How to bring geriatrics and oncology together
Prof Hans Wildiers - University Hospital of Leuven, Leuven, Belgium
Hans, let me congratulate you on your receipt of the Calabresi award, now this is for your work in bringing geriatrics and oncology together. A main issue in this, one of the issues coming out of this conference, has been assessment – could you tell me about geriatric assessment and its pivotal role in the kinds of things you’re talking about here?
As an oncologist you tend to focus on the cancer but you have the patient besides that. The problem with older people is that they have a lot of other problems besides the cancer and a geriatric assessment is meant to detect these other healthcare problems. This is well known and it is becoming more and more spread in the oncology world to do a geriatric assessment to detect the problems but that’s only the start. Because if you detect these problems you need to do something with it – if you find a malnutrition problem you need to have someone looking at the nutrition problem and solving it so they can tolerate the therapy better. So that’s exactly the challenge, to be able to solve the geriatric problems that you detect.
So you’ve got a systematic procedure in place for doing the assessment, how do you advise doctors and teams to set things up so that you can implement everything?
The secret is that you have to work together with other healthcare professionals and with other healthcare programmes. In Belgium, for instance, there is a well-established geriatric care programme independent from oncology. In Belgium we decided with the oncology world to work very closely together with the existing geriatric care programme and so the geriatric assessments were done within the oncology units by an ambulatory nurse or a liaison person. But then that liaison person closely works together with geriatricians and they decide on how to refer patients to the ergotherapist, the physiotherapist, the dietician, the psychologist. So we streamlined all these procedures; we first detect problems and then we have a referral pathway that is integrated within the geriatric care programme.
Could you give me some examples of what happens because factors like nutrition, factors like comorbidities come into all of this. Can you give me a typical example of the sorts of things you put into place once you’ve done the assessment?
For instance, you have an early breast cancer patient and she’s operated and you need to decide on a treatment afterwards but you find in a geriatric assessment a nutrition problem that you were not aware of and you find that the mini mental state is not so good so that there might be a cognitive problem that was unknown previously to the physicians. So in that case these are health problems that are not related to the cancer directly but that can affect the treatment significantly. If this patient has dementia she might not take her pills at all and you would not even be aware. So what we do is have a dietician going to look at that patient and investigate in depth why there is a feeding problem and it might be a very stupid reason, for instance the teeth that are not good anymore or a prosthesis that is not functioning well, that may be the only reason for malnutrition. We, as an oncologist, we cannot solve all these problems, you need a specialist like a dietician to look at it and to find treatable causes.
Presumably the oncologist is the one who needs to organise the team or at least to nominate someone who makes all of the practical decisions then?
Yes. In Belgium we had a huge investment of the government and they financed trained healthcare workers to do these assessments everywhere in the oncology units in collaboration with the geriatricians. So it was a nationwide implementation; we did a huge study in 22 hospitals and we included 8,500 patients in three years. So it’s really an implementation programme. We are not focussing on research anymore, we really want to have assessment done in all older patients that have a cancer problem.
Are you able to give me the data on outcomes resulting from this more effective implementation?
Yes, we just finished the database and Cindy Kenis tomorrow will present the first data we have but we are not at all finished yet with the analysis. But it is very descriptive because the goal of our study mainly was to implement geriatric assessment and interventions and we have done a lot of geriatric interventions and we will describe in each centre how this is established, what the good things are, where the problems are, where the bottlenecks are because we are not perfect and we miss patients. Sometimes we find a nutrition problem but the dietician did not have time to see the patient. We will document all this and describe what we learned from this huge implementation study.
So what are the procedures, then, to summarise, that doctors need to implement in order to make all of this happen effectively?
As an oncologist you cannot solve all the healthcare problems of the elderly by yourself. So you need in your own healthcare structure to find collaborations with existing geriatric care programmes and it will be very different in every healthcare setting.
And although the data are not out yet, you’re fairly confident this is going to improve outcomes overall?
Yes, in the geriatric world there is level 1 evidence that geriatric interventions improve survival, decrease hospitalisation, decrease institutionalisation, they go less to nursing homes. So in the geriatric world we have very nice randomised studies showing that if you have a holistic approach to a patient that their outcome is much better than if you just treat one disease. We don’t have these studies yet in oncology but my personal opinion is that we don’t need them anymore. It is quite common sense that you need to look at nutrition status, at functional status. We have clear evidence in the general older population and we don’t have to prove again and again that we need these very basic parameters. For instance, measuring blood pressure, there is no randomised study that shows that you need to measure blood pressure. Everyone does it and it’s logical if you find hypertension that you treat it; it’s logical that if you find malnutrition that you treat it and solve a problem. We don’t need randomised studies over and over again to prove this.
So better for the patient, is it also cost effective?
There are in oncology no cost effectiveness studies, in geriatrics there is and, as I say, you reduce death, hospitalisation, hospital length of stay. So I’m very convinced that you decrease healthcare costs but I’m not aware of good cost effectiveness studies in oncology.
So potentially a win-win situation.
Potentially certainly a win-win.