Postacute and Long-Term Care Teams Increasingly Participate in Cancer Care

Abstract

By 2030, cancer incidence will have increased by 67% in 20 years among elderly people, compared with just an expected 11% climb in younger adults. By then, 70% of all cancers will be diagnosed in adults 65 years or older, a group at MD Anderson Cancer Center has calculated from Census Bureau and epidemiology data. The role of nursing homes in cancer care will be shaped over time, but trends point toward greater involvement of facilities in a wide range of areas: patient assessment and treatment decisions, the administration of a growing number of oral therapies, monitoring for treatment side effects, palliative and supportive care, and survivorship care. Nursing home staff have valuable insight and knowledge and can “act as advocates for the patients,” said Dr. Supriya Mohile, a geriatrician and oncologist at the University of Rochester (N.Y.) “We need more and better communication between oncologists and the people who are taking care of older patients day-to-day, communication that [takes into account] the fact that most oncologists have not been trained in geriatrics at all.” If a study of more than 145,000 nursing home residents in the United States is any indication, the rate of cancer diagnoses in nursing homes is already sizable. Fourteen percent of the residents in this study, reported by Dr. Giuseppe Colloca at the 2011 annual meeting of the International Society for Geriatric Oncology (SIOG), had cancer diagnoses, occurring at an average age of 75-84 years. Nursing homes and assisted living facilities, moreover, may be increasingly viewed by oncologists as safe havens for cancer care, especially for older individuals who are teetering between independent and assisted living when a cancer diagnosis strikes. “I actually feel better about treating much older patients when they're in assisted living or nursing home care,” said Dr. Mohile. “If they're at home, I worry that I won't hear about issues until we can't intervene.” For one of Dr. Mohile's patients, an 85-year-old woman with advanced, recurrent lung cancer, a move from her lifelong home to a high-level assisted living facility made her treatment possible. “If she had chosen to [continue living] independently, she would not have been a candidate for treatment, as we didn't think she would be able to manage the instructions for medication or report side effects … and she had had two recent falls,” Dr. Mohile explained. A geriatric assessment revealed significant independence in activities of daily living but functional impairment in instrumental activities of daily living (she needed help with shopping and housework). The patient had no cognitive impairment, but she did not fully understand her medications and how to take them. She was not deemed a candidate for palliative chemotherapy because of her functional impairments, frailty, and high risk of side effects, Dr. Mohile said. She was, however, a candidate for erlotinib (Tarceva), an oral treatment for non-small cell lung cancer that has spread and is positive for epidermal growth factor inhibitor. The medication, which is also approved for advanced pancreatic cancer, can be a symptom reliever. Since the woman's admission to the assisted living facility, Dr. Mohile and her team have communicated with the facility's nursing staff on what to look for and how to manage side effects. And now, “with modifications [in her regimen], she is doing well with a good quality of life,” Dr. Mohile said. The case of Dr. Mohile's 85-year-old patient is reflective of two trends that are especially pertinent to nursing homes. One is an evolving shift from traditional, intravenously administered chemotherapy toward the use of more oral biologic or chemotherapeutic agents that are not as indiscriminately cytotoxic as traditional chemotherapy drugs. The other is a growing interest in the use of comprehensive geriatric assessments to help guide treatment. For years, studies have shown that elderly cancer patients are less likely than younger patients to receive anticancer therapies. The National Cancer Institute's 2011-12 “Cancer Trends Progress Report” states, for instance, that women with node-positive breast cancer receive chemotherapy less often if they are 65 and older, that older women are less likely to receive radiation treatment after breast-conserving surgery, and that patients with stage IIIB or IV lung cancer who are 80 years or older receive chemotherapy less than half as often as patients under 70. In Dr. Colloca's study of U.S. nursing home residents, chemotherapy and radiation treatment were infrequent. Chemotherapy, for instance, was administered to approximately 17% of those residents with breast cancer, 3% with colon cancer, and 3% with lung cancer. Whether such rates reflect age-related undertreatment or wise decision-making is a complicated question and a source of debate. This is partly because few, if any, studies of cancer treatments have included patients at the extremes of age or those with poor functional status, leaving physicians and patients with a dearth of evidence on the safety and efficacy of geriatric cancer treatment. Knowing the Right QuestionsCollaboration between nursing home caregivers and oncologists is increasingly important, according to experts interviewed for this story. These are among the questions they recommended that caregivers ask oncology teams, and themselves, as they care for residents with cancer: ▸What can we do to help oncologists and family members decide whether or not to pursue treatment? How can our geriatric assessments or other tools be helpful?▸What do we know about the chemotherapy or oral cancer therapy being prescribed? Potential side effects? Risk of infections, skin problems, nausea, diarrhea, fatigue?▸What are the warning signs that should prompt an urgent call to the oncologist or termination of a drug?▸What can be done before and during treatment to maintain a nursing home resident's strength?▸How can we make sure the patient gets adequate sleep, nutrition, hydration, and oral care during treatment?▸What can we do to further decrease the risk of falls, as chemotherapy-induced neuropathy appears to be linked to falls and difficulty walking?▸How can we best control pain, manage symptoms, and provide palliative or hospice care when treatment of a cancer is deemed too risky or is refused?▸What can we reasonably do to follow up after cancer care? Collaboration between nursing home caregivers and oncologists is increasingly important, according to experts interviewed for this story. These are among the questions they recommended that caregivers ask oncology teams, and themselves, as they care for residents with cancer: ▸What can we do to help oncologists and family members decide whether or not to pursue treatment? How can our geriatric assessments or other tools be helpful?▸What do we know about the chemotherapy or oral cancer therapy being prescribed? Potential side effects? Risk of infections, skin problems, nausea, diarrhea, fatigue?▸What are the warning signs that should prompt an urgent call to the oncologist or termination of a drug?▸What can be done before and during treatment to maintain a nursing home resident's strength?▸How can we make sure the patient gets adequate sleep, nutrition, hydration, and oral care during treatment?▸What can we do to further decrease the risk of falls, as chemotherapy-induced neuropathy appears to be linked to falls and difficulty walking?▸How can we best control pain, manage symptoms, and provide palliative or hospice care when treatment of a cancer is deemed too risky or is refused?▸What can we reasonably do to follow up after cancer care? In general, experts agree, comorbidities and frailty can complicate the delivery and tolerability of cancer treatment, which means that the risks of surgery, radiotherapy, and especially active medical treatment may often outweigh potential benefits in older nursing home residents. While benefits of chemotherapy are largely similar in older compared with younger patients, the risks of toxicity rise with age. Still, individual risk-benefit analyses need to be made, sources for this story said. A growing number of experts and medical bodies – from the international International Society of Geriatric Oncology (SIOG) to the U.S.–based American Society of Clinical Oncology and National Comprehensive Cancer Network – are calling for the integration of comprehensive geriatric assessment into oncologic decision making. “We're doing a lot of work [in oncology now] with comprehensive geriatric assessment tools and with briefer assessments, trying to figure out [what works best] and how to administer and pay for them,” said Dr. Hyman Muss, professor of medicine and director of the geriatric oncology program at the University of North Carolina at Chapel Hill School of Medicine. While no one tool is in widespread use, it is clear that formal assessments of life expectancy and the risk of morbidity from cancer and other problems “can be very, very helpful” in determining whether and how aggressively to treat cancer in geriatric patients, Dr. Muss said. One such tool, developed by geriatric oncologist Dr. Arti Hurria and her colleagues in the multi-institution Cancer and Aging Research Group, may be helpful specifically in informing chemotherapy decision making. In an observational, multicenter study of 500 patients ages 65-91 with various types and stages of cancer, the researchers used the tool to develop a scoring system that identifies levels of risk of adverse effects from chemotherapy (grade 3-5 chemotherapy toxicity). They then assessed patients before treatment and observed them through their chemotherapy courses (J. Clin. Oncol. 2011;29:3457-65). The tool captured demographics, tumor and treatment characteristics, laboratory test results, and geriatric status (function, comorbidity, cognition, psychological status, social activity/support, and nutritional status). It is a brief but comprehensive tool that can largely be self-administered or administered with the help of family or a nursing home caregiver, said Dr. Hurria of the City of Hope Comprehensive Cancer Center in Duarte, Calif., who is the president of SIOG. Another study involving a different compilation of geriatric assessment tests found that three factors – advanced disease, a low nutritional assessment score, and poor mobility – can predict early death after chemotherapy among patients older than 70 years (J. Clin. Oncol. 2012;30:1829-34). Dr. Hurria and other sources said that when it comes to treatment planning, they see valuable synergies between oncologists and nursing home caregivers, many of whom routinely use geriatric evaluations to identify vulnerabilities and to direct interventions. Facility caregivers may play a valuable role, Dr. Hurria added, in helping residents and families with decision making. “Patients [who are deemed to be possible candidates for cancer therapy] may decide they don't want any of the treatments, but they should at least have the opportunity to know what their different options are,” she said. Armamentarium UpdateTargeted therapy and biologic therapy (also called immunotherapy) are among the types of anticancer treatments that are a major focus of cancer research and that are gradually making their way into practice, according to the National Cancer Institute and the American Cancer Society.Technically, these two types of therapy are forms of chemotherapy because that term is broadly defined as the use of drugs to treat cancer. However, because these newer categories of drugs work differently and have different side effects, oncologists often talk about them separately.Targeted therapies aim to attack cancer cells, while doing little damage to normal cells, by zeroing in on the cancer cells’ inner workings. Targeted therapies called enzyme inhibitors block certain proteins that act as signals for cancer cells to grow, for instance. Others called angiogenesis inhibitors block the formation of blood vessels that would otherwise feed tumors the oxygen and nutrients they need to grow.In most cases, targeted therapy is used with treatments such as traditional chemotherapy, surgery, and radiation. Depending on the type of cancer and its spread, targeted therapy can cure a cancer, slow its growth, kill cancer cells that have spread from a primary tumor, or relieve symptoms caused by the cancer.Immunotherapy, sometimes called biologic therapy, uses the immune system directly or indirectly to fight cancer or to lessen side effects from other treatments. Sometimes it involves stimulating the body's own immune system to work better. In other cases, it trains the immune system to attack specific parts of cancer cells. (In this sense, some types of immunotherapy are also a form of targeted therapy.)Immunotherapy can involve the use of laboratory-generated immune system components. Monoclonal antibodies, for instance, are manufactured versions of immune system proteins that can be designed to attack a specific part of a cancer cell. Similarly, interferons, interleukins, and colony-stimulating factors alter the interaction between the body's immune defenses and cancer cells, as the National Cancer Institute puts it, “to boost, direct, or restore the body's ability to fight the disease.” Targeted therapy and biologic therapy (also called immunotherapy) are among the types of anticancer treatments that are a major focus of cancer research and that are gradually making their way into practice, according to the National Cancer Institute and the American Cancer Society. Technically, these two types of therapy are forms of chemotherapy because that term is broadly defined as the use of drugs to treat cancer. However, because these newer categories of drugs work differently and have different side effects, oncologists often talk about them separately. Targeted therapies aim to attack cancer cells, while doing little damage to normal cells, by zeroing in on the cancer cells’ inner workings. Targeted therapies called enzyme inhibitors block certain proteins that act as signals for cancer cells to grow, for instance. Others called angiogenesis inhibitors block the formation of blood vessels that would otherwise feed tumors the oxygen and nutrients they need to grow. In most cases, targeted therapy is used with treatments such as traditional chemotherapy, surgery, and radiation. Depending on the type of cancer and its spread, targeted therapy can cure a cancer, slow its growth, kill cancer cells that have spread from a primary tumor, or relieve symptoms caused by the cancer. Immunotherapy, sometimes called biologic therapy, uses the immune system directly or indirectly to fight cancer or to lessen side effects from other treatments. Sometimes it involves stimulating the body's own immune system to work better. In other cases, it trains the immune system to attack specific parts of cancer cells. (In this sense, some types of immunotherapy are also a form of targeted therapy.) Immunotherapy can involve the use of laboratory-generated immune system components. Monoclonal antibodies, for instance, are manufactured versions of immune system proteins that can be designed to attack a specific part of a cancer cell. Similarly, interferons, interleukins, and colony-stimulating factors alter the interaction between the body's immune defenses and cancer cells, as the National Cancer Institute puts it, “to boost, direct, or restore the body's ability to fight the disease.” Treatment options today are more numerous than just a decade ago. Geriatric oncologists say that a growing array of oral anticancer therapies (pill or liquid form), from newer chemotherapies to biologic and endocrine therapies to targeted therapies (see sidebar), have the potential to expand the ease of treatment for elderly patients, both in terms of convenience and tolerability. For instance, erlotinib, the targeted oral medication that Dr. Mohile prescribed for her 85-year-old patient with advanced non–small cell lung cancer, is in a class of targeted therapies called kinase inhibitors. They block the action of an abnormal protein that signals cancer cells to multiply. Erlotinib was the only appropriate treatment for this patient, given her frailty, Dr. Mohile said. Two oral drugs approved in the past 2 years for treatment of late-stage prostate cancer – enzalutamide (Xtandi) and abiraterone acetate (Zytiga) – are similarly more likely to be tolerated by the elderly than other anticancer drugs. “These drugs [seem to be] pretty well tolerated, even in frail elderly, so clinically, we favor them,” Dr. Mohile said. “The problem is, the costs are significant. I have patients who, even with 80% [insurance] coverage, have to pay several thousand [dollars] a month.” Therein lies the main impediment thus far to wider usage of oral anticancer treatments. Many of these drugs are still under patent protection and significantly more expensive than older cancer therapies. Moreover, oral anticancer medications are generally considered a pharmacy benefit under Part D of Medicare and are therefore covered differently than traditional outpatient intravenous therapy. Some oral anticancer drugs (but not all) are covered by Medicare Part B for Medicare recipients, as well as dually–eligible Medicare–Medicaid patients living in long-term care facilities. Coverage may improve as states continue passing “oral oncology parity laws,” which more than a dozen states have done thus far. Also, the Centers for Medicare & Medicaid Services continues to review Medicare coverage of new oral anticancer treatments. Hormonal therapy (primary, secondary, or adjuvant) is an increasingly common treatment approach to prostate and breast cancer, which with lung and colon cancer were the cancer types most often diagnosed among nursing home residents in Dr. Colloca's study. Many women who enter nursing homes with previously treated breast cancer are still receiving adjuvant hormonal therapy. But, in addition, women who are diagnosed with breast cancer later in life are significantly more likely to have breast cancer with hormone-receptor expression, making them good candidates for primary therapy with tamoxifen or aromatase inhibitors, which “in general are less toxic than most of the [anticancer] drugs older people take,” said Dr. Muss. Even in cases of advanced disease, in which surgery is not a good option, “there are very good studies that show that endocrine therapy can shrink these tumors over an average of 1½-2 years,” he said. According to recommendations on managing elderly patients with breast cancer, updated last year by SIOG and the European Society of Breast Cancer Specialists, 85% of women ages 80-84 and having been diagnosed with breast cancer have estrogen receptor–positive cancers, compared with approximately 60% of women ages 30-34 with breast cancer (Lancet 2012;13:e148-59). Hormonal therapy for prostate cancer includes therapy prescribed over long periods for older men diagnosed with clinically localized cancer, as well as androgen-deprivation therapy for patients with metastatic prostate cancer, according to recommendations of an SIOG work group on management of prostate cancer in older men (BJU Int. 2010;106:462-9). Both men receiving androgen-deprivation therapy and women taking aromatase inhibitors are at increased risk of osteoporosis and fracture, making calcium and vitamin D supplementation all the more important in these patients, said Dr. Stuart Lichtman, a geriatric oncologist at the Memorial-Sloan Kettering Cancer Center in New York City, which has a “65+ Clinical Geriatric Group.” The most significant risk factor with tamoxifen therapy is venous thrombosis, he noted. In general, caregivers must be just as aware of the side effect profiles of newer oral anticancer therapies as of older chemotherapy regimens, Dr. Hurria said. “You'd think otherwise, since they're easier to administer [and often more tolerable], and since we're using them more and more,” she said, but caregivers should not let their guard down. Cognitive impairment should be considered a potential chronic toxicity with any medical anticancer therapy, even though most of the research on cognition and cancer treatment has been done thus far in younger patients receiving chemotherapy, Dr. Lichtman noted.