Download Basics in Geriatric Oncology - National Cancer Centre Singapore

Basics in Geriatric
Oncology
Ravindran Kanesvaran
Consultant Medical Oncologist and
Course Director
National Cancer Centre Singapore
How did it start?


Ongoing geriatric oncology service at NCCS (
the only one in SEA)
Idea to promote its principles to other health
professionals in the community

3 workshops : GPs, Nurses, Allied Health

Funding : SSO / MSD/ NCCS PGEU
The GAP





Knowledge on elderly cancer patients
Misconceptions about treatment – ageism
New assessment techniques
Working as a team
Key role of GPs in management of elderly
patients ( where can you contribute)
Course Overview
Objectives

Demographics of cancer in the elderly

Introduction to Geriatric Oncology

Geriatric Asssessment and Treatment

Geriatric onco NCCS

Summary
Population Ageing in Singapore by 2030
Aging and chronic disease




The big 3—cardiovascular disease, cancer and
stroke—increase with age
4 out of 5 persons ≥ 65 years of age have one or
more chronic conditions
Once acquired, chronic conditions usually
remain
Disability associated with aging is often the
result of chronic disease
Aging and chronic disease
Report on Registry of Birth and Death, 2014. Retrieved from: www.ica.gov.sg
Cancer and the elderly



60 % of all malignant tumors occur in the age group
65 years and older
Incidence data shows that as one ages the potential
for developing cancer increase
Persons age 65 and older are eleven times more
likely developing a cancer than persons under age
65
Cancer is a disease associated with aging
Rates per 100k
population
60% of cancer occurs in people >64
CDC, Morbidity & Mortality Wkly Rpt 2013
Age Groups
Top 5 Cancers in Singapore
ASR- age standardised rate per 100,000 population , MOH Singapore website
Cancer Registry 2010-2014
Heterogeneity of Aging
Geriatric Oncology

There is gross under representation of this
group in clinical trials
Talarico et al JCO 2004


A lack of data regarding their cancer treatment
outcomes
Geriatric Oncology is rapidly coming to the
foreground of oncology practice
Current Practice of Oncologic
Assessment


We use functional status (ECOG or
Karnofsky’s scales) assessment
It has been shown to poorly predict functional
impairment in the elderly
Repetto et al JCO 2002
What is a Comprehensive Geriatric
Assessment (CGA)?



Multidisciplinary evaluation of older persons in
which their multiple problems are uncovered,
described and explained
CGA has been used by firstly by geriatricians
and later oncologists to understand these group
of patients better
Multiple benefits to patients assessed using
CGA
Components of CGA
Why Do CGA?
• Predictive value for chemotherapy toxicity, survival and
treatment choices.
• Identify reversible conditions that may improve
patient’s fitness for treatment
• Determine patient decision making capacity
• Clarify patient’s values and goals for treatment
The role of CGA
• Some components of the CGA have been shown to be
prognostic in both Western and Asian populations
independent of performance status alone
• Asmis et al JCO2008, Kanesvaran et al JCO 2011
• CGA evaluation has been shown to impact treatment
toxicity , survival and treatment decisions in elderly
cancer patients
• Puts et al JNCI 2012
Why don’t we use CGA for our patients at present?
• Time constraints (takes 25- 30 minutes to administer)
• Requires manpower
• Lack of functionalization of CGA data
• Specifically in Asia: Lack of data to support its use
CGA and Chemo
Toxicity Prediction
Predictive Model for Chemotherapy Toxicity
Risk Factors for Gr.3-5 Toxicity
OR (95% CI)
Score
Age > 73
1.2 (1.2-2.7)
2
GI/GU cancer
2.2 (1.4-3.3)
3
Standard dose
2.1 (1.3-3.5)
3
Poly-chemotherapy
1.8 (1.1-2.7)
2
Hemoglobin
(male: <11, female: <10 )
2.2 (1.1-4.3)
3
Creatinine Clearance (Jelliffe-ideal wt)
<34
2.5 (1.2-5.6)
3
1 or more falls in last 6 months
2.3 (1.3-3.9)
3
Hearing impairment
(fair or worse)
1.6 (1.0-2.6)
2
Limited in walking 1 block (MOS)
1.8 (1.1-3.1)
2
Assistance required in medication intake
1.4 (0.6-3.1)
1
Decreased social activity (MOS)
1.3 (0.9-2.0)
1
Hurria et al. JCO 2011; 29 3457-3466
Model Performance:
Prevalence of Toxicity by Score
Grade 3-5
Toxicities
“High” 83%
(>11)
“Mid” 53%
(6 - 11)
“Low” 27%
(0 - 5)
Hurria et al. JCO 2011; 29 3457-3466
CGA and survival
Patients and Methods




Retrospective analysis of 249 consecutive cancers
patients at NCCS aged 70 years and above
Univariate and Multivariate analysis done using CPH
method
Simple nomogram developed using regression coefficients from multivariate model
All cause mortality was captured from hospital database
and national death registry
Kanesvaran et al JCO 2011
CGA NOMOGRAM
The scales of the
nomogram
reflected the
coefficients from
the Cox model
rescaled to a user
friendly (100
point) range
Kanesvaran et al JCO 2011
“Its too time
consuming..”
“I have no time to do this in the
clinic..”
Screening tools
Tool
Components
Data in community
dwelling elderly
Data in oncology
patients
VES-13
Age, self-rated health,
Score predictive of
functional capacity and increased risk of death
physical performance
or functional decline
over 2 years
Mixed results for
identifying CGA
impairment in
different populations
Groningen Fraility
Indicator
Correlation between
Mobility/physical
fitness, vision/hearing, the GI score and CGA
nutrition, comorbidity, cognition,
psychosocial
Predicts mortality in
older cancer patients
receiving
chemotherapy
G8
Nutrition, mobility,
cognitive defect,
polypharmacy, age,
self-perceived health
status
Derived from MNA
Sensitive for predicting
deficits on CGA
Geriatric Oncology Service NCCS




Started in 2007 by Dr Donald Poon
Took over in 2010
HMDP at Duke Centre for Aging and DCI in
2011-2102
Restarted Geriatric Oncology service in July
2015
CGA workf low
Patient
(Criteria: ≥70 years old, newly
diagnosed case)
Consent Taking
No
Yes
Comprehensive
Geriatric
Assessment
(CGA) & 20ml
Blood Taking
No action
required
Negative
No action
required
Positive
Recommendations
will be given to
primary physician
Recommendations to primary
physician
Recommendations:
1) Refer memory clinic
2) Refer dietitian
3) Control BP
4) Stop drug XXX, YYY
CARG chemotox score: 7
G3-5 tox risk: 51%
The 3 important Questionnaires

Pre workshop

Post workshop

3 Months later
Conclusions

Cancer is a common problem among the elderly

The elderly should be treated as a unique group
Once diagnosed, treatment will depend on the GA
and patients goals/choice –
IT IS NOT THE END OF THE ROAD !

Acknowledgement





PGEU staff and Prof Simon Ong
All the invited speakers
SSO
MSD
All the participants
THANK YOU
[email protected]
Members of the SingHealth Group
Changi General Hospital • KK Women’s and Children’s Hospital • Singapore General Hospital
National Cancer Centre Singapore • National Dental Centre Singapore • National Heart Centre Singapore • National Neuroscience Institute • Singapore National Eye Centre
SingHealth Polyclinics