A Perspective: Geriatric Oncology Becoming the Masterpiece of the Art of Oncology Care
By Cynthia Abarado DNP, APRN, GNP-BC; Independent Consultant, Sugar Land, Texas
Why is geriatric oncology evolving as the mainstream in cancer care?
The world’s population among people 60 years of age will increase from 900 million to 2 billion between 2015 and 2050, (World Health Organization, 2017). In the USA, 60% of those affected by cancer are 65 years of age and older. This population also comprise most of deaths from cancer. There are insurmountable financial, personal and social costs involved in geriatric oncology care continuum. In addition, the impacts of health and aging generally have significant burden globally. Please see: http://www.who.int/ageing/events/world-report-2015-launch/healthy-ageing-infographic.jpg?ua=1
The change in the tapestry of the population poses significant challenges on the care of older cancer patients. The advanced technology and diagnostics have improved early cancer detection and prevention leading to early treatment. At times, cancer is diagnosed at later stages affecting the treatment, goals of care and outcomes. The complexed care of cancer in an older patient is also affected by co morbidities. Recent improvements in treatment modalities have changed the trajectory of cancer illness posing significant financial, care-giving, acute and chronic care challenges. While there are issues in the management of cancer treatment, cancer-related symptoms there is also evidence of increased five-year survival. According to the Center for Disease Control and Prevention (2017), there are 15 million Americans alive today who had a diagnosis of cancer. The presence of co-morbidities among survivors makes the care of the older cancer patient even more complexed. A comprehensive geriatric care model is proposed to encourage nurses and other health team members ensure a well-coordinated care that promotes patient-centered, personalized care plan.
What are the unique attributes of the older cancer patient or population that are essential in a comprehensive geriatric oncology care?
The geriatric oncology patient or population has unique characteristics which can be the basis of identifying their needs, develop individualized plan of care that are meaningful to the patient and family, attain outcomes aligned with the patient goals and foster a patient-centered high-quality care. These attributes include biological, physiological, psychological, sociological, pharmacogenomics, and molecular components. Each attribute is unique to each older cancer patient. The support system of an older cancer patient determines the patient’s ability to cope cancer, cancer treatment and cancer treatment related side-effects. A person’s perception of his quality of life is significantly affected by his knowledge of his disease process, prognosis and goals of cancer treatment. Moreover, this population comes from diverse global and unique multicultural background influencing each individual’s perception of health, illness and quality of life.
Example of the Comprehensive Geriatric Oncology Care Assessment Model
|Attributes||Aspects of Attributes|
|Biological/ Physiological||Cancer Diagnosis, Presence of co-morbid conditions, Geriatric Syndromes, Frailty|
|Psychological||Depression, neurodevelopmental disabilities, psychiatric and behavioral conditions, dementia, cognition|
|Pharmacogenomics||Drug allergies, drug interactions, laboratory evaluation|
|Pharmacy profile||Polypharmacy, insurance profile re coverage|
|Social Profile||Family/ community support, living arrangements, financial needs|
|Molecular Profile||Genotype profile, histology and liquid biopsy profile|
The model is based upon the assumption that the geriatric oncology population requires a comprehensive oncology care in the presence of co morbidities, frailty and geriatric syndromes. It is also based upon the knowledge that each geriatric oncology patient has unique characteristics unique to each subset of this population that would affect types and goals of treatment. The model views cancer care as complex. It requires collaboration and coordination across systems and locations. Moreover, the model is based upon the assumption of a collaboration between each health team member and functions within a multidisciplinary approach.
A perspective on the Proposed Comprehensive Geriatric Oncology Care Model
The comprehensive geriatric oncology care assessment proposed in this model uses the Comprehensive Geriatric Assessment (CGA) as a framework. CGA is defined as “multidisciplinary evaluation in which multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus in the person’s problems (Solomon, 1988). A meta-analysis analyzing 28 controlled trials of five types of geriatric assessments in various settings was done in 1993. It demonstrated that CGA programs that link geriatric assessment with strong long-term follow-up and management are effective for improving survival and functions in older adults (Suck, 1993). The utilization of CGA in cancer care has not been fully established. However, assessments of different components have been studied in various settings in Europe.
In this model, the geriatric oncology patient and population are the most important focus of care. The dynamic interactions between the environments, nurse, person to attain the state of health constantly changes. An assessment of the diverse attributes that is unique to each person utilizes several established tools that have established internal validity and have been utilized in different research endeavors. Biophysiological attributes include cancer diagnosis, geriatric syndromes, pain, fluid/electrolyte imbalances, abnormal biomarkers, cancer treatment related toxicities, co morbidities and educational needs related to disease process. The Symptom Distress Scale developed by McCorkle and Young has been widely used to assess symptom distress among oncology patients. It is reported to have a Cronbach’s alpha co-efficient of 0.70-0.92 (McCorkle, 2000). The role of co morbidity in cancer management and decision-making is yet to be studied more extensively in this population. Charlton Comorbidity Index and Cumulative illness rating scale index-geriatrics have been proposed to assess comorbidities although none has been validated for use in older adults with cancer. Psychological and sociocultural factors include depression, ineffective coping, lack of support systems, impaired self-care, lack of financial resources and educational needs. Utilization of the Geriatric Depression Scale has been recommended. It is reported to be 84% sensitive and 95% specific for diagnosing clinical depression. Assessment of social support is markedly important as it plays in a cancer patient’s health and linked to mortality. Caregiving in cancer has shifted to family members giving rise to caregiver burden. Caregiver Reaction Assessment is a 24-item instrument that assesses reactions of family members caring for older patients with physical impairments, cancer and Alzheimer’s. Utilization of Elder Assessment Instrument to review signs, symptoms, complaints of elder abuse, neglect, exploitation and abandonment among at risk population maybe warranted. Functional status can be measured Katz Index of Activities of Daily Living, Instrumental Activities of Daily Living and the Eastern Cooperative Oncology Group Performance Status (ECOG PS). Cognition includes assessment for dementia, delirium, decision-making ability and identification of a surrogate decision-maker. The Holstein Mini-Mental State Examination (MMSE) is one of the most widely used. The Confusion Assessment Method (CAM) has been widely used and validated as an instrument for assessing delirium. Advance directives should be discussed initially or at an early stage of treatment but should not be mistaken as stopping treatments. Pharmacogenomics include assessments related to biomarkers, liver function tests and renal functions. These are necessary to adjust treatment doses and determine types of treatments. Pharmacy profile review includes evaluation for polypharmacy and identification of financial/ insurance coverage for treatments. Reconciliation of medications, review of medication interactions and incompatibilities are also important components of this aspect. This model could be utilized efficiently using evidence-based practice assessment tools with established internal validity and tested using randomized clinical trials. The comprehensive geriatric oncology assessment is also based on nursing process, interdisciplinary care approach and collaboration. It proposes utilization of assessment tools that have established internal validity and reliability to increase its internal and logical adequacy.
The utilization of this model could be expanded to other chronic care coordination programs. The model requires a comprehensive assessment and is multidimensional. Demonstration projects to measure that the application of a comprehensive geriatric oncology practice model would decrease overall cancer expenditure would be necessary. The economic impact of this model can also be demonstrated by decreased hospitalization and readmissions. Other outcome measures are related to decreased mortality from treatments and complication and most of all improved oncology care coordination through utilization of evidence-based guidelines and informatics.
Implications to Advanced Practice Nurses
I have used this model in an acute care setting. Roy’s Adaptation Model plays a role in some aspects of my practice model. Nursing process and nursing interventions are the fundamental guiding principles. Future nursing research based upon the model could investigate the impact of evidence-based cancer care management on survivorship of cancer patients particularly among the older population. The global consultative role of the DNP based on this model could open opportunities for the DNP. Overall the application of this model expands the role of the DNP to a global health care environment for geriatric oncology patients.
The Comprehensive Geriatric Oncology Care Model proposes the comprehensive geriatric oncology assessment, a modified version of the CGA to be incorporated in cancer care. Assessment of the specific domains using established tools would lead to a comprehensive care plan and efficient care coordination across systems. The model is multidimensional and utilizes chronic care model, application of nursing process.
There is a need for more educational training among nurses to care for older patients with cancer. The use of assessment tools to evaluate each attribute of older patient eith cancer require special training among multidisciplinary team members. Although using a comprehensive geriatric care model is a tedious process, identification of problems during initial assessment of each attribute can lead to safe, timely, effective, efficient, patient centered and equitable quality of care throughout the cancer care continuum.
Opportunities and Resources
The proposed Comprehensive Geriatric Oncology Care Model can be applied to daily clinical practice, nurse navigation, case management, and global care coordination.
Some resources for geriatric oncology are available on the following websites: