Download SIOG 2014 dettino_aldo

Interdisciplinary geriatric oncology models of care –
the international perspective.
One institutional Brazilian experience as an
example of Latin American Models of Care.
CGA IMPLEMENTATION IN A CANCER CENTER
PROGRAM IN Brazil, LATIN AMERICA.
Clinical Oncology – Oncogeriatric Unit,
A. C. Camargo Cancer Center (ACCCC), Sao Paulo, Brazil
Dr. Aldo L. Abbade Dettino, MD, PhD
Dept. de Oncologia Clínica
PhD in Science (Pathology) – FMUSP/2008
Post-graduation program – International Center for Research and Education (CIPE)-ACCCC.
Discipline: Therapeutic update to target therapy and translational research.
SIOG 2014. 24/Oct/2014
[email protected]
Presentation topics
• Epidemiology – aging: world and local.
• Examples of efforts to better health care in the
elderly
• Possibilities of geriatric assessments
• Experiences in Brazil
• Our experience of implementing geriatric
oncology in our cancer center
– Some lessons and strategies
– Feasibililty, difficulties
– Perspectives
Life expectancy: world and some regions
United Nations, Department of Economic and Social Affairs, Population Division (2013).
World Population Ageing 2013. ST/ESA/SER.A/348.
Population aging
United Nations, Department of Economic and Social Affairs, Population Division (2013).
World Population Ageing 2013. ST/ESA/SER.A/348.
80+ population in 2013 and projected in 2050
United Nations, Department of Economic and Social Affairs, Population Division (2013).
World Population Ageing 2013. ST/ESA/SER.A/348.
[http://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2013.pdf
]
Brazilian population by sex and age
group – 2000 vs 2010
http://censo2010.ibge.gov.br/sinopse/webservice/frm_piramide.php
Brazilian population by sex and age
group – 2000 vs 2010
http://censo2010.ibge.gov.br/sinopse/webservice/frm_piramide.php
Age pyramide – projection to 2040,
Brazil
http://www.ibge.gov.br/home/estatistica/populacao/projecao_da_populacao/2008/piramide/piramide.shtm
Age pyramide - comparisons
http://www.ibge.gov.br/home/presidencia/noticias/imprensa/ppts/
00000014425608112013563329137649.pdf
1,166,060 deaths/age group - 2011
Brazil
180'000
160'000
140'000
120'000
100'000
Men
Women
80'000
60'000
40'000
20'000
0
<1
1-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
>80
Adapted from: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?idb2012/a08.def
Indicadores e Dados Básicos (IDB) - Brasil - 2012
Five/Ten most incident CA – 2014
projection, Brazil
• Men:
1) Prostate
2) Lung
3) Colorectal
4) Gastric
5) Oral cavity
• Women:
1) Breast
2) Colorectal
3) Cervical
4) Lung
5) Thyroid
Instituto Nacional de Câncer José Alencar Gomes da Silva. Estimativa 2014: Incidência de Câncer no Brasil. Rio de Janeiro:
INCA, 2014 [Estimate/2014 – Cancer Incidence in Brazil].
http://www.inca.gov.br/estimativa/2014/estimativa-24042014.pdf
Efforts to better care in geriatric
oncology (GO) - examples
• 2000: SIOG
• ASCO
• McGill GO fellowship
• Senior Adult Oncology Program
• ONCODAGE project and so on ...
Brazilian efforts to better care in
geriatric oncology (GO) – some ex.
• Giglio et al. Oncogeriatria (book – multidisciplinar
approach). 2012
• Wildiers et al (Co-author: Karnakis T.). International
Society of Geriatric Oncology Consensus on Geriatric
Assessment in Older Patients With Cancer. J Clin
Oncol 2014;32:2595-603.
• Pontes et al. Physicians expertise in geriatric
oncology care: A Web survey among Brazilian
medical oncologists. J Clin Oncol 32, 2014 (suppl;
abstr e20527)
– 933 emails, 117 answered (12.5%) – concepts of GO
widespread but insufficiently applied*
• SIOG 2013 – INCA/National Cancer Institute (Rio de
Janeiro) – abstracts about CGA domains; other
groups and institutions.
http://www.elsevierdigital.com/JGO/SIOG2013/
•
* conceptual knowledge different from intervening???
Our time line
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Until 2009 – ideas
2009 – proposal, no administrative support yet
2010 – pilot phase – + 1 nurse and 1 psychologist
2011-3: more routine use of CGA – 2 nurses
2014: less adherence to CGA... Staff with multiple
tasks, besides GO, such as pre-elective hospitalization
(all ages); incresing volume. However:
• New opportunities: previous data presentation (ESMO
2013, ASCO 2014), today´s opportunity (SIOG 2014)
• Today: doctors and fellows, 2 nurses; other specialties
referred inside the hospital (geriatric oncology unit, no
formal geriatric expertise nearby).
Brazilian efforts to better care in
geriatric oncology (GO)
• Our in A C Camargo, S. Paulo
• Hospital site: Elderly, quality of life and Geriatric Oncology
• Our time line – long way...
http://www.accamargo.org.br/saude-prevencao/artigos/idosos-qualidade-de-vida-e-oncogeriatria/50/
Brazil - GO
• Retrospective, n=666; 60% male. Median age: 74.2 years (range: 65 to 99).
Pontes et al. Einstein (São Paulo) 2014;12:300-3
Brazilian efforts to better care in
geriatric oncology (GO)
• 2006-7: Health
Ministry – Aging and
health of elderly
people
Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Envelhecimento e
saúde da pessoa idosa. Brasília, 2007.
192 p.: il. – (Série A. Normas e Manuais Técnicos) (Cadernos de Atenção Básica; n. 19).
http://bvsms.saude.gov.br/bvs/publicacoes/abcad19.pdf
• 2012 – Attending elderly
health:conceptual aspects
• (OPAS, MS/BRA).
Moraes EM. [Atenção à saúde do Idoso: Aspectos Conceituais. Brasília:
Organização Pan-Americana da Saúde], 2012.
http://apsredes.org/site2012/wp-content/uploads/2012/05/Saude-do-Idoso-WEB1.pdf
Lessons from other experiences and
literature review
• ageing is a global
phenomenon
• huge impact in
healthcare
• CGA is gaining
importance
• CGA in Geriatric
Oncology is an open
research field so far
(continued)
Sattar et al. The Oncologist 2014;19:1-13
GA – how to do?
Decoster et al. Ann Oncol 2014;00:1-12 (Epub June 16, 2014)
Wildiers et al. J Clin Oncol 2014;32 (Epub July 28, 2014)
Geriatric assessments
• Full GA
• Short
• Short >
+ > full
• Which
one?
• Health
Range 2-10
professional
to 120
• Selfmin!
administered
• Prior to visit?
• Many of both
in virtually
all!
• Domains > +
> further
specific
evaluations >
interventions
Sattar et al. The Oncologist 2014;19:1-13
Interdisciplinarity and collaborations
• Efforts to better
interdisciplinary
approach for the elderly
• Demands worldwide
multi-institutional
collaboration; and
LOCAL
CONTEXTUALIZATION
Hamaker et al. Acta Oncologica 2014;53:289-96
Different settings
Extermann M. Cancer Res Treat. 2010;42(2):61-68
Different settings
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•
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public or private
acute or intensive care unit
ambulatory, nursery
hospice, home care
Assistance, administrative, or research points of
view
• Different needs, available time and staff;
• Pros and cons
GA models in different settings
Wildiers et al. J Clin Oncol 2014;32:2595-603
Administrative and financial support
• People interested
• “Hands on”
• Different tasks, different payments vs. task
overlap. Different objectives?
Tremblay D et al. BMJ Open 2012;2:e001483
Integrated Oncogeriatric Approach (IOGA) Model.
Tremblay D et al. BMJ Open 2012;2:e001483
©2012 by British Medical Journal Publishing Group
Transdisciplinar aspects
http://csis.org/files/media/csis/pubs/090324_gai_english.pdf
Our institutional recent reality in
numbers:
• ~4,000 consultations /month in clinical
oncology
• ~10,000 pts / year
• ~ 2/3: 65+ years old.
• 20%: 70+ years old.
Some of our previous work
Dal Molin et al. ESMO 2013, # 1559
http://www.poster-submission.com/board/
ONCOGERIATRIA – Sociedade Brasileira de
Oncologia Clínica (Brazilian S. Clinical Oncol.)2011
Breast
NHL
Other
Other
CRC
Prostate
2nd primary
NHL
• 85+, ambulatory; 2010
•N=110; 76% fem.; 17,6% metastatic; 25% second primary
•35% chemotherapy
Geriatric oncology: comprehensive geriatric assessment tools
(CGA) - implementation and interdisciplinary clinical
approach for elderly patients (pts) in A. C. Camargo Cancer
Center (ACCCC), Sao Paulo, Brazil.
Methods
Set: clinical oncology pts, ambulatory evaluation, age>70y.
Dimensions of CGA assessment:
PS/ECOG; Activities of daily living (ADL): basic-KATZ, instrumental-Lawton
Mini-nutritional assessment
Depression: geriatric depression scale (GDS)
Comorbidities
Polypharmacy
Patient (pt) classification:
fit, vulnerable or frail
End-points of interest:
dose reduction
hospitalization
treatment discontinuation
Dettino et al. J Clin Oncol 32:5s, 2014 (suppl; abstr 9549)
Geriatric oncology: comprehensive geriatric assessment tools
(CGA) - implementation and interdisciplinary clinical
approach for elderly patients (pts) in A. C. Camargo Cancer
Center (ACCCC), Sao Paulo, Brazil.
Variable
Age
Range (IQR)
Median/Mean
Sex
Katz
Lawton
ECOG
GDS
Polypharmacy
Undernutrition
Female
Male
A
<27
0-1
2
3-4
>4
>=5
MNA<12
N (total: 620)
%
70-94 (72-78)
75/76
345
275
465
310
520
70
30
62
304
173
56
44
75
50
84
11
4,8
10
49
28
Dettino et al. J Clin Oncol 32:5s, 2014 (suppl; abstr 9549)
Geriatric oncology: comprehensive geriatric assessment tools
(CGA) - implementation and interdisciplinary clinical
approach for elderly patients (pts) in A. C. Camargo Cancer
Center (ACCCC), Sao Paulo, Brazil.
Figure 2. Cancer primaries.
Figure 3. ECOG: n (%).
• Ambulatoty setting
Dettino et al. J Clin Oncol 32:5s, 2014 (suppl; abstr 9549)
Results
Correlations
Choice of tx
Original vs. modified;
and additional dose
reduction
Ability to complete proposed treatment
Hospitalization
Variables
Katz
Lawton
Depression
Nutrition scale +
Lawton
Comorbidities
Katz worse than A
Lawton<27
Depression scale +
p
0.011
<0.001
0.035
0.004
0.04
0.038
0.004
0.012
0.032
lr
6
26
9
14
9
na
4.5
6.5
10
lr: likelihood ration
Dettino et al. J Clin Oncol 32:5s, 2014 (suppl; abstr 9549)
Conclusions:
• CGA feasible in our institution, in daily practice.
• Domains: strong predictors of complications of systemic
oncology treatments.
• Its application may help to better individualize treatment
strategies for oncogeriatric pts, with aims of:
– quality of life,
– lower toxicity, and
– survival improvements.
Dettino et al. J Clin Oncol 32:5s, 2014 (suppl; abstr 9549)
Perspectives
• Starting a project hoping for government grant, aiming to:
• PREVENT COMPLICATIONS - Detect predictive factors of complications in
oncological treatment
• · Prevent additional common complications in elderly: falls, polypharmacy,
undernutrition, depression, sarcopenia, for example.
• TREATMENT PROTOCOLS - Propose treatment protocols adapted to
functional capacity - avoid over and under treatment.
• REHAB - Offer ways to rehabilitation of reversible vulnerability and frailty,
with combined interprofessional work.
• PSYCHOLOGIC AND COGNITIVE SUPPORT - Detect early signs of
psychological or cognitive alterations that may contribute to additional
deficits.
• DIFFERENT SETTING SUPPORT - Offer home, ambulatory and hospital
support to all patients, specially for the ones that cannot receive specific
cancer treatment (oncogeriatric palliative care).
• INTERDISCIPLINARITY - Combine assistance to comorbidities with the
oncology team, better GO interventions to better care.
Closing remarks
• CGA in daily practice – high volume hospital:
• feasible and useful
• predict needs and complications of systemic cancer
treatment
– dose adjustment,
– ability to complete proposed treatment, and
– hospitalisation.
• Next step: look for correlations with markers
of efficacy, such as:
– survival and
– quality of life.
Closing remarks
• Importance of comparison of different
approaches in Geriatric Oncology:
• Help to improve their applications in many
settings and services, institutions and regions
• Good ideas being applied: local
contextualization.
• Those efforts will directly benefit elderlies,
including cancer patients.
(...)
And us all!
[email protected]
And us all!
Thank you for your attention!
[email protected]
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review some topics in Geriatric Oncology, highlighting strategies and difficulties of implementing such a unit. Daily routine of a
interdisciplinary Geriatric Oncologic team work will be discussed, to put into the context of a high volume cancer hospital, the daily
needs of caring for elderly oncology patients. Attending public will discuss, among other topics:
a) epidemiology of aging and cancer around the world;
b) efforts to better care in geriatric oncology;
c) CGA in cancer patients;
d) important points in geriatric oncology in different settings (public or private; acute or intensive care unit, ambulatory, nursery,
hospice, home care);
e) administrative and financial support for geriatric oncology.
In A. C. Camargo Cancer Center, in Sao Paulo, Brazil, we are starting a project hoping for government grant, aiming to:
· Detect predictive factors of complications in oncological treatment
· Propose treatment protocols adapted to functional capacity, to avoid over and under treatment.
· Offer ways to rehabilitation of reversible vulnerability and frailty, with combined interprofessional work.
· Prevent additional common complications in elderly: falls, polypharmacy, undernutrition, depression, sarcopenia, for example.
· Detect early signs of psychological or cognitive alterations that may contribute to additional deficits.
· Offer home, ambulatory and hospital support to all patients, specially for the ones that cannot receive specific cancer treatment.
· Combine assistance to comorbidities with the oncology team.
Topics above will be illustrated by our experience, initiated in 2010, in the implementation of a Geriatric Oncology Unit in A. C. Camargo
Cancer Center - one of the largest oncology hospitals in Latin America - specially how to apply a time-consuming elderly evaluation in a
high volume cancer center for multidisciplinary treatment.
In our initial retrospective cohort, the incorporation of CGA in daily practice was feasible and useful to predict needs and complications
of systemic cancer treatment, like dose adjustment, ability to complete proposed treatment, and hospitalisation. Next step should be to
look for correlations with markers of efficacy, such as survival and quality of life. We believe that the comparison of different
approaches in Geriatric Oncology may help to improve their applications in many settings and services, with good ideas being applied
with local contextualisation. Those efforts will directly benefit elderly cancer patients.