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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 • • • • • 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 • • • • • 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] • • • • • • • • • • • • • • • • 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.