Treating cancer is always a challenge, but elderly patients can add another level of complexity. For that reason, Brigham and Women’s Hospital and the Dana-Farber Cancer Institute banded together to create the Older Adult Hematologic Malignancy Program.
The program was originally developed to address the unique needs of geriatric patients being treated for blood cancers including leukemias, lymphomas and multiple myeloma. It is now open to anyone over age 65 being treated for any type of cancer, especially those patients who have comorbidities such as heart, lung or kidney disorders; diabetes; or dementia. The program is the only one of its kind in New England.
“This program is special because the geriatrician and the oncologist are true collaborators,” said Tammy Hshieh, MD, MPH, a geriatrician at the Brigham’s Division of Aging. “I work side by side with the oncologists, with the goal of making sure each patient gets the best care possible.”
It was once unusual for older people to be treated for cancer, because being elderly and frail made it difficult for them to withstand rigorous treatments like chemotherapy. But thanks to better therapies to manage the most common diseases of old age, as well as progress made in the field of medical oncology, age increasingly is not a factor in determining the course of someone’s cancer treatment, or whether to treat them at all.
Advances in oncology include the development of treatments like targeted drugs and immunotherapies, which may have fewer side effects than chemotherapy, as well as newer cancer drugs that can be taken at home as oral medications. Thanks in large part to these newer drugs, it is no longer uncommon for people in their 70s, 80s and even 90s to receive treatment for cancer.
But the other medical conditions commonly seen in older people, as well as the medications they take to treat these conditions, can impact how they do with cancer treatment.
“One example is that people are usually given steroids along with chemotherapy, but steroids can significantly bump up one’s blood sugars. This can cause problems for older patients with diabetes. They may end up needing insulin for better control,” Dr. Hshieh said. “Other cancer drugs may actually lower someone’s blood pressure, eliminating the need for hypertension drugs. For cancer patients who are already taking other medications, it’s important to have someone co-managing their care who is aware of the complications that may arise and the adjustments that need to be made.”
Problems with dementia and memory loss can also make it difficult for some older patients to remember to take their medications and to know when to seek appropriate medical attention for common treatment complications like fever and dehydration. This is a challenge that geriatricians are often able to address. Another important contribution of geriatricians is the ability to take the time to discuss the pros and cons of cancer treatment with patients and their families. “It’s so personal, based on each patient, so that’s a really important aspect of this program,” Dr. Hshieh noted.
In addition to high-touch medical care, another element that has made this program so strong is its research component. Earlier this year, Dr. Hshieh and her colleagues published a study in JAMA Oncology that looked at the relationship between cognitive function, blood cancer treatment and outcomes. The investigators concluded that screening for cognitive impairments could benefit patients. They also suggested ways that oncologists might tailor their explanations and care to meet the needs of patients with reduced cognitive function.
Other studies are now ongoing, including a randomized controlled trial assessing whether cancer patients categorized as “frail” or “prefrail” benefit from having a geriatrician involved in their care. One goal of that trial, which recently finished enrolling patients, is to determine whether including a geriatrician on the care team ultimately affects patient outcomes.
“More and more older people with cancer come in asking for treatment. Oncologists, patients and patients’ families are all grateful to be able to get the extra care that they need from our geriatricians,” Dr. Hshieh concludes.