Supporting the older woman with a gynaecological malignancy
Dr William Tew - Memorial Sloan Cancer Center, New York, USA
You were talking here in Prague about supporting older women with ovarian cancer. What are the big issues that you’ve been looking at?
Well ovarian cancer is a very complex disease, in part because women are diagnosed at advanced stages. About 80% of women are going to be diagnosed with stage 3 or stage 4 disease and treatment for potential remission or cure requires an aggressive surgery plus chemotherapy, a platinum-based chemotherapy. So for older patients that means being able to not only survive but tolerate all the significant morbidities that this aggressive surgery requires as well as the chemotherapy.
What do your patients expect out of therapy, do you find?
It depends. I’d say the vast majority of our patients are looking for good quality of life, good symptom control, survival. So it’s really patient-specific and I think that is an important question to ask at the onset of diagnosis as far as expectations and goals of care.
It’s a difficult disease, outcomes are not that great so how do you broach all of this with your patient?
You’re right, the prognosis is often not curative when patients are diagnosed with stage 3 or stage 4. However, 20% of women are cured and many patients are surprised by that finding because they feel that often it’s a death sentence. Particularly because women present with such significant symptoms and because of such poor screening tests and because it’s a rare disease it’s often caught late. So I first tell my patients that this is potentially curable and that’s our goal at time of diagnosis. Some patients that’s important, some it’s not.
When it’s not a prospect of cure what do you tell them then?
My focus then is on controlling symptoms and trying to limit the toxicities from surgery and chemotherapy.
What are patients’ anxieties mostly?
The major concern is the symptom of pain and controlling symptoms that this disease causes like abdominal distention, bowel obstructions, inability to eat or drink, effects on function and independence.
You’ve got quite an interesting nurse-led telephone intervention system, could you tell me about that?
Yes, this is something we’re really proud of and presented here at the SIOG meeting. We were given funding by the NCCN, which is a guideline panel in the United States, to look at different interventions for women with newly diagnosed ovarian cancer. We did a geriatric assessment at four time points throughout the continuum of their up-front treatment – before surgery, after surgery, before chemotherapy and after chemotherapy - and found specific variables in the geriatric assessment that were predictive of both surgery and chemotherapy side effects. The nurse practitioner intervention was a secondary component of the study to see if it was feasible for a geriatric nurse practitioner to call and act almost like a coach to the patient where she would call the patient weekly and discuss any symptoms that she was having, making sure that the symptoms were addressed, being a navigator. We’re in a large cancer centre in the middle of New York city and can our patients find all these wonderful supportive services that we offer and are they using them properly? So navigating throughout the system. Then the third thing is referring, so if the patient reports a symptom, making sure that it gets back to the primary team, whether it be the primary nurse or oncologist or if there’s a symptom that the nurse practitioner felt could be better addressed by, say, a nutritionist, physical therapist, she would arrange those referrals.
I would imagine from the patient’s point of view they would be overjoyed to hear from a human being who cares, is a professional and can actually do something but what do you find are the benefits?
Yes, I think you’re right. We were expecting that and we found that, that patients were highly satisfied and 95-100% of patients reported very high satisfaction and felt that the service was very helpful and would recommend the service to other patients with the diagnosis. 25 of the patients received this intervention, the other half of patients did not and so we also looked at outcomes as far as quality of life measures, patient satisfaction. At least from quality of life there was definitely an improvement in those patients that received the intervention versus those that didn’t.
And that is a very important outcome.
It is; this is a small study and this truly was being tested as is it feasible but it proved our hypothesis that this is a type of intervention that we can easily do that helps patients and it definitely has good outcomes.
So looking at your telephone intervention but also the overall approach to supporting women, older women, with ovarian cancer, how would you sum up the big messages coming out of this for cancer doctors?
First and foremost we have to understand that this is potentially a curable disease and we should educate our patients at that. Two, that we should understand what the expectations and goals of our patients are and first and foremost that’s going to be symptom control. So that means, three, we’re going to need to tailor our treatments and provide proper supportive care and interventions such as this nursing call to help them, get them through their treatment.
What do you think the patients think are the most important aspects of this care?
You know, at least the literature says that many of these priorities are similar, at least what I addressed. Now, what I addressed may not necessarily be the same order that many GYN oncologists do and there’s a large heterogeneity of the types of doctors that treat patients with ovarian cancer in the United States, it’s primarily a surgeon who does both the surgery and the chemo; in Europe it’s often a general gynaecologist and an oncologist. So there’s lots of different care models so I feel like the way that I laid out the preferences is probably similar to what most women feel.
Now, in the case of ovarian cancer it’s easy to get discouraged, there haven’t been huge steps forward. So have you got a good news message on which to end for doctors?
Yes, I think the first thing is that ovarian cancer, even in women that it’s not cured, it’s one of the most highly sensitive diseases to chemotherapy. We have shown in many studies through the GOG co-operative group that chemotherapy is actually a symptom control treatment. So chemotherapy can improve quality of life in many of our patients. The other thing that I think is worth mentioning is that this is a disease, although it’s often not curable women live for many years and so we can provide good quality of life for many years of our patients.