The number of U.S. adults aged 65 and over is rapidly increasing: by 2030, they’re estimated to represent about 70% of cancer diagnoses. During a session on Friday, April 12, 2019, at the ONS 44th Annual Congress in Anaheim, CA, speakers discussed how the complexities of cancer care can affect the expanding population of older adults with cancer.
Sincere McMillan, MS, ANP-BC, RN, nurse practitioner in the Department of Geriatric Medicine at Memorial Sloan Kettering Cancer Center in New York, NY, described scenarios of older adults who are the same age, yet have quite different physical, psychosocial, and supportive care needs. Through case discussions, McMillan conveyed the need for personalizing care because “a one-size-fits-all approach to caring for an older adult with cancer misses the fundamental importance of individualized, comprehensive assessment."
Use of a geriatric assessment (GA) also promotes informed decision making. McMillan described GA as a multidimensional, interdisciplinary evaluation that identifies various deficits, possible triggers that exacerbate those deficits, and potential risks for adverse treatment effects. It includes measurement of cancer treatment’s effect on cognition, functional status, and psychological domains, so nurses can use evidence-based interventions to improve patients’ quality of life and clinical outcomes. Experts recommend a baseline GA when cancer treatment decisions are being made and at regular intervals throughout treatment, McMillan said.
Comorbidities, Chemo Toxicity, and Tools to Measure Them
Diane G. Cope, PhD, APRN, BC, AOCNP®, director of nursing and oncology nurse practitioner at Florida Cancer Specialists and Research Institute in Fort Myers, explained how integrating assessment findings and evidence-based toxicity screening tools into treatment decisions can help predict chemotherapy toxicity in older adults. Treatment evaluation should include assessing risk versus benefit and must consider comorbidities. More than 50% of older adults have three or more chronic conditions, often resulting in polypharmacy, and about 49%–64% of them are likely to experience at least grade 3 toxicity during cytotoxic treatment, Cope cited.
Valid and reliable tool selection is critical, Cope explained, because “the use of screening chemotherapy toxicity tools may improve quality of life, maximize dose intensity, and improve outcomes in older adults with cancer.” Although a GA can be helpful in identifying geriatric-related problems, it should not be used to determine chemotherapy toxicity risk. According to Cope, tools that have shown effectiveness in predicting treatment toxicity risk include the Chemotherapy Risk Assessment Score High-Age Patients Toxicity Tool, and the Cancer and Aging Research Group Chemo Toxicity Calculator.
Rowena (Moe) Schwartz, PharmD, BCOP, associate professor of pharmacy practice at the University of Cincinnati James L. Winkle College of Pharmacy in Ohio, stressed the importance of early risk identification and use of effective strategies that help minimize the impact polypharmacy can have on cancer treatment. Schwartz discussed possible consequences of inappropriate medication use, including case studies of adverse drug reactions or drug interactions that resulted in increased complexity and cost of care. Methods of screening for inappropriate medications including the Beers Criteria, Screening Tool of Older Person’s Prescriptions, Healthcare Effectiveness Data and Information Set, and Medication Appropriateness Index.
Schwartz also detailed tactics to optimize cancer drug therapy when potentially problematic polypharmacy has been identified, including using treatment plan and medication reviews, computerized system alerts, educational interventions, and medication reduction or discontinuation.