Advances in geriatric oncology: Update in supportive care
Dr Christopher Steer - Border Medical Oncology, Wodonga, Australia
We’re looking particularly at this meeting in supportive care, there’s quite an emphasis on it, and you have been given the very important job of pulling together what’s happening in supportive care. What are the big challenges, would you say, that are facing doctors for older patients in supporting them during their cancer therapy?
One of the things I say is that looking after older patients with cancer, otherwise known as the field of geriatric oncology, is all about supportive care. So to look after our patients correctly, or in the best way possible, we need to focus on all of their needs and a lot of those revolve around their supportive care needs. Another thing that I say is that to look after your patients properly, in other words to treat them appropriately, you need to assess them adequately and a lot of the assessment that we do, the so-called comprehensive geriatric assessment, is based around the supportive care aspects of looking after them. So not just the treatment approaches such as which immunotherapy you might use or which chemotherapy you might use, but how you’re going to look after your patients better utilising their supportive care needs and it’s particularly important in older adults.
Now, with a patient, communicating with the patient and getting the patient to come out of their shell and tell you what are the big issues for them, it can’t be easy all this, can it?
We need to often pay particular needs to the wishes of the patient and good communication skills, they’re a key component of looking after patients in general but they do sometimes represent particular challenges in older adults. You need to go out against paternalism where possible, not assume that the patients are going to want certain things just because they’re old or just because their life may be closer to meeting its end. The basic thing that I teach is you cannot assume on the basis of age alone, you need to ask the patient and part of that is adequate assessment.
We heard about the CGA, the comprehensive geriatric assessment, but what simple things do you recommend doctors to be doing or asking their patients?
Comprehensive geriatric assessment has been criticized, if you will, for being a time-consuming process that is not easy to do in the clinic. So there are certainly some simple things that you can do to appreciate your patients’ fitness, if you will, as simple as watching them walk from the waiting room to your office, for example. There are formalised screening tests called things like the time to get up and go and other aspects where you can look at them but just being mindful of the way your patients move is one of the simpler things you can do.
How have things changed, because doctors have, for many years, been using their personal skills and their knowledge to assess patients so how have things changed recently that might give doctors some clues as to what to do?
Anecdotally I think that the biggest change in the last 10-12 years has been the recognition of the importance of the multidisciplinary team in cancer care. The paternalism, if you will, of some clinicians has often been able to be changed by the opinions of others within a team approach and so the thing that has changed for me is the treatment of the patient using this team approach so that we can avoid some of those mistakes, if you will, of paternalism and of assuming that patients should be treated in a certain way on the basis of their age, age alone. I find that’s one of the biggest changes. The ability to facilitate the team approach, for example, in our own situation even in rural and regional Australia where we recognise the importance of the multidisciplinary team but you need to be able to fund that adequately, for example you need to have the administrators in place to make sure that clinicians, the nurses, the doctors, aren’t the ones responsible for that team. So this is the role of government health administrators, to make sure that the teams are adequately resourced so that clinicians get on with their job and part of that is looking after their older patients better.
What are the key components of the multidisciplinary team? We were hearing, for instance, about including pharmacists as part of that and, of course, nurses.
Indeed and the level of resourcing then impacts that. So we have the key people in the clinical team are the doctors and nurses, for example, but the radiologists, the histopathologists who establish the diagnosis in cancer and work out the extent of it, for example. So they’re the key people within the first part of the multidisciplinary team approach but then once you start looking after the patient using guided intervention, so if you assess your patient properly and if you have the multidisciplinary team in place to perform an intervention guided by that assessment, then you start talking about a lot of other people in the team such as the pharmacist, the rehab physicians, the occupational therapists, the physios. I’ll be honest and say it is difficult to resource that, certainly in centres such as our own.
To sum up, what are the take home messages coming out of this whole approach from especially your perspective in rural Australia?
Even in rural Australia supportive care is a key part of looking after our older patients with cancer. You need to listen to your patients carefully and perform an adequate assessment of the patient and then that will yield appropriate treatment.