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Advancing Cancer Care for the Older Adult-Geriatric

By Neil Grauer

According to the U.S. Census Bureau, 7,918 Americans turned 60 every day last year-that’s 330 people each hour. The number of 65-year-olds is expected to grow three percent annually after 2010.

As the population ages, the number of cancer cases inevitably will rise, too. The average age of those diagnosed with all types of cancer is 70; for lung cancer it’s 72; colon cancer 71; breast cancer 68. Yet despite these statistics, surprisingly little is known about how cancers develop and progress in older patients or how best to treat them.

“Old-fashioned misconceptions-and prejudices-have prevented patients over the age of 65 or 70 from being included in clinical tests of cancer treatments,” says Gary Shapiro, M.D., chairman of the department of oncology at Johns Hopkins Bayview and co-founder of its new Geriatric Oncology Program.

“The common thoughts used to be that it wasn’t worth treating cancer in older patients; that they’d lived their lives; they might be dying anyway; they couldn’t tolerate the treatment; the treatment might adversely affect their quality of life; or that they didn’t want to live with the side-effects of treatment,” Dr. Shapiro says.

In many cases, all of those ideas are false, according to Dr. Shapiro. “Most people want to live,” he says. The new Geriatric Oncology Program that he and Ilene Browner, M.D., have launched at the Sidney Kimmel Cancer Center at Johns Hopkins Bayview-site of the nation’s number one Division of Geriatric Medicine and Gerontology-aims to prove that cancer in the elderly can be treated compassionately and effectively.

Drs. Shapiro and Browner’s program operates a special clinic for cancer patients who are 80 years of age or older. They also see patients who or are as young as 65 who have other chronic health problems and take multiple medications that could affect the treatment of their cancer.

“Often the cancer is the least of their problems-they have severe heart disease or other conditions that have to be managed, and the cancer impacts those problems as those problems impact the cancer. They all have to be managed together,” says Dr. Shapiro. That is what he and Dr. Browner are expertly prepared to do.

Dr. Shapiro has a special interest in the specific, unique needs of older people with cancer. He also is a trained medical ethicist who has extensive experience handling the complex medical questions older cancer patients often face, such as when treatment is called for and when it may be best to hold off.

Dr. Browner is one of the country’s first physicians specifically trained to be a geriatric oncologist. She was one of a handful of physicians to study a special geriatric oncology curriculum at Johns Hopkins.

The Geriatric Oncology Program’s clinic began operation in January. It is open on Wednesdays, but its schedule is expected to expand. Most patients come from the Baltimore area, but some already have arrived from Pennsylvania, Kentucky, Tennessee-even Greece. They have ranged from a 45-year-old amputee with failing kidneys and other geriatric-like problems despite his youth to a 101-year-old who still lives on his own.

“What we’re all about is trying to help people make good decisions for when we use what type of treatment-be it palliative or anti-cancer treatment-and how to manage the whole picture,” says Dr. Shapiro. With older patients, doing that involves “a greater balancing act,” Dr. Browner observes, because of other conditions the patients have or the medications they already are taking.

When a patient makes an appointment, the need’s assessment begins almost immediately to help identify issues and get the whole picture. Using a form that Dr. Browner devised, patients and their families are asked about whatever geriatric issues they may have-mobility limitations, heart conditions, memory difficulties-so that the clinic can prepare to factor those problems into its plans for treating the patient’s cancer.

When the patients arrive, screening tests are performed to determine how the medicines they already are on, their social support system, and general physical condition will impact their cancer care. Then either Drs. Shapiro or Browner examines each patient.

Once the patients have been screened and examined, Drs. Shapiro and Brown meet with a multidisciplinary panel of Johns Hopkins Bayview specialists representing a broad spectrum of medical fields-from psychology and psychiatry to nutritional support, physical therapy and palliative care. After discussing each patient’s case, the group’s members put together an individually tailored treatment plan that involves all their disciplines.

Dr. Shapiro notes that he and Dr. Browner “feel very strongly that we should partner with the patients’ primary doctors” or oncologists while treating the patients. These physicians may know their patients best, even if they are not geriatricians.

Yet it’s the subtle things that the geriatric oncologists spot or anticipate that sometimes can make a major difference in an elderly cancer patient’s care. For example, one of Dr. Shapiro’s breast cancer patients developed an unusual side effect to her chemotherapy: Her hands began to peel. It would clear up in a week, Dr. Shapiro said, but “unless you saw her walking out of the clinic, using a cane, and realized that because of her sore hand she couldn’t hang onto that,” the problem might not have been addressed.

“We had a physical therapist see her and provide a different, mechanical type of support that she could grasp.”

“Often elderly people are on a tightrope and they compensate and are perfectly fine,” says Dr. Shapiro. “But it doesn’t take much-be it the treatment or the effects of the cancer-to throw them over. It’s important to try to identify up front what those things are.”

For more information about the Geriatric Oncology Program, call 410-550-6580.

  • Comprehensive cancer evaluation, including treatment planning and surgical, medicinal and radiation oncology treatment
  • Geriatric evaluation
  • Special consultation on other medical conditions, such as high blood pressure, diabetes, dementia or heart disease
  • Geriatric psychiatry program
  • Dementia evaluation
  • Memory loss evaluation
  • Continence evaluation
  • Nutrition evaluation and support
  • Pain management
  • Social work support
  • Physical therapy/rehabilitation
  • Hospice care
  • Cancer Counseling for patients and their loved ones
  • Community education
  • Assistance with identifying and managing healthcare financing and billing
  • Chaplain consultation
  • Support groups
  • Clinical trial options
 

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