Better assessments in cancer care for older people

Some of these poor outcomes are related to chemotherapy's potentially toxic side effects to older patients, says William Dale, a geriatrician and director of the Center for Cancer and

Aging Research at City of Hope in Duarte, California. In general, he says, “people become so focused on wanting to live longer and treating the cancer that they are not likely to understand

how the treatment may affect their lives. They'll overlook it.” After all, cancer treatment often has trade-offs. “Cancer treatment can take someone totally independent and make them

dependent,” says Judith Owen Hopkins, a geriatric oncologist with Novant Health Forsyth Medical Center in Winston-Salem, North Carolina. Her patient Marie Sechrest, 87, from Greensboro,

North Carolina, was diagnosed in 2015 with myelodysplasia. The treatment for this kind of blood cancer typically involves intense chemotherapy to wipe out a patient's “bad” red blood

cells followed by a bone marrow transplant used to grow new, healthy ones. However, “in people Marie's age, the treatment could be fatal,” says Hopkins. Sechrest's geriatric

assessment showed, among other things, that she lived alone and had no family in town. “I would have not necessarily investigated that fact without a geriatric assessment,” Hopkins says. She

recommended Sechrest get an aide and chose to balance her patient's ability to take care of herself with the available treatment options. For now, Hopkins is giving her patient

chemotherapy to slow the disease and make her comfortable so she can continue to go out to lunch with her friends. “At 87, I'm thankful she is keeping me going,” Sechrest says. But for

all the hype and hope for geriatric assessments, many physicians are not using them. "The vast majority of medical oncologists are [employed by] large hospital-based corporations. Their

reimbursement is based on the number of people they see,” says Hopkins. New patients are slotted for 30 minutes. Returning patients are usually scheduled every 15 minutes. Adding on a

geriatric assessment can take up 20 to 25 extra minutes, and “that time is hard to sell in the community,” she says. Dale, who gives assessments, notes that his colleagues have different

comfort levels with referring patients to him for one. “Some don't understand the reasoning, but without a geriatric assessment there is little discussion about aging issues and whether

a patient can tolerate treatment,” he says. Absent such a screening, he notes, there's often not enough emphasis on identifying depression or anxiety in older patients — a task that

can be tricky in that population. For instance, he says, older patients often hold back, thinking that “complaining” will lead an oncologist to stop treatment.