impact of aging for older adults with cancer requires a unique approach that addresses both health factors related to aging and the disease pathogenesis. Therefore, in developing a coordinated care plan, the CARE clinic model considers specific cancer subtypes. We outline specific needs of cancer subspecialties for older adults at the CARE clinic, including hematologic malignancies, as well as lung, gastrointestinal, and breast cancers.
Hematologic Malignancies: Understanding the impact of aging for older adults with blood cancer requires a unique approach that both addresses the disease pathogenesis and health factors related to aging particularly as it applies to hematopoietic stem cell transplant (HSCT). In terms of treatment for hematologic malignancies, numeric age alone should not be a contraindication to HSCT. The expanded use of alternative stem cell donors (unrelated/haploidentical)21 and reduced intensity conditioning (RIC) regimens have resulted in increased tolerability of HSCT and similar non-relapse mortality, relapse, disease-free survival, or overall survival (OS).22 In allogeneic transplant, GA variables predict OS; specifically, limitations in IADL, slow gait speed, comorbidities, and low mental health scores are all factors shown to be significantly associated with inferior OS.23 A standard pre-transplant assessment using performance status alone has been shown to not identify frailty in 25% and pre-frailty in 58% of those with “good” health.24 Factors that enhance transplant-related recovery and interventions to mitigate transplant morbidity are under study within the CARE clinic. For example, low physical pre-transplant function and weight loss are associated with longer transplant hospitalizations.25 The CARE clinic assesses older adult transplant candidates as well as younger patients for whom the referring provider has specific concerns. The CARE clinic uses a standardized GA, Rockwood’s clinical frailty scale,26 and the 1-year overall Center for International Blood and Marrow Transplant Research survival calculator27,28 The CARE clinic’s primary goal in evaluating transplant candidates is to identify deficits and mitigate risk factors to improve tolerability of the transplant.
Lung Cancer: Lung cancer is particularly challenging for older adults, as it carries a high physical and emotional symptom burden. While there are many new treatments available, clinical trials predominantly sample younger adults, thereby limiting generalizability of outcomes to older adults particularly regarding new treatments.29 This is particularly relevant in non-small cell lung cancer (NSCLC), where the new standard of care for first-line treatment is now a combination of chemotherapy plus immunotherapy.30 A lack of clinical trial evidence regarding important clinical outcomes, such as treatment toxicity, disease response, and functional status among older adults receiving lung cancer treatment perpetuates uncertainty for clinicians, patients, and their families.31 Geriatric-specific assessments32,33 have been developed as management tools, which can help guide treatment for older adults with lung cancer, specifically in reducing toxicity exposure while not sacrificing improvement in overall survival. At the CARE clinic, our approach employs GA assessments to identify multifactorial geriatric health conditions and interventions are personalized for patients with lung cancer based on identified deficits. Specific attention to maintaining functional status and preventing functional decline is an active area of research in this area and across malignancies.34
Gastrointestinal Cancers: Gastrointestinal (GI) cancers represent unique challenges for older adults, as they often require multimodality treatment including chemotherapy, radiation therapy and surgery. Determination of fitness for surgery and recovery post-surgery are frequently impacted by comorbidities. Complications of surgery may make nutritional recovery more challenging include pancreatic exocrine insufficiency leading to malabsorption and delayed gastric emptying, which may impair appetite and lead to reduced oral intake. Post-operatively, physicians also need to be cognizant of the increased sensitivity of older adults to side effects from opioid use and the risk for delirium.35 The GA may uncover risk factors that may predispose a patient to worse surgical outcomes and may help to identify issues such as cancer-associated cachexia and sarcopenia or poor functional status. Importantly, this may trigger a referral for prehab prior to embarking on a major surgical procedure such as a Whipple procedure.36
Breast Cancer: Almost one-half of breast cancer diagnoses occur in women age 65 years and older.37 Although older women are more likely to be treated with lower doses of chemotherapy, studies have shown that older women who are in good health tolerate chemotherapy as well as younger patients.38 A recent phase II study found that a GA-based risk score predicted treatment toxicity in older adults with metastatic breast cancer who received chemotherapy treatment.39 At the Breast CARE Clinic, each patient is consented and followed longitudinally with a complete geriatric assessment, focusing on all of the domains described in the CARE clinic model, with the exception of audiology. Identifying gaps and dynamics of geriatric deficits among patients with breast cancer will help identify where clinical outcomes can be improved.
Nursing and Education: Recognition of the current evidence in normative aging, multifactorial geriatric health conditions, wellness, and prevention are important aspects of nursing best practices.40 Given the complexities of geriatric care, providing competent geriatric nursing education is critical to management of care in older adults with cancer. Conducting screening using the GA to identify limitations that may potentially impact cancer care is an important role of primary care and advanced practice nurses.41 At the CARE clinic, nurses work with the oncology team to develop management strategies intended to enhance functional status and address untreated comorbidities. Nursing teams are trained in Geriatric specific needs (e.g. cognitive assessment, elder abuse) to provide best practice care to older adults with cancer and is a major priority of the CARE clinic.
Survivorship Care: As cancer survivors live longer, evaluating long-term adverse effects is imperative.42 These include physical and psychological issues including, fatigue, pain, osteoporosis, cardiac toxicity, weight and nutritional changes, cognitive changes, depression, anxiety, and neuropathy, among others.43 Furthermore diminished social and economic resources may also impact the survivorship experience.44 This myriad of unmet needs and complexities, coupled with the reduction in services available for older cancer survivors post-treatment, warrant a more robust provision of survivorship follow-up care.45,46 Addressing survivorship among older adults requires a comprehensive approach considering recommended follow-up care, managing multi-morbidity and medications, deciphering between age- or cancer-related physical and mental symptoms, and coordinating care from multiple physicians.47 Survivorship care plans (SCPs) may improve existing and potential survivorship issues experienced by cancer survivors after cancer treatment. SCPs include key information regarding cancer and treatment, potential late or long-term adverse events, surveillance, and health lifestyle recommendations, and identification of providers who will coordinate care.48 SCPs should include tailored information to address the needs of older adults including modifiable health behaviors (e.g. diet, exercise), polypharmacy, comorbidities, and social support.49,50 Strategies include the utilization of geriatric assessment to outline health concerns, care coordination models to outline the responsibilities of various providers for comorbid conditions, and partnering with caregivers in the care delivery. The CARE clinic at OSUCCC is developing and implementing SCPs into routine cancer care for older adults.